Automatic Withdrawal Authorization (pdf)
The University Billing Office's form is used to authorize the automatic withdrawal of insurance premiums from your checking or savings account to cover billed expenses for retirees, temporary employees, students, and those on COBRA. 

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.

• Acceptance by Nominated Custodian Designation Form (pdf)

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.

• Catastrophic Leave Application, Family (pdf)
• Catastrophic Leave Application, Individual (pdf)

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.

• Catastrophic Leave Donation Form (university workflow)

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.

• Personal Deviation/Extension of Insurance Coverage (pdf)
• CISI Coverage Manual (pdf)
• Dependent Enrollment Form for Insurance (pdf)
• CISI Claim Form (pdf)

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.

• Domestic Partner Affidavit - Faculty and Staff (pdf)
• Domestic Partner Affidavit - Students (pdf)
• Domestic Partner Affidavit - Termination (pdf)

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.

Double Spouse Credit Form (pdf)
 

• Dependent Care Spending Account
  • Receipt Template (pdf)
    Use this form as a receipt for the care provided.
     
• 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.
     
• 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.

• 2021 UIHA Enrollment Form (pdf)
• 2021 UIHA ACH 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:

• Life Conversion Policy Application (pdf)

Voluntary Term Life application:

• Voluntary Term Life Portability Application (pdf)

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.

Personal Health Information Release Form (pdf)

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), 2022 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.