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Forms and Brochures

This page contains links to benefit applications, brochures and other plan documents.  Please note that at hire and during Open Enrollment, employees should use eBenefits to enroll in benefits.

Health Insuranc​e​​​​​​​​​

2023 It's Your Choice website

2023 It's Your Choice Decision Guide​

2023 Health Plan Search by County

2023​ Health Plan Resource Page

Health Insurance Application

Affidavit for Insurance Purposes (if employee or dependent doesn't have SSN)

​ Navitus Member Portal

Serve You - Prescription Mail Order Vendor

Sick Leave Escrow Application

Sick Leave Credit Conversion Program Brochure

Health Sav​ings Account (HSA)

2023 HSA Website

Optum Financial/​ConnectYourCare Employee Website

Optum Store​

​ Optum Financial Mobile App​

HSA Resources Page (Optum Financial/​​ConnectYourCare)

​ 2022 HSA Enrollment Form


HSA Beneficiary Designation

HSA Claim Form

HSA Eligible Expenses Flyer​ ​

State Group Life Insurance (SGL)

State Group Life Insurance Page

Life Insurance Application

State Group Life Insurance Beneficiary Designation Form (Used for both SGL and WRS accounts)

State Group Life Insurance Brochure/Plan Certificate

Lifestyle Benefits Summary

Income Continuation Insurance (ICI)

Income Continuation Insurance Page

Income Continuation Insurance Application

Income Continuation Insurance Brochure

Vision Insurance (DeltaV​ision)

DeltaVision Website

DeltaVision Application​

DeltaVision Continuation Form (bottom of form must be completed by agency)

2023 Guide to Supplemental Vision Benefits​

2023 Vision Benefits Summary​​​

Vision Provider Search

Online Retail Options​

Delta Dental Supplementa​l & Preventive Plans

Delta Dental Website

2023​ Guide to Supplemental Dental Benefits

2023 Plan Summary and Comparison​

Additional Dental Benefits Available

​ Dental Provider Search

Delta Dental Application

Delta Dental Continuation/Retiree Form (employer section must be completed by agency)

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Accident Plan​ by Securian Financial

Accident Plan Informational Website

Accident Plan Application

How to File a Claim

Beneficiary Designation (same form used for both your WRS and State Group Life Insurance accounts)​​

2023 Plan Brochure

Group Accident Certificate of Insurance

Accident Insurance Coverage Benefits

​ Identity Theft Protection Benefits

Accident Plan Continuation Form

​
Flexible​ Spe​ndin​g/Pre-Ta​x Savings Accounts​

2023 Pre-Tax Savings Plan Website (ETF)

Optum Financial​/ConnectYourCare Website

Optum Store

​​​ Optum Financal Mobile App

2022 Enrollment Form (all plans)

2022 Late Enrollment Request Form

2022 Rescind Enrollment Form

​ Change in Status Form (all plans)

Healthcare FSA Claim Form

Dependent Day Care Claim Form

Transit & Parking Claim Form

Transit & Parking Attestation Form

Wisco​nsin Deferred Compensation (WDC)

WDC Program Page​

Beneficiary Designation

Enrollment Form

Full Enrollment Form​

​Mobile App Information​

For more information, see the WDC Website

Wisconsin Retirement System (WRS)

WRS Summary Page

Beneficiary Designation

Beneficiary Designation Alternate

Election to Participate in the Variable Fund

Election to Cancel Variable Fund Participation

Benefit Information Request

Edvest

​​ Edvest Informational Flyer

Edvest Enrollment Booklet

Payroll Contribution Form

See the Edvest website for additional information.