Forms
Find all benefit forms in one place - ACH, FSA forms, Domestic Partner Affidavits, and more.
Plan Documents
Find info about specific benefits, costs, limitations/expectations, and more.
Insurance Overviews
Are you looking for your benefit category and what insurance you may be eligible for?
Below is where you will find all of the Benefits Office's forms, plan documents, insurance overviews, and many more resources.
Forms
Authorization for Automatic Withdrawal of Insurance Premiums (pdf)
This form is used to authorize the automatic withdrawal of insurance premiums for retirees, temporary employees, students, those on COBRA, etc.
Adding or making changes to beneficiaries can be done once a month on Employee Self Service under Benefits & Wellness >> Benefits >> Manage Beneficiaries.
However, if the following situation(s) arises, you will need to fill out a paper Beneficiary Designation Form (pdf) and submit it to our office at benefits@uiowa.edu.
- If you are trying to designate a trust or an estate;
- If you are electing a flat amount for one of your beneficiaries instead of a percentage;
- If you have already made a change on Employee Self Service during the month and need to make another change;
- or it is the Annual Open Enrollment Period, and the Manage Beneficiary application is closed.
The Uniform Transfers to Minors Act (UTMA) allows you to transfer financial assets to a minor without establishing a trust. Use the Principal form below if you are listing a minor as a beneficiary to your Life Insurance policies.
Please submit your form online through Employee Self Service.
- Once logged in, select the "Benefits & Wellness" link from the left-side menu >> select "Benefits" >> then select the link "Benefits Change Request"
Use this form to notify the Benefits Office of a qualifying event.
These forms are used to request the donation of hours due to your own catastrophic illness or that of a family member to be completed by the employee and their physician.
If you would like to donate some of your unused vacation time to an employee in need, please fill out the form below. You will need to enter a recipient for your donated time. If you do not have anyone specific, you can find a list of employees in need on our Cat Leave site.
Declaration of understanding that a common law marriage is legally recognized as a marriage.
- Common Law Marriage Affidavit (pdf)
This form is for use by Faculty, Professional and Scientific, Merit Staff, House Staff, Employed Graduate Student, Postdoctoral Scholars/Fellows.
Declaration of domestic partners and criteria for eligibility for certain insurance benefits under the University of Iowa benefits program. Also, affidavit of termination of the domestic partner relationship.
If you and your spouse/domestic partner both work at the University of Iowa in benefits-eligible positions and have dependent children who require coverage under your policy, you may be eligible for the Double Spouse Credit.
Depending on what health plan (UISelect and UIChoice) you choose to enroll in, you and your spouse/partner can receive family health coverage for free or minimal cost.
If you are not covering dependent children, you and your spouse/domestic partner should sign up for Employee Only coverage since it is also provided at no or little cost depending on which health plan you choose.
- Dependent Care Spending Account
- Receipt Template (pdf)
Use this form as a receipt for the care provided.
- Receipt Template (pdf)
- Health Care Spending Account
- HCSA Letter of Medical Necessity (pdf)
Your health care professional must complete this form to recommend a specific treatment for a specific medical condition. - The employee can only use the Letter of Medical Necessity (LMN) form to reimburse eligible expenses. Ineligible items are not eligible, even with an LMN.
- HCSA Letter of Medical Necessity (pdf)
- Other Forms
- Salary Reduction Agreement for Flexible Spending Accounts Form (pdf)
Use this form to begin, end, or change your Flexible Spending Account contribution amount.
- FSA Transportation Worksheet (pdf)
Use this form to request reimbursement for transportation costs to an appointment that is an eligible expense.
- Salary Reduction Agreement for Flexible Spending Accounts Form (pdf)
Forms can be used for employees and students
- Drug Care Prescription Claim Form (pdf)
- International Claim Form (pdf)
- Wellmark/Blue Cross Patient Claim Form #C-2318978 (pdf)
- Wellmark/Blue Cross Patient Form #C-4614 (pdf)
Lodging Reimbursement Form for Transplant-Related Expenses
You may purchase an individual life insurance policy if your group or voluntary term insurance ends and you qualify for individual purchase (conversion/portability). Please visit the Group or Voluntary Term Life Insurance accordion under the Plan Documents section of this page to read more about this process.
Group Term Life application:
Voluntary Term Life application:
Form is available on Employee Self Service >> My Self Service >> Personal Information >> Information Release Form
Use this form to allow the benefits office to discuss your benefits with someone you choose, such as a spouse, parent, partner, secretary, etc.
Visit the Privacy Information page to learn more about how medical information about you may be used and disclosed and how you can get access to this information.
An employee must be at least 57 years old with 15 years of service in order to participate in this program. The request must go through the appropriate administrative offices for final approval.
Request to Participate in the Phased Retirement Program (pdf)
- Temporary Insurance with Department Contribution
Temporary Employees (50% or Greater) Request for Payment of Health Insurance Contributions.
Departments use this form if they wish to contribute to the health insurance premiums of a temporary Faculty or Staff employee.
- Voluntary Retirement Savings Program (VRSP), 2021 Calculation Worksheet (xlsx)
Available on Employee Self Service
Use this file to determine if you are eligible for the VRSP and if so, how much you're eligible to contribute.
-
Voluntary Retirement Savings Program (VRSP), Salary Reduction Agreement
Available on Employee Self Service - use the online form to begin, end, or change your VRSP contribution amount
Note: If you are a bi-weekly employee and wish to participate, please contact University Benefits at benefits@uiowa.edu.
Visit the Workers' Compensation Forms page.
Plan Documents & Manuals
Please visit the forms section on the Benefits Resources page under the "Life Insurance Conversion Policy" accordion item to fill out a life conversion application.
2021
Active Employee
Retiree
- 2021 UIChoice Retiree Summary of Benefits and Coverage (pdf)
- 2021 UIChoice Retiree Coverage Manual (pdf)
2020
Active Employee
Retiree
2021 Documents
2020 Documents
2021
Active Employee
- 2021 UISelect Health Insurance Summary of Benefits and Coverage (pdf)
- 2021 UISelect Coverage Manual (pdf)
Retiree
- 2021 UISelect Retiree Summary of Benefits and Coverage (pdf)
- 2021 UISelect Retiree Coverage Manual (pdf)
2020
Active Employee
Retiree
- Continuation of Life Insurance Information (pdf)
- Principal Financial Group VTL Insurance Exit Information (pdf)
- Voluntary Term Life Portability Rates (pdf)
Please visit the forms section on the Benefits Resources page under the "Life Insurance Conversion Policy" accordion item to fill out a voluntary term life portability application.
Insurance Overviews
Graduate students who hold an assistantship of at least 25% time or a fellowship of at least $5,000 for the semester or $10,000 per academic year, and are registered for classes, are eligible to receive a contribution from the university toward the cost of health and dental insurance coverage.
2021 Overview
2020 Overview
Graduate students and health science majors may choose between the Student Health Insurance Plan (SHIP) or UIGRADCare.
2021 Overview
2020 Overview
2021 Overview
2020 Overview
Other Resources
When adding a new dependent (e.g., spouse, domestic partner, child) to your health and/or dental insurance, you will be required to submit proof of their eligibility. Below is a printable list of what documents are needed for specific verification of your dependents.
Connect not only virtually but personally with providers dedicated to your health, 24/7. See someone who gets you. Gets what you need. And gets you on with your day.
Below is the Open Enrollment 2021 "How to Enroll in Benefits on Employee Self Service".
As a benefit-eligible employee, you have two health plans to choose from, UIChoice and UISelect. Below are two real-world examples of costs for an employee with family coverage (Robert) or single coverage (Selena) when using either UISelect or UIChoice in 2021.