State Group Health

The Employer Completes section of the ETF State Group Health application is located on page 4 of the application as shown below. 

Regardless of whether the employee is enrolling for the first time as a newly benefit eligible employee, or is making a change because of a Qualifying Event, the Institution Benefit Administrator must verify all fields on the application have been filled in appropriately and complete the "Employer Completes" section before entering the information in HRS and forwarding the application to ETF.

1. EIN:  Enter 0001131
2. Employer Name:  University of Wisconsin
3. Payroll Representative Email:  Institution Benefit Administrator's business email address
4. Group Number:  83445
5. Employee Type:  Enter '03' for University Staff, '04' for Faculty, Academic Staff, or Limited Appointee, or '12' for Grad Assistant
6. Coverage Type:  check either Single or Family coverage
7. Health Plan Name/Suffix:  Enter the full health plan name (i.e. Dean with Dental)
8. Business Unit:  Enter your Institution Name (i.e. UW-Madison, UW-Stout, UW-Eau Claire...etc)
9. Employment Status of Applicant: Indicate if the employee is a Full, Part Time, or an LTE.
10. Employee Deductions:  Check whether the premiums will be deducted from an employee's payroll check before or after federal and state taxes.
11. Hire Date or WRS Eligible Employment Date or Grad Appointment Began:  This date must reflect an employee's original date of hire OR the date they became eligible for the Wisconsin Retirement System (WRS) benefits.  If the employee is not eligible for the WRS, indicate the date they began the appointment that made them eligible for Grad benefits.
12. Employer Received Date:  Indicate the date you physically received the completed, signed, and dated health insurance application
13. Event Date:
    
    • New Hire:  Enter first of the month following two months of employment for University Staff (biweekly paid) employees if the employee chooses to wait for the employer contribution to their premium.  Enter the first of the month on or following the Date of Hire for a Grad or FA/AS/LI (monthly paid) employee.
    • Newly Eligible for benefits:  University Staff:  Enter the first day of the month following two months of employment from the date they became eligible for the WRS if the employee chooses to wait for the employer contribution to their premium.  Grad or FA/AS/LI:  Enter the first of the month on or following the date they became eligible for benefits.
    • Qualifying Event:  Enter the date of the qualifying event (i.e. date of divorce, date of baby's birth, date child is placed for adoption, date of marriage, etc.)
14. Prospective Coverage Change:  The effective date for the new or changing coverage.  For more information on prospective coverage change effective dates, please visit the UWSHR website.)
15. Answer the following questions regarding previous State/Local WRS Service.  For information on how to look up this information on the ETF One Net system, click here.
    • Are you a WRS Participating employer?  Answer:  Yes
    • Previous Service Check Completed?  Answer:  Yes  (if this employee appears on the New Hire Hold report, you must manually look up the employee previous service on the ETF system.)
    • Source of Previous Service Check?  Answer:  If this is an employee with no prior service or you manually verified this information on the ETF One system, the answer is "Online Network for Employers."  If you called ETF on the phone to obtain this information, the answer is "ETF."
    • Did employee participate in the WRS prior to being hired by you?  Answer:  If the employee appears in the ETF One system, answer this question as "yes," otherwise answer this question as "no."
16. Payroll Representative Signature:  Institution Benefit Administrators must sign every application to verify that the employee works for the University, that they have agreed to payroll deductions to pay for premiums, and that they are eligible to enroll.
17. Phone Number:  Enter your business phone number
18. Date Signed:  Institution Benefit Administrators must date every application to indicate that the application was completed on a timely basis.

Delta Dental

1. Effective Date:  Enter the first day of the month on or following the date of hire.  For a Qualifying Event, enter the date of the Qualifying Event.
2. Received By:  The name of the individual completing this section of the application.
3. Received Date:  Indicate the date you physically received the completed, signed, and dated the Delta Dental application.

Delta Vision

The "For Employer Use Only" employer section is located at the bottom of the Delta Vision application.

1. Effective Date:  Enter the first day of the month on or following the date of hire.  For a Qualifying Event, enter the date of the Qualifying Event.
2. Received By:  The name of the individual completing this section of the application
3. Date Received:  Indicate the date you physically received the completed, signed, and dated the Delta Vision application

State Group Life Insurance

The "Employer Completes" section is located at the bottom of page 3 of the State Group Life Insurance Application:

1. ETF Employer Number:  Enter 69-036-0001-131
2. Name of Employer:  Enter your Institution Name (i.e. UW-Madison, UW-Stout, UW-Eau Claire...etc)
3. Employer Billing Unit Number:  Enter 2832G
4. Employer Agent Signature:  Signature of the individual completing this section of the application
5. Prepare By:  The name of the individual completing this section of the application
6. Telephone Number:  Enter the business phone number for the individual completing this section of the application
7. Date WRS employment began with current employer (mm/dd/ccyy):  This date must reflect the date they became eligible for the Wisconsin Retirement System (WRS) benefits with the University.
8. Date Provided to Employee (mm/dd/ccyy):  Enter the date you provided this application to the employee to complete
9. Date Received From Employee (mm/dd/ccyy):  Indicate the date you physically received the completed, signed, and dated the State Group Life Insurance application
10. Coverage Effective Date: 
    • New Hire:  Enter first of the month following 30 days of employment for all employees.
    • Newly Eligible for benefits:  Enter first of the month following 30 days they became eligible for the WRS benefits.
    • Qualifying Event:  Coverage is effective on the first of the month on or following 30 days from qualifying event (i.e. date of divorce, date of baby's birth, date child is placed for adoption, date of marriage, etc.)
11. Calendar Year Earnings:  Enter the annual salary that premiums will be based on.  Follow the rules for setting up Annual Benefit Base Rates (ABBRs) in KB 17090.
12. Earnings Are:  Check whether the salary amount entered under number #11 is an estimated salary or an actual salary based on the previous year's WRS qualified earnings.

Individual and Family Life Insurance

The "For Office Use Only" section is located at the bottom of page 3 of the Individual and Family Life Insurance Application:

1. Date Received by Employer:  Indicate the date you physically received the completed, signed, and dated the Individual and Family Life Insurance application
2. Received by:  The name of the individual completing this section of the application
3. Hire/Event Date:  Original date the employee became benefit eligible
4. Coverage Effective Date:  First day the employee should be covered by the insurance
5. UWS Affidavit:  Indicate if the employee has a UWS Domestic Partner Affidavit on file or if this is Not Applicable (N/A)  Please note that the ETF Affidavit no longer applies as of 1/1/2018.
6. Premium: Enter the calculated premium based on coverage level and age
7. Processor Initials:  Enter your initials
8. Employee ID:  Enter the employee's HRS 8 digit Empl_ID

UW Employee's Inc. Life Insurance