University of Wisconsin Medical Foundation

2015 Executive

DDiirreeccttiioonnss ttoo UUWW MMeeddiiccaall FFoouunnddaattiioonn 7974 UW Health Court Middleton, WI 53562

Location for: New Employee Orientation (Day 1 and Day 2) Medical Reception Orientation Clinical Orientation Employee Health & Infection Control

Directions: From the Beltline, take the University Ave/US-14 W exit toward Spring Green/LaCrosse. Turn right onto University Ave/US-14W. Go 0.5 miles and turn right onto Deming Way. Go another 0.5 miles and turn left onto UW Health Court. In the roundabout, you will see the driveway on the right.. Parking: There is ample parking available on site. Please park in the visitor area at the front of the building. Assistance: If you have any questions, please call Human Resources at (608) 821-4164.

UW Medical Foundation New Employee Orientation Orientation Day 1 Agenda

Start at 8:00 am Light Breakfast Items ID Badge/U-Connect Photos

Paperwork Collection

8:15-8:45 am Welcome to UW Medical Foundation – Senior Management Welcome and Introductions

Explore UW Health and UWMF’s Mission/Vision/Values

8:45-10:30 am Service Excellence – Human Resources

Break during presentation Service Philosophy and Patient Satisfaction Survey

10:30 am-12:00 pm A.S.S.I.S.T. – Patient Resources The role of Patient Resources and dealing with difficult customers

12:00-12:30 Lunch

12:30-1:00 pm 1:00-2:15 pm

Payroll – Payroll Department Payroll information, resources, and KRONOS time keeping system

Total Rewards Philosophy – Human Resources UWMF compensation philosophy and benefit highlights

2:15-2:30 pm 2:30-3:30 pm 3:30-3:45 pm

Break Safety – Safety Department Emergency plans, chemical safety, security, and ergonomics

Wellness – Employee Wellness Department

Wellness opportunities, activities, and resources

3:45-4:30 pm

Confidentiality – Health Information Department

HIPAA and confidentiality guidelines

UW Medical Foundation New Employee Orientation Orientation Day 2 Agenda

Start at 8:00 Greetings and Overview of the Day – Human Resources Clinical Staff 8:15-9:30 am Blood Borne Pathogens – Employee Health/Infection Control

Blood Borne Pathogens & OSHA Standards

9:30-10:30 am Computer Skills – Information Services

IS security

10:30-10:45 am

Break

10:45-11:00 am 11:00 am-12:00 pm

Benefits Collection Computer Skills – Human Resources

Outlook, U-Connect and Employee Self Service

12:00-12:45 pm Lunch

12:45-1:45 pm Policies, Acceptance, & Inclusion – Human Resources Department

HR resources, company policies, and Acceptance & Inclusion

1:45-2:15 pm 2:15-2:30 pm 2:30-3:30 pm

Compliance – Compliance Department Compliance awareness and program information

Break 401(k) – Fidelity Representative

401(k) information and online enrollment

3:30-5:00 pm Benefits –Human Resources Department

1:1 Meeting with HR representative to complete benefit paperwork

End at 5:00 Employee Health (if applicable)

Questions? Questions?

Contact a member of the

UWMF Benefits Team!

Kyle Gosdeck, Benefit Specialist kyle.gosdeck@uwmf.wisc.edu 608-821-4925 Kathi Skemp, Benefits Representative kathi.skemp@uwmf.wisc.edu 608-821-4161

Carrie Cichy-Krantz, Compensation & Benefit Analyst carrie.cichy-krantz@uwmf.wisc.edu 608-821-4159 Troy Schuhmacher, Compensation & Benefit Specialist Troy.Schuhmacher@uwmf.wisc.edu 608-821-4156 Sara Broge, Leave & Benefit Specialist Sara.Broge@uwmf.wisc.edu 608-821-4891

Quick Links:Quick Links: Information on All Benefits uconnect

Health Insurance www.unityhealth.com

Flexible Spending Accounts www.discoverybenefits.com. Employee Assistance Program www.eapheitzingerandassoc.com

Executive Benefit Summary 2015

Health Insurance

If eligible, you have the option to enroll in health insurance the first of the month following one month of employment. UWMF offers an HMO plan through Unity Health Insurance. Premiums are shared. Coverage is available for single, employee plus one or family. Domestic Partner (DP) coverage is available; however, a portion of the total premium may be subject to taxation to the employee. Please see Human Resources for additional information on DP taxation, if applicable. You can view the online provider directory when you visit www.unityhealth.com.

UWMF offers a Health Risk Assessment (HRA) so that we can implement and incent healthy lifestyles and greater wellness. By participating in the HRA and biometrics, you will receive a discount to the monthly premium rate.

Health Insurance Buy-Back Under UWMF’s Health Insurance Buy-Back program, eligible employees receive $100 for each month they are eligible for the medical benefit during the current benefit year, but elected to waive the health coverage through UWMF due to other medical coverage.

To receive the Buy-Back, you must be eligible for UWMF’s health insurance. You must also have participated in the Health Risk Assessment (HRA) for the applicable year.

If eligible, you will receive an email in January of the following year notifying you of your eligibility and requesting that you submit proof of your alternative coverage for the prior benefit year. The Buy-Back is paid annually in a lump sum payment on the second paycheck in February, to each eligible employee who has met the requirements and is actively employed at the time of the payment.

Dental Insurance

If eligible, you have the option to enroll in dental insurance the first day of employment. Premiums are shared. UWMF offers single ($23.22 per month) or family ($66.00 per month) coverage through Delta Dental of Wisconsin (www.deltadentalwi.com). Domestic Partner coverage is available under the family option; however, a portion of the total premium may be subject to taxation to the employee. See coverage outline, premium amount, and online directory for more information. For more information on all UWMF benefits, please visit the UWMF Benefits for Staff page on uconnect.

Paid Time Off

Paid time off is a combination of vacation, personal, and sick days. If eligible, you will begin accruing time on the first day of employment on a per pay period basis. An employee who works 40 hours per week accrues time based on the schedule listed. The accrual is pro-rated based on hours paid. Time accrued in the first six months of employment is not considered earned until the completion of that period of employment. New employees may borrow up to three days of accrued PTO, prorated based on their FTE, after the completion of three months. Further information can be found on uconnect.

Please note this is a summary only. Any conflict between the summary and the contracts will be determined by the contract.

Coverage

Employee Rate

Monthly Per Pay Period

Single $145.00 $72.50

Single Discount $85.00 $42.50

Employee plus 1 dependent $160.00 $80.00

Employee plus 1 dependent Discount $100.00 $50.00

Family $170.00 $85.00

Family Discount $110.00 $55.00

Years of Service Employee accrues

0 – 9 years 216 hours (27 days)/year 8.31 hours/pay period

10+ years 256 hours (32 days)/year 9.85 hours/pay period

Executive Benefit Summary 2015

Please note this is a summary only. Any conflict between the summary and the contracts will be determined by the contract.

Short & Long Term Disability Insurance If eligible, you are covered by Short Term disability insurance the first of the month following one month of employment and Long Term Disability insurance effective on your first day of employment.

Short term benefits, which are equal to 70% of your current rate of pay, begin on the eighth day of disability and may continue for up to 12 weeks. Premiums are paid by UWMF.

Long term benefits, which are equal to 66 2/3% of W-2 wages, begin after 90 days of disability. Premiums are paid by UWMF.

Additional coverage is provided under a supplemental wrap program through the MassMutual Insurance Company. This is an individualized policy therefore costs for additional coverage are based on your current rate of pay. The “base wrap” provides a $2,000 monthly benefit in the event of disability. It is prorated if you are disabled, but working and suffer a loss of income. This policy uses your occupation to define disability.

The “supplemental wrap” uses your occupation to define disability. It provides additional coverage in the event you are working, but suffer a loss of income due to a disability (partially disabled). The amount of benefit available, and the monthly premium, will be determined based on your age and income. Coverage under these policies discontinues at

the end of your plan year, after turning age 65.

Beneficiaries You must designate a beneficiary for your Basic and Employee Supplemental Life insurance (if applicable), as well as the UWMF Profit Sharing and 401(k) plan. This is done by completing and submitting the beneficiary form for the life insurance and the beneficiary designation for the 401(k) plan. Please seek legal advice before naming a minor or incompetent adult as a beneficiary.

It is the responsibility of the employee to keep beneficiary information up-to-date. Your current beneficiary designation will not be revoked or changed automatically when you marry or divorce. If you wish to change your beneficiary designation due to marriage or divorce, you will have to do so by means of a new designation form.

In the event that your beneficiary dies, please ensure that a new designation is completed and submitted to UWMF. Otherwise, the beneficiary’s portion will be distributed according to the law.

You are the primary beneficiary for Supplemental Spouse/Child Life Insurance coverage elected. You are also the primary beneficiary for Dependent Life Insurance coverage elected.

Please Note: In the state of Wisconsin, your spouse must be 100% primary beneficiary unless a spousal consent form is signed and notarized.

Flexible Spending Accounts (FSA) If you are eligible and you have qualified day care expenses, you may enroll in the Day Care Flexible Spending Account (DCSA) plan effective immediately upon employment. Your annual elected enrollment amount will be deducted from your paycheck before taxes (pre-tax dollars) up to the annual maximum of $5,000 per family.

Eligible employees with qualified health or dental care expenses may enroll in the Health Care Flexible Spending Account (HCSA) plan effective the first of the month following one month of employment. Your annual elected enrollment amount will be deducted from your paycheck before taxes (pre-tax dollars) up to an annual maximum of $2,550.

You can benefit from the FSA Debit Card, a tool that allows you and/or your dependents to deduct qualifying expenses directly from your FSA. This eliminates the need for claim forms, out of pocket expenses, and the wait for reimbursement checks! For more information, visit www.discoverybenefits.com.

Life Insurance and AD&D If eligible, you will be enrolled in a term life insurance policy on the first day of employment. The benefit is equal to three (3) times your prior calendar year W-2 wages. Premiums are paid by UWMF.

Your coverage also includes Accidental Death & Dismemberment (AD&D) for the same amount of coverage.

Dependent Life Insurance You may elect dependent life insurance, if eligible, effective on your date of hire.

The plan offers $10,000 of benefit for spouse/domestic partner and $5,000 per child. The coverage for a dependent child is available up to age 19 if they are not a full time student, or up to age 25 if they are a full time student, and unmarried. Your cost is $0.93 per month, regardless of the number of dependents covered.

Supplemental Life Insurance, AD&D If eligible, you have the option to enroll in Supplemental life coverage the first of the month following one month of employment. Within the first month of hire, if you work 20 hours or more, you may elect increments of $10,000 to a maximum of $750,000 with a guaranteed issue amount of $250,000. Your coverage also includes Accidental Death & Dismemberment (AD&D) for the same amount elected.

Your spouse/domestic partner is also eligible for coverage in increments of $10,000 to a maximum of $250,000 with a guaranteed issue amount of $30,000. The spouse amount cannot exceed 50% of the amount you elect for yourself.

Children are eligible for coverage at $10,000 up until age 19 if not a full time student, or age 25 if a full-time student, and unmarried.

Additional information on various life insurances policies can be found on uconnect.

Executive Benefit Summary 2015

Please note this is a summary only. Any conflict between the summary and the contracts will be determined by the contract.

Length of Service Recognition Program UWMF recognizes employees celebrating service anniversaries of five-year increments. You can select from an array of gifts prior to your anniversary, and you will be awarded with the gift and recognized on or near your service anniversary.

Hi-5

Perhaps a co-worker has made a difference in your day by doing something special. There is a quick and easy way to say “thanks” or give someone a pat on the back. The Hi-5, was created for this purpose and allows employees/physicians to send a note of thanks or congratulations to a fellow co-worker. The employee/physician wishing to send this type of recognition simply needs to log on to uconnect, find their co-worker in the online directory, and select the Hi-5 tool. Both the co-worker and the co-worker’s manager (via carbon copy) will receive an email which, upon opening, reveals the Hi-5 note.

Thanks For Caring Recognition Program Thanks for Caring is a recognition program is designed to reward UWMF staff who exemplify behaviors guided by one or more of our UW Health Values with on-the-spot recognition. UWMF managers have access to this recognition program and can reward employees with a Thanks For caring branded thank you card and/or small gift.

Domestic Partner UWMF seeks to promote acceptance of diversity in all dimensions. In light of this goal, the benefit provided to domestic partners, both same and opposite-sex, are the same benefits provided to spouses of legally married employees.

Registration of a domestic partnership is not required to take advantage of Human Resources policy provisions with the exception of benefits. Please see Human resources for additional information.

Baby Day You are eligible for one paid holiday based on your scheduled FTE for the birth or adoption of your child.

Employee Assistance Program Effective immediately upon employment, all employees are eligible to use Employee Assistance Program. EAP is designed to be a confidential source of information and assistance to help employees and their families find solutions to personal problems that may affect their health, family, or job. For more information:

Phone: 1-800-362-3902, ext. 1310 Or visit www.eapheitzingerandassoc.com

Holidays The following paid holidays, based on eligibility and scheduled FTE, are effective immediately upon hire. Please review this year’s holiday schedule regarding when UWMF will observe these holidays. Note: Some locations may be open on these holidays.

New Year’s Day Memorial Day Independence Day Labor Day Thanksgiving Day Christmas Eve Christmas Day

Bus Passes UWMF provides a subsidized bus pass to its employees, good for unlimited rides throughout the month. If you work at least a 0.2 FTE and use Madison Metro Transit System as your only means of transportation, you are eligible for a subsidized bus pass. Visit uconnect for additional information. Employees are responsible to pay 50% of the total cost and UWMF pays 50%. This fee will be taken as a payroll deduction.

Learning & Development Services Are you interested in learning, developing your skills, and expanding your knowledge? Would you enjoy meeting other UWMF employees and hearing new perspectives? Our service offerings are continuously expanding to include learning sessions and a resource library covering a variety of topics including team and individual development, computer/technical skills, supervisory or management development, tools for new employees, and organizational learning. You are eligible immediately. Session attendance is paid time and requires supervisor approval. To explore the learning opportunities available to you, visit uconnect or call 608-821-4882. Visit uconnect often, as it is continuously being updated.

Tuition Reimbursement If you have completed one year of service and work 20 hours or more per week, you have the option to request reimbursement of tuition costs. Up to $2,500 per calendar year will be reimbursed upon satisfactorily completing eligible courses through an accredited two-year or four-year college. You must be in good performance standing and approved for reimbursement in advance. Visit uconnect for more information.

Corporate Discounts UWMF offers a wide variety of discounts to area vendors such as restaurants, fitness clubs, car care facilities & Wisconsin Dells. Visit the uconnect home page to view all of the corporate discounts available and request coupons.

Executive Benefit Summary 2015

Please note this is a summary only. Any conflict between the summary and the contracts will be determined by the contract.

Care.com Care.com is the largest and fastest growing service for people to get connected with providers for child care, senior care, pet care, housekeeping, tutoring and more!

Care.com provides pre-screened profiles of providers, monitored messaging, and access to background checks, recorded references, and educational information on interviewing process.

There is no cost to join as UWMF pays the membership fee, you are responsible for covering costs of care providers you may hire. Visit uconnect for additional information on how it can assist you in managing your career and personal responsibilities. Sign up by going to Care.com/uwhealth. You will need to use your computer login username (abc123) as your unique ID

Retirement

401(k) Plan

You are eligible to participate in the 401(k) plan beginning the first of the month following one month of employment. Once eligible, UWMF will automatically withhold four percent (4%) of your gross wage to be deposited to your UWMF 401(k)/Profit Sharing Plan. You have the option to either accept this automatic enrollment or “opt out” of the automatic enrollment option by electing a different deferral percentage. No action is needed if you accept the automatic enrollment option. If you wish to opt out of the automatic enrollment option, you may change your deferral percentage via Employee Self Service through the Fidelity website: www.fidelity.com/atwork. You may defer up to 50% of pre-tax wages (if you wish to defer more, please contact Human Resources for approval), up to the annual IRS maximum contribution limit. Participants who are age 50 or older by the end of the plan year may defer up to the IRS limit. This portion of the plan is subject to IRS regulations and may change in future plan years. Vesting is immediate.

Profit Sharing

You are automatically enrolled for the Profit Sharing Contribution the first of the month following one year of employment and the completion of 1,000 hours of service during that year of employment. This is your Profit Sharing Eligibility Date. Employer contributions are made on a yearly basis and are 8% of gross annual wages, with an additional discretionary 0-2%. Your first profit sharing contribution will be calculated using your gross wages earned from your eligibility date through the end of that calendar year. Subsequent contributions will be calculated using the full calendar year, provided you work 1,000 hours or more during that time and are actively employed on December 31. Vesting is 100% after three calendar years with 1,000 hours of service in each year.

Wellness Program UW Health’s Wellness Options at Work Program offers and promotes activities, education and resources to all UW Health faculty and staff, and supports them in changing behaviors and making healthier choices. The program’s activities and educational resources offer to help to manage stress, refrain from tobacco use, increase physical activity, reach and maintain a healthy weight, manage alcohol and drug addictions, maintain good nutrition and improve general health.

Visit uconnect for information on current programs and resources.

Non-Physician Referral Program UWMF eligible employees who refer a candidate for a position within UWMF are now eligible to receive either $100 (for non difficult to recruit positions) or $250 (for difficult to recruit positions). A Referral Request Form must be filled out prior to or within seven days of the candidate applying to UWMF. Both the referring and new employee must be employed six months following the date of hire of the new employee. A referral is valid for six months - the referred candidate must begin employment with UWMF within six months of the time of the referral. Visit uconnect for more information.

Note: UW Health physicians and executives, UWMF temporary employees, Human Resources staff, and staff from career placement and staffing offices are not eligible. Supervisory or management staff are not eligible when hiring in their department.

LifeLock

LifeLock works to safeguard your identity 24 hours a day 7 days a week. If you become a victim of identity theft, LifeLock will spend up to $1 million to hire experts, lawyers, investigators, consultants and whoever else it takes to help your recovery. Deductions will be taken after taxes (post-tax) each pay-period.

Plan Option LifeLock Identity

Theft Protection

LifeLock Ultimate

Employee Only $4.25 $10.63

Employee + Spouse/DP $8.50 $21.25

Employee + Children $7.45 $15.41

Employee + Family $11.70 $26.03

Program details:

1. Employees who participate in the HRA will receive a $60 per month reduction in their health insurance premiums (at any level of coverage). Please reference the 2015 Health Insurance rate document for further information.

2. Employees who chose to take the HRA rates will be charged the discounted rate for 2015 health insurance premiums. Employees who choose not to take the HRA will be charged the standard rate for 2015 health insurance premiums.

3. Employees eligible for the health insurance buy back are asked to complete the HRA and biometrics to be eligible for 2015 payment (paid February, 2016).

4. Employees who are not eligible for health insurance, but who participate in the HRA, will receive a $100 incentive to be paid on the second paycheck in February, 2016.

For questions, please contact a member of the UWMF

benefits team:

Kyle Gosdeck (608/821-4925)

Carrie Cichy-Krantz (608/821-4159)

Kathi Skemp (608/821-4161)

Troy Schuhmacher (608/821-4156)

Sara Broge (608/821-4891)

Health Risk Assessments

(HRA) Our 2015 health insurance program reflects our commitment to a healthy workforce. All

new employees will be asked to complete a confidential online questionnaire, to undergo

or provide results of health screenings, and will ultimately receive a brief health status

report with analysis. HRA screening and health status report will take place during New

Employee Orientation.

2014 Payroll Schedule

Pay Period Check Date If deduction is semi-monthly, it pays for: 12/29/13 – 1/11/14 1/17/14 January

1/12/14 – 1/25/14 1/31/14 January

1/26/14 – 2/8/14 2/14/14 February

2/09/14 – 2/22/14 02/28/14 February

2/23/14 – 3/8/14 3/14/14 March

3/09/14 – 3/22/14 3/28/14 March

3/23/14 – 4/5/14 4/11/14 April

4/6/14 – 4/19/14 4/25/14 April

4/20/14 – 5/3/14 5/9/14 May

5/4/14 – 5/17/14 5/23/14 May

5/18/14 – 5/31/14 6/6/14 No Deductions

6/1/14 – 6/14/14 6/20/14 June

6/15/14 – 6/28/14 7/3/14 June

6/29/14 – 7/12/14 7/18/14 July

7/13/14 – 7/26/14 8/1/14 July

7/27/14 – 8/09/14 8/15/14 August

8/10/14 – 8/23/14 8/29/14 August

8/24/14 – 9/6/14 9/12/14 September

9/7/14 – 9/20/14 9/26/14 September

9/21/14 – 10/4/14 10/10/14 October

10/5/14 – 10/18/14 10/24/14 October

10/19/14 – 11/1/14 11/7/14 November

11/2/14 – 11/15/14 11/21/14 November

11/16/14 – 11/29/14 12/5/14 December

11/30/14 – 12/13/14 12/19/14 December

12/14/14 – 12/27/14 1/2/15 No Deductions

Deduction Schedule Bi-Weekly Deductions: 401(k) Semi-Monthly Deductions: Health Insurance, Dental Insurance, Supplemental Life, LTD, STD, Flexible Spending Monthly Deductions: Bus Pass, Dependent Life Insurance, Group Term Life, Parking

2015 Payroll Schedule

Pay Period Check Date If deduction is semi-monthly, it pays for:

12/14/2014 – 12/27/2014 1/2/2015 No Deductions

12/28/2014 – 1/10/2015 1/16/2015 January

1/11/2015 – 1/24/2015 1/30/2015 January

1/25/2015 – 2/7/2015 2/13/2015 February

2/8/2015 – 2/21/2015 2/27/2015 February

2/22/2015 – 3/7/2015 3/13/2015 March

3/8/2015 – 3/21/2015 3/27/2015 March

3/22/2015 – 4/4/2015 4/10/2015 April

4/5/2015 – 4/18/2015 4/24/2015 April

4/19/2015 – 5/2/2015 5/8/2015 May

5/3/2015 – 5/16/2015 5/22/2015 May

5/17/2015 – 5/30/2015 6/5/2015 No Deductions

5/31/2015 – 6/13/2015 6/19/2015 June

6/14/2015 – 6/27/2015 7/3/2015 June

6/28/2015 – 7/11/2015 7/17/2015 July

7/12/2015 – 7/25/2015 7/31/2015 July

7/26/2015 – 8/8/2015 8/14/2015 August

8/9/2015 – 8/22/2015 8/28/2015 August

8/23/2015 – 9/5/2015 9/11/2015 September

9/6/2015 – 9/19/2015 9/25/2015 September

9/20/2015 – 10/3/2015 10/9/2015 October

10/4/2015 – 10/17/2015 10/23/2015 October

10/18/2015 – 10/31/2015 11/6/2015 November

11/1/2015 – 11/14/2015 11/20/2015 November

11/15/2015 – 11/28/2015 12/4/2015 December

11/29/2015 – 12/12/2015 12/18/2015 December

12/13/2015 – 12/26/2015 12/31/2015 No Deductions

Deduction Schedule Bi-Weekly Deductions: 401(k)

Semi-Monthly Deductions: Health Insurance, Dental Insurance, Supplemental Life, LTD, STD

Flexible Spending, Lifelock, Parking

Monthly Deductions: Bus Pass, Dependent Life Insurance, Group Term Life

2014 Holiday Schedule

Holiday Date Celebrated

New Year’s Day Wednesday, January 1, 2014 Same Day

Memorial Day Monday, May 26, 2014 Same Day

Independence Day Friday, July 4, 2014 Same Day

Labor Day Monday, September 1, 2014 Same Day

Thanksgiving Day Thursday, November 27, 2014 Same Day

Christmas Eve Wednesday, December 24, 2014 Same Day

Christmas Day Thursday, December 25, 2014 Same Day

New Year’s Day Thursday, January 1, 2015 Same Day

Note: The half day holiday historically given for each Christmas Eve and New Year’s Eve Day were combined to allow a full day on Christmas Eve. New Year’s Eve Day will be a scheduled business day.

Name: _________________________________________

DOH: _____________

FTE: _____________

Regular / Temporary

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You are eligible for Full-Time Employee benefits. Please see the Employee Benefit Summary for details.

W-4 (Federal Tax Withholding)

WT-4 (State Tax Withholding)

Direct Deposit Form – please attach a voided check

__________________________________________________________________________________

Federal I-9 (Employment Eligibility Verification) and Appropriate Forms of Identification (Note: If you begin employment before attending new employee orientation, please present the Federal I-9

form and identification to your supervisor for completion of Section 2 on your first day of employment.)

You must bring your ID acceptable for completion of the I-9 to orientation! Please refer to the back of the document for a list of acceptable documents.

Employee Set-Up Form

For coordination of benefits, are you currently enrolled on a UWMF benefit plan (health, dental, flex spending, life insurance) through a spouse, Domestic Partner or other family member? Yes ______ No ______

Health Insurance Enrollment Form (Unity application*) – Waiver form if applicable Dental Insurance Enrollment Form (Delta application*) – Waiver form if applicable Supplemental Life / AD&D Insurance Enrollment Form* Life Insurance & LTD Group Enrollment Form Dependent Life Insurance Enrollment Form* LTD Pre/Post Tax Option Form Flexible Spending Account- Health Care/Dependent Care Enrollment Form*

Life Lock Identity Theft Protection Retirement Beneficiary Form (in the back of the Fidelity booklet) License or Certification, if applicable Please Note: Forms with (*) must be signed and dated whether enrolling or declining benefit!

**IMPORTANT: Please be prompt to all orientations!

Please bring the following completed forms with you to new employee orientation!

7974 UW Health Court 608.821.4164 Employee Set-Up Form

Middleton, WI 53562 608.821.4151 FAX www.uwhealth.org

We are an Equal Employment Opportunity, Affirmative Action employer that values diversity. Minorities, females, veterans and individuals with disabilities are strongly encouraged to apply.

Employee Information Employee Name Last First Middle Initial

Address Street City State Zip

Home Phone # Birth Date Social Security Number

Office Phone # Cell Phone #

UWMF Email (if known) Work Cell Phone # (if known)

Gender: Male____________ Ethnic Category: _____Caucasian _____American Indian or Alaskan Native _____African American

Female__________ _____Hispanic or Latino _____Asian _____Native Hawaiian or Pacific Islander

_____Two or more races (not Hispanic or Latino)

A disabled individual is defined as an individual who has a mental or physical impairment which substantially limits one or more major life activities, has a record of such impairment, or who is perceived as having such impairment. Do you consider yourself disabled? Yes_____ No_____ If so, please explain__________________________________________________________________________________________________________________

Emergency Contact Name

Address

City State________________ Zip_____________________________

Emergency Telephone and Type Relationship

Alternate Telephone and Type ___________________________________________________________________________________________________________________________

Alternate Telephone and Type ___________________________________________________________________________________________________________________________

Invitation to Self-Identify Veteran University of Wisconsin Medical Foundation (UWMF) is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows: A “disabled veteran” is one of the following:

A veteran of the US military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay

would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs; or

A person who was discharged or released from active duty in the U.S. military, ground, naval, or air service.

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the US military, ground, nava l or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the US military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Protected Veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll free, at 1-866-4-USA-DOL.

Continued

Self Identification As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. I belong to the following classifications of protected veterans (choose all that apply):

Disabled veteran

Recently separated veteran

Active wartime or campaign badge veteran

Armed forces service medal veteran

I am a protected veteran but I choose not to self-identify the classifications to which I belong.

I am NOT a protected veteran.

If you a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

For Human Resources Use Only

Employee ID Number________________ Site of Service__________________________ Department/Specialty_______________________________ Position Title_____________________________________

Position Code______________________________ FTE__________________________ Status: FT_____________ PT_____________ LH_____________ On-Call_____________ Temp_____________

Supervisor_______________________________ Account # ___ ___ / ___ / ___ ___ ___ / ___ ___ ___ ___ ___ / ___ ___ ___ ___ / ___ / ___ ___ ___ ___ ___ Revised 04/01/14

WT-4

W-204 (R. 11-04) Wisconsin Department of Revenue

Employee’s Wisconsin Withholding Exemption Certificate/New Hire Reporting

Employee’s SectionEmployee’s Name (last, first, middle initial Social Security Number Date of Birth

Employee’s address (number and street) City State Zip Code

Date of HireSingle Married Married, but withhold at higher Single rate. Note: If married, but legally separated, check the Single box.

FIGURE YOUR TOTAL WITHHOLDING EXEMPTIONS BELOWComplete Lines 1 through 3 only if your Wisconsin exemptions are different than your federal allowances.

1. (a) Exemption for yourself – enter 1 .........................................................................................................

(b) Exemption for your spouse – enter 1 .................................................................................................

(c) Exemption(s) for dependent(s) – you are entitled to claim an exemption for each dependent .......

(d) Total – add lines (a) through (c) ..........................................................................................................

2. Additional amount per pay period you want deducted (if your employer agrees) ....................................

3. I claim complete exemption from withholding (see instructions). Enter “Exempt” ..................................

I CERTIFY that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. If claiming complete exemption fromwithholding, I certify that I incurred no liability for Wisconsin income tax for last year and that I anticipate that I will incur no liability for Wisconsin income tax for this year.

Signature Date Signed ,

EMPLOYEE INSTRUCTIONS:• WHO MUST FILE:

Every Employee is required to file a completed Form WT-4 with each of his or heremployers unless the Employee claims the same number of withholding exemp-tions for Wisconsin withholding tax purpose as for federal withholding tax purpose.Form WT-4 (or federal Form W-4 if a Form WT-4 is not filed) will be used by youremployer to determine the amount of Wisconsin income tax to be withheld fromyour paychecks. If you have more than one employer, you should claim a smallernumber or no exemptions on each Form WT-4 filed with employers other thanyour principal employer so that the total amount withheld will be closer to youractual income tax liability.

Your employer may also require you to complete this form to report your hiring tothe Department of Workforce Development.

You may file a new Form WT-4 any time you wish to change the amount of with-holding from your paychecks, providing the number of exemptions you claim doesnot exceed the number you are entitled to claim.

• UNDER WITHHOLDING:If sufficient tax is not withheld from your wages, you may incur additional interestcharges under the tax laws. In general, 90% of the net tax shown on your incometax return should be withheld.

• OVER WITHHOLDING:If you are using Form WT-4 to claim the maximum number of exemptions to whichyou are entitled and your withholding exceeds your expected income tax liability,you may use Form WT-4A to minimize the over withholding.

• WHEN TO FILE IF YOUR EXEMPTIONS CHANGE:You must file a new certificate within 10 days if the number of exemptions previouslyclaimed by you DECREASES.

You may file a new certificate at any time if the number of your exemptionsINCREASES.

• HOW TO COMPLETE FORM WT-4Clearly print your full name (last, first, middle initial), address, social securitynumber and date of birth.

Ý• LINE 1:

(a)-(c) Number of exemptions — Do not claim more than the correct number ofexemptions. If you expect to owe more income tax for the year than will be with-held if you claim every exemption to which you are entitled, you may increase yourwithholding by claiming a smaller number of exemptions on lines 1(a)-(c) or youmay enter into an agreement with your employer to have additional amountswithheld (see instruction for line 2).(c) Dependents — Those persons who qualify as your dependents for federalincome tax purposes may also be claimed as dependents for Wisconsin purposes.The term “dependents” does not include you or your spouse. Indicate the numberof dependents that you are claiming in the space provided.

• LINE 2:Additional withholding — If you have claimed “zero” exemptions on line 1, but stillexpect to have a balance due on your tax return for the year, you may wish torequest your employer to withhold an additional amount of tax for each pay period.If your employer agrees to this additional withholding, enter the additional amountyou want deducted from each of your paychecks on line 2.

• LINE 3:Exemption from withholding — You may claim exemption from withholding ofWisconsin income tax if you had no liability for income tax for last year, and youanticipate that you will incur no liability for income tax for this year. You may notclaim exemption if your return shows tax liability before the allowance of any creditfor income tax withheld. If you are exempt, your employer will not withhold Wis-consin income tax from your wages.You must revoke this exemption (1) within 10 days from the time you anticipateyou will incur income tax liability for the year or (2) on or before December 1 if youanticipate you will incur Wisconsin income tax liabilities for the next year. If youwant to stop or are required to revoke this exemption, you must file a new FormWT-4 with your employer showing the number of withholding exemption you areentitled to claim. This certificate for exemption from withholding will expire on April30 of next year unless a new Form WT-4 is filed before that date.

Employer’s SectionEmployer’s Name Federal Employer ID Number

Employer’s payroll address (number and street) City State Zip Code

EMPLOYER INSTRUCTIONS for Department of Revenue:• If you do not have a Federal Employer Identification Number (FEIN), contact the

Internal Revenue Service to obtain a FEIN.

• If the Employee has claimed more than 10 exemptions OR has claimed completeexemption from withholding and earns more than $200.00 a week or is believedto have claimed more exemptions than he or she is entitled to, mail a copy of thiscertificate to: Wisconsin Department of Revenue, Audit Bureau, P.O. Box 8906,Madison, WI 53708 or fax (608)-267-0834.

• Keep a copy of this certificate with your records. If you have questions about theDepartment of Revenue requirements, call (608) 266-8646 or (608) 266-2776.

EMPLOYER INSTRUCTIONS for New Hire Reporting:• This report contains the required information for reporting New Hire to Wisconsin.

Mail the original form to the Department of Workforce Development, NewHire Reporting, PO Box 14431, Madison, WI 53708-0431 or fax toll free to1-800-277-8075.

• If you are reporting New Hires electronically, you do not need to forward a copy ofthis report to Department of Workforce Development.

• If you have questions about New Hire requirements, call toll free (888) 300-HIRE(888-300-4473).

Savings ____ Checking ____

Savings ____ Checking ____

Date: 1234

Sample

$

Financial Institution Name

123456789 1234567 1234

↑ ↑

I authorize UWMF to initiate credit entries to my checking or savings account at the Financial Institution indicated above. The Financial Institution so indicated

is authorized to credit, and if necessary, debit for any credit entries made in error, to the same account. This authority is to remain in full force and effect until

UWMF has received written notification from me of its termination. Notice of its termination shall be made in such time and manner as to afford UWMF

and the Financial Institution a reasonable opportunity to act on it.

Bank Routing Number (9 Digits)

Please be advised: It takes at least one pay period for the Direct Deposit to take

effect. This means that a negotiable check will be issued the first payroll period after

input of a new routing and account number.

Deposit Amount

Net Check ____ or Balance ____

Return this form to: UWMF Payroll Department, ID Mail: 414-FIN, U.S. Mail: P.O. Box 620993, Middleton, WI 53562-0993 , Fax: 821-4288

UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION

Name

Address

City, State Zip

Name of 1st Financial Institution Branch (if applicable)

PAYROLL DIRECT DEPOSIT AUTHORIZATION AGREEMENT

Social Security NumberEmployee Name

HOW TO IDENTIFY YOUR BANK ACCOUNT INFORMATION

Name of 2nd Financial Institution

PLEASE ATTACH A VOIDED CHECK (NOT A DEPOSIT SLIP) TO THIS FORM FOR ACCOUNT VERIFICATION

Account Number

$__________________________

Deposit Amount

Check one of the following: Start _____ Stop _____ Change _____

Bank Routing Number (9 Digits) Account Number

Employee ID

City, State, Zip Type of Account

Routing Number is a 9-digit

number which identifies the

Financial Institution

Account Number may vary in length of digits

and spaces. At the end of the account number,

you will most often find a symbol of two vertical

lines followed by a small solid rectangle. This

may be followed by your check number.

Branch (if applicable)

City, State, Zip Type of Account

Employee Signature Date

 

1 of 7

Coverage Period: 1/1/2015 - 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Single/Family| Plan Type: HMO

Questions: Call 1-800-362-3310 or visit us at www.unityhealth.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.unityhealth.com/glossary or call 1-800-362-3310 to request a copy.

UW MEDICAL FOUNDATION

9081229 - HMO Deductible

Tracking ID: SPUAQ

HMO Deductible SBC

UH01201 (10 13)

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.unityhealth.com or by calling 1-800-362-3310.

Important Questions Answers Why this Matters:

What is the overall deductible?

$250 Single/$500 Family per Benefit Year.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. $6,600 Single/$13,200 Family per Benefit Year.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, penalties for failure to obtain prior authorization, and health care this plan doesn't cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of participating providers in the network, see www.unityhealth.com/findadoctor or call 1-800-362-3310.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

In-Network providers: No. Out-of-Network providers: Yes, written referral is required.

In-Network:You can see the specialist you choose without permission from this plan. Out-of-Network:This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan's permission before you see the specialist.

Are there services this Yes. Some of the services this plan doesn't cover are listed on page 4. See your policy or

2 of 7

plan doesn't cover? plan document for additional information about excluded services.

Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use participating providers by charging you lower deductibles, co-payments and co-insurance amounts.

Common

Medical Event

Services You May

Need

Your cost if you use an Limitations & Exceptions

In Network Provider Out of Network Provider

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$40 co-pay/visit Not Covered

$0 co-pay/visit for dependent children under the age of 26. e-Visits for members under the age of 26 are covered with a $0 co-pay. e-Visits for members age 26 and older are covered with a $25 co-pay.

Specialist visit $40 co-pay/visit Not Covered $0 co-pay/visit for dependent children under the age of 26.

Other practitioner office visit

Chiro/Vision: $40 co-pay/visit Not Covered $0 co-pay/visit for dependent children under the age of 26.

Preventive care/screening/immuni-zation

No Charge Not Covered ---------------none---------------

If you have a test

Diagnostic test (x-ray, blood work)

No Charge Not Covered ---------------none---------------

Imaging (CT/PET scans, MRIs)

0% co-insurance after deductible

Not Covered ---------------none---------------

If you need drugs to treat your illness or condition More information about prescription

Generic drugs Value Tier: $5 co-pay All others: $10 co-pay

Value Tier: $5 co-pay All others: $10 co-pay

---------------none---------------

Preferred brand drugs Value Tier: $5 co-pay All others: $45 co-pay

Value Tier: $5 co-pay All others: $45 co-pay

---------------none---------------

Non-preferred brand drugs

$70 co-pay $70 co-pay ---------------none---------------

3 of 7

Common

Medical Event

Services You May

Need

Your cost if you use an Limitations & Exceptions

In Network Provider Out of Network Provider

drug coverage is available at www.unityhealth.com/drugformulary

Specialty drugs $100 co-pay $100 co-pay ---------------none---------------

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

0% co-insurance after deductible

Not Covered ---------------none---------------

Physician/surgeon fees 0% co-insurance after deductible

Not Covered ---------------none---------------

If you need immediate medical attention

Emergency room services

$100 co-pay/visit $100 co-pay/visit ---------------none---------------

Emergency medical transportation

0% co-insurance after deductible

0% co-insurance after deductible

---------------none---------------

Urgent care $40 co-pay/visit $40 co-pay/visit $0 co-pay/visit for dependent children under the age of 26.

If you have a hospital stay

Facility fee (e.g., hospital room)

0% co-insurance after deductible

Not Covered ---------------none---------------

Physician/surgeon fee 0% co-insurance after deductible

Not Covered ---------------none---------------

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$40 co-pay/visit Not Covered $0 co-pay/visit for dependent children under the age of 26.

Mental/Behavioral health inpatient services

0% co-insurance after deductible

Not Covered ---------------none---------------

Substance use disorder outpatient services

$40 co-pay/visit Not Covered $0 co-pay/visit for dependent children under the age of 26.

Substance use disorder inpatient services

0% co-insurance after deductible

Not Covered ---------------none---------------

If you are pregnant

Prenatal and postnatal care

$40 co-pay/visit Not Covered $0 co-pay/visit for dependent children under the age of 26.

Delivery and all inpatient services

0% co-insurance after deductible

Not Covered ---------------none---------------

4 of 7

Common

Medical Event

Services You May

Need

Your cost if you use an Limitations & Exceptions

In Network Provider Out of Network Provider

If you need help recovering or have other special health needs

Home health care 0% co-insurance after deductible

Not Covered Coverage is limited to 60 visits per Benefit Year.

Rehabilitation services 0% co-insurance after deductible

Not Covered

Coverage for Physical, Speech and Occupational therapy is limited to a combined total of 40 visits per Benefit Year. Cardiac Rehab is limited to 36 visits per event.

Habilitation services Not Covered Not Covered ---------------none---------------

Skilled nursing care 0% co-insurance after deductible

Not Covered Coverage limited to 90 days per confinement.

Durable medical equipment

20% co-insurance Not Covered Coverage for -- Hearing Aids: Limited to one per ear every 36 months.

Hospice service 0% co-insurance after deductible

Not Covered ---------------none---------------

If your child needs dental or eye care

Eye exam No Charge Not Covered $0 co-pay/visit for dependent children under the age of 26.

Glasses Not Covered Not Covered ---------------none---------------

Dental check-up Not Covered Not Covered ---------------none---------------

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture••

Cosmetic surgery

•

Dental care (Adult)

•

Infertility treatment

•Long-term care

•Non-emergency care when traveling outside the U.S.

•Private-duty nursing

•

Routine foot care

Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Chiropractic care • Hearing aids • Routine eye care (Adult)

5 of 7

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-362-3310. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

For questions about your rights, this notice, or for assistance, you can contact: Office of the Commissioner of Insurance, Complaints Department, PO Box 7873, Madison, WI 53707-7873, or if coverage is under a group health plan the Employee Benefits Security Administration at 1-866-444-EBSA (3272).

Does this Coverage Provide Minimum Essential Coverage?

The affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health

coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-362-3310 or 608-643-1421 (TTY). Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-362-3310 or 608-643-1421 (TTY)

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-362-3310 or 608-643-1421 (TTY)

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-362-3310 or 608-643-1421 (TTY)

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

6 of 7

Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $7,540 Plan pays: $6,660 Patient pays: $880

Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $250

Co-pays $600

Co-insurance $0

Limits or exclusions $30

Total $880

Amount owed to providers: $5,400 Plan pays: $4,600 Patient pays: $800

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies

$1,300

Office Visits and Procedures

$700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $0

Co-pays $800

Co-insurance $0

Limits or exclusions $0

Total $800

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

7 of 7

Questions: Call 1-800-362-3310 or visit us at www.unityhealth.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.unityhealth.com/glossary or call 1-800-362-3310 to request a copy.

Tracking ID: SPUAQ

HMO Deductible SBC

UH01201 (10 13)

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

The patient’s condition was not an excluded or preexisting condition.

All services and treatments started and ended in the same coverage period.

There are no other medical expenses for any member covered under this plan.

Out-of-pocket expenses are based only on treating the condition in the example.

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, co-payments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Waiver of Group Health and/or Dental Insurance Coverage I have been given an opportunity to apply for group insurance as offered by the policyholder, and after careful consideration have decided not to take advantage of this offer. I certify that this wavier was signed voluntarily and in no way did anyone coerce or induce me to waive coverage. Elect to decline Group Health Insurance Elect to decline Group Dental Insurance Reason: ____________________________________________________________ __________________________________________________________________ __________________________________________________________________ Should I desire to apply for health and/or dental insurance coverage in the future, I understand my dependents and I may be subject to a waiting period, unless I am applying due to loss of coverage or a qualifying event. I further understand that if I experience a loss of coverage, I may be eligible to enroll my dependents and myself provided that I do so within 30 days after my other coverage ends. If I experience a qualifying event (i.e. new dependent as a result of marriage, birth, or adoption), I may be able to enroll my dependents, and myself provided I request enrollment within 30 days of the date of the event. Failure to request coverage within the required time frame, will result in a delay of coverage for my dependents and myself. ____________________________________ _____________________ Employee Name (Please Print) Social Security Number ____________________________________ _____________________ Employee Signature Date

2015

HMO Health Insurance and

s Dental Insurance Rate

Unity Health Insurance HMO Plan

Coverage

Employee Rate

Monthly Pay Period*

Single $145.00 $72.50

Single-

Discount

$85.00

$42.50

Employee plus 1 dependent $160.00 $80.00

Employee plus 1 dependent- Discount

$100.00

$50.00

Family $170.00 $85.00

Family-

Discount

$110.00

$55.00

Delta Dental Insurance

Coverage

Employee Rate

Monthly Pay Period*

Single $23.22 $11.61

Family $66.00 $33.00

*Please note employees will not receive a deduction on their 1/2/2015, 6/5/2015 or 12/31/2015 paychecks.

UH00674 (rev 08 14)

840 Carolina Street

Sauk City, Wisconsin 53583-1374

(800)-362-3309 Fax (608) 643-2564

www.unityhealth.com

Please Complete Entire Form in BLACK INK.

EMPLOYEE APPLICATION

EMPLOYMENT INFORMATION:

Name of Group/Employer: Hours Worked Per Week:

Employment Status: Active Retired LOA: Requested Effective Date of Coverage:

Date Employed: Plan Requested: HMO POS PPO Other:

Type of Coverage: Employee Employee and Spouse Employee and Child(ren) Family

Reason for Enrollment: New Hire Marriage date (__/__/__) Loss of other Insurance Add a dependent Name Change

EMPLOYEE INFORMATION (Please do not use abbreviations or nicknames on this application)

Applicant’s Last Name First Name MI

Social Security Number

Mailing Address City State Zip Code County

Date of Birth

/ /

Gender

M F

Marital Status:

Single

Married (provide date

and state where marriage

occurred): _______________

_______________________

Divorced

Primary Language Spoken:

English Spanish

Other

Home Phone # ( )

Work Phone # ( )

Cell Phone # ( )

*Primary Care Physician (PCP) and Clinic:

*If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN”

Current

Patient?

Y N

Applicant’s E-Mail Address:

APPLICANT INFORMATION – Please list all other Members to be covered:

Dependent Name

(Last, First, MI)

Mailing Address if

different than

subscriber.

SSN# Relation

-ship

Date of

Birth

Gender *Clinic and PCP

Name

Current

Patient?

M F Y N

M F Y N

M F Y N

M F Y N

M F Y N

OTHER INSURANCE INFORMATION:

Will you or any of your dependents continue to have other insurance, including Medicare, after the Unity Health Insurance effective

date of this policy? If Yes, complete:

Name(s) of Insured Employer

Insurance Company Subscriber # Group #

Effective Date of Coverage Insurance Company Phone # Do you or any dependents have medical coverage that has ended or will end within 30 days? If Yes, complete:

Carrier Phone # Subscriber #

Effective Date of Coverage Termination Date

Names of those covered under policy:

Are you or a family member currently involved in a Workers Compensation case? Yes No

If Yes, indicate family member involved and start date/accident date:________________-

________________________________________________________________

Workers Compensation Condition:______________________________________________________________________________

___________________________________________________________________________________________________________

Insurance Co Name:__________________________________________________________________________________________

Insurance Co Address:________________________________________________________________________________________

UH00674 (rev 08 14)

(where claim is sent) ________________________________________________________________________________________

Insurance Co Phone:_________________________________________________________________________________________

Group#:____________________________________________________________________________________________________

Effective Date:________________________________________Term Date (if applicable):_________________________________

WAIVER of GROUP COVERAGE:

I elect not to apply for the Group Health Benefit Plan coverage: Employee Spouse Children

Reason for waiving coverage: (please see back of form for additional information)

I/we will be covered by a health benefit plan which provides similar benefits. Name of Insurance Co.:_______________________

I/we will be enrolled in a similar health benefit plan offered by my employer. Name of Insurance Co.:_______________________

The annualized premium contribution to be paid by me for Unity would exceed 10% of my annualized gross earnings.

Other _______________________________________________________________.

I understand that enrollment and/or eligibility for benefits may be conditioned upon my willingness to provide written authorization permitting Unity to obtain medical records from health care providers who have treated me, my spouse or any dependents applying for coverage under this application. If medical records are needed, Unity will provide me with an authorization form. To the best of my knowledge, all statements and answers in this application are complete and true. I understand that any misstatement or omission may result in denial of a claim and/or rescission of coverage.

Date: Employee Signature:

Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents' other coverage). However, you must request enrollment within 31 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

New Health Insurance Marketplace Coverage Options

General Information

When key parts of the health care law take effect in 2014, there will be a new way for you to buy health insurance:the Health Insurance Marketplace. To assist you as you look at options for you and your family, this noticeprovides some basic information about the new Marketplace and the employment based coverage offered to you.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find private health insurance that meets your needs and fits your budget.The Marketplace offers “one-stop shopping” to find and compare private health insurance options. You may alsobe eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for privatehealth insurance coverage through the Marketplace begins in October 2013 for coverage starting as early asJanuary 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offercoverage, or offers coverage that doesn’t meet certain standards. The savings on your premium that you areeligible for depends on your household income.

Does the Health Insurance We Offer to You Affect Your Eligibility for Premium SavingsThrough the Marketplace?

Yes. If we have offered you health coverage that meets certain standards, you will not be eligible for a tax creditthrough the Marketplace and may wish to enroll in our health plan. However, you may be eligible for a tax creditthat lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverageto you at all or does not offer coverage that meets certain standards. If the cost of self-only coverage under ourhealth plan is more than 9.5% of your household income for the year, or if our health plan does not meet the"minimum value"

1standard set by the Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through the Marketplace instead of accepting our health plan coverage, thenyou may lose our contribution (if any) to your coverage under our health plan. Also, our contribution—as well asyour employee contribution—is often excluded from income for Federal and State income tax purposes. Yourpayments for coverage through the Marketplace are made on an after— tax basis.

How Can I Get More Information About the Marketplace?

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through themarketplace and its cost. You can visit HealthCare.gov for more information, including an online application for

health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the

plan is no less than 60 percent of such costs.

Information About the Health Coverage Offered by Your Employer

If you complete an application for coverage through the Marketplace, you will be asked for information about our

health plan. The information below will help you complete an application for coverage in the Marketplace.

You may also be asked whether or not you are currently eligible for our health plan or whether you willbecome eligible within the next three months. In addition, if you are or will become eligible, you may berequired to list the names of your dependents that are eligible for coverage under our health plan.

If you would like information about the eligibility requirements for our health plan, please read theeligibility provisions described in the Summary Plan Description for our health plan. You can obtain a copyof the Summary Plan Description by contacting your Employer at the phone and/or email listed above.

If you are eligible for coverage under our health plan, you may be required to check a box indicatingwhether or not our health plan meets the minimum value standard. Our health plan coverage meets theminimum value standard.

If you are eligible for coverage under our health plan, you may be asked to provide the amount ofpremiums you must pay for self-only coverage under the lowest-cost health plan that meets the minimumvalue standard. If you had the opportunity to receive a premium discount for any tobacco cessationprogram, you must enter the premium you would pay if you received the maximum discount possible fora tobacco cessation program.

If you would like information about the premiums for self-only coverage under our lowest-cost healthplan, please contact your Employer at the phone and/or email listed above.

You may also be asked whether or not we will be making certain changes to our health plan coverage forthe new plan year. As usual, we will notify you about changes to our health plan coverage after weapprove any such changes and inform employees about those changes at the appropriate time. If you arenot sure how to answer this question on your Marketplace application, please contact the Marketplace.

Employer Name:

Employer Identification Number (EIN):

Employer Address:

Employer Phone Number:

Who can we contact about employee health coverage at this job? Phone Number (ifdifferent from above):

E-mail address:

UW MEDICAL FOUNDATION POLICIES AND PROCEDURES

Human Resources

Domestic Partner Statement and Policy

Effective Date: 11/05/08

Supersedes Policy Date: 1/1/06

PURPOSE:

University of Wisconsin Medical Foundation (UWMF) seeks to promote acceptance of

diversity in all its dimensions. In light of this goal, the benefits provided to domestic

partners are the same benefits as provided to spouses of legally married employees.

Registration of a domestic partnership is not required in order to take advantage of Human

Resources policy provisions, with the exception of benefits.

POLICY:

Domestic partners are defined by UWMF as persons who:

• Are at least 18 years of age.

• Are competent to contract at the time the domestic partnership statement is

completed.

• Are not legally married to any person and not related in any way that would

prohibit marriage in our state of operation.

• Are each other’s sole domestic partner.

• Share permanent residence.

• Domestic partners must have at least three of the following:

- Joint lease, mortgage, or deed

- Joint ownership of vehicle

- Joint ownership of a checking account or credit account

- Designation of the domestic partner as beneficiary for the employee’s life

insurance or retirement benefits

- Shared household expenses (i.e. bills, etc).

• Neither the domestic partner nor the UWMF employee has entered into the

relationship for the purpose of obtaining health care.

UWMF reserves the right to require documentation of the above criteria before

authorizing coverage of the domestic partner.

Registration of a domestic partnership will be required for coverage under the group

health, dental, survivor income benefit for long-term disability, and dependent and

supplemental life insurance benefits.

• An employee who wishes to register a domestic partnership needs to

contact the Human Resources Department for information and the

registration form. Upon receiving a properly completed form, Human

Resources will consider the partnership registered as of the date on the

signature on the form.

• Children of domestic partners are eligible for benefits under the same

conditions as are the children of employees’ legal spouses.

• Enrollment of domestic partners and eligible dependent children is subject to

the same rules as enrollment of other dependents.

• Domestic partners and their enrolled dependents receive the same or

equivalent benefits as spouses and their enrolled dependents receive for

group continuation health coverage through COBRA and/or individual

conversion.

• An employee may terminate a domestic partnership by notifying Human

Resources in writing of the termination of the domestic partnership within

thirty days of its termination. (The same guideline exists for married couples

that divorce.) The employee must then wait six months from the date of the

notice before registering another domestic partnership, except in either of

the following cases:

- The employee is registering the same domestic partnership within thirty

days notification of the termination of that domestic partnership, or

- The employee’s former domestic partnership was dissolved through the

death of the employee’s domestic partner.

Eligibility: To be eligible for coverage as a domestic partner, the employee and the

domestic partner must complete and file with Human Resources department the “Domestic

Partnership Affidavit.”

Enrollment: In order to insure a domestic partner, the employee may enroll that individual

with the Human Resources department during the annual enrollment period. This is done

by completing the Domestic Partnership Affidavit. This Affidavit needs to be filed once per

year– employees do not need to complete one affidavit per benefit. It is the employee’s

responsibility to notify Human Resources if a domestic partner relationship ends. A new

Affidavit would have to be filed if another relationship comes into existence in the future and

the employee could enroll their domestic partner during the annual enrollment period.

The tax consequences of a domestic partnership are the responsibility of the employee,

not UWMF. Under the Internal Revenue Code, an employee is not taxed on the value of

benefits provided by an employer to an employee’s spouse or dependent. However, the

IRS has ruled that a domestic partner does not qualify as a spouse.

The value of benefits provided to an employee’s domestic partner (and the domestic

partner’s eligible children) is considered part of the employee’s taxable income, unless

the employee’s domestic partner qualifies as a dependent under Section 152 of the

Internal Revenue Code. UWMF will treat the value of the benefits provided to the

employee’s domestic partner (and the domestic partner’s eligible children) as part of the

employee’s income and will withhold the taxes on the value of those benefits from the

employee’s paychecks. If the employee’s domestic partner qualifies as a dependent under

Section 125 of the Internal Revenue Code, the employee may file the proper

documentation with the IRS and seek a refund for taxes withheld.

Some courts have recognized non-marriage relationships as the equivalent of marriage for

the purpose of establishing and dividing community property. A declaration of common

welfare, such as the registration of a domestic partnership, may therefore have legal

implications.

 

2015 Domestic Partnership Affidavit

For Health Insurance, Dental Insurance, Survivor Income Benefit for Long-Term Disability, Dependent Life Insurance, and/or Supplemental Life Insurance

We, , and Name of Employee Name of Domestic Partner Certify that: 1. The effective date of this Domestic Partnership is and that this Domestic Partnership has

been in existence for a period of twelve (12) consecutive months prior to our signature of this Affidavit. 2. We share the common necessities of life. 3. We are not legally married to anyone else. 4. We are at least eighteen (18) years of age or older. 5. We are not related by blood closer than would bar marriage in the state of our residence and are mentally

competent to consent to contract. 6. We are each other’s sole Domestic Partner and intend to remain so indefinitely and are responsible for our common

welfare. 7. Domestic partners must have at least three of the following:

Joint ownership or common leasehold in a residence; Joint ownership of motor vehicle; Joint ownership of a checking account or credit account; Designation of the domestic partner as beneficiary for the employee’s life insurance or retirement benefits Shared household expenses.

8. Neither the domestic partner nor the UWMF employee has entered into the relationship for the purpose of obtaining insurance coverage.

9. We understand that any person, employer, or company who suffers any loss because of false statements contained

in a “Domestic Partnership Affidavit” may bring a civil action against us to recover the losses, including reasonable attorney fees.

10. We understand the information in this affidavit will be used by the Employer for the sole purpose of determining our

eligibility for Domestic Partnership benefits. We further understand that this information will be held confidential and will be subject to disclosure only upon our expressed written authorization or pursuant to a court order.

11. We affirm, under penalty of perjury, that the statements in this Affidavit are true and correct to the best of our

knowledge.

12. (If applicable) I am part of a same sex marriage and was married in the State of _______________________ which recognizes same sex marriage.

Signature of Employee Signature of Domestic Partner

Employee’s Social Security Number Domestic Partner’s SSN

Employee’s Date of Birth Domestic Partner’s Date of Birth

Date Date

Declaration of Tax Status Form Employees: Return completed form inter-department mail to 414-HR or fax to 608-821-4151

UWMF Human Resources to Complete: PS Entry Completed By: ___________________ Date of Entry: ______________

This form is only completed if you are enrolling your Domestic Partner (DP), Qualifying Child (with a disability) or Qualifying Relative in medical and/or dental coverage. The Affordable Care Act requires group health plans to provide dependent medical coverage of children up to the age of 26. UWMF also offers a dental plan which covers unmarried dependents up to the age of 25. This form does not get completed in these cases.

The University of Wisconsin Medical Foundation (UWMF) offers health and dental coverage to qualified domestic partners, qualified adult child(ren) or relative(s). Qualified child(ren) or relatives are typically an adult the employee has guardianship over due to permanent and total disability, including children over the age of 25. Please see Human Resources if this situation may apply to you. To ensure proper taxation of the cost of health and dental insurance applicable to the Domestic Partner or qualified adult, UWMF must know the Federal and/or State tax status of these individuals. The tax status of these family members doesn’t affect their eligibility for coverage, but does affect whether you (the subscriber) will be taxed on the value of their health coverage.

Section 1: Determining Dependent’s Federal and/or State Tax Status

Complete and return this form to declare whether your Domestic Partner or Other Qualifying Relative qualifies as an Internal Revenue Code (IRC) Section 152 dependent. Please apply the following tests to each dependent to determine their Federal and/or State Tax Status. Note that the individual(s) has to pass Test A OR Test B in order to qualify as an IRC Section 152 dependent. We recommend that you consult your tax advisor if you have questions about your specific circumstances. Note: If applicable, domestic partner coverage is subject to State and Federal Taxes.

TEST A: Qualifying Child TEST B: Qualifying Relative

IRC requires a qualifying child meet all of the following tests to qualify as your tax dependent: 1. The child must be your son, daughter, stepchild, foster child, brother, sister, half-sibling, step-sibling, or a descendant of any of them.

2. The child must be (a) under age 19 at the end of the year and younger than you (or your spouse, if filing jointly), (b) under age 24 at the end of the year, a FT student and younger than you (or your spouse, if filing jointly), or (c) any age if permanently and totally disabled. 3. The child must have lived with you for more than half the year (exceptions exist). 4. The child must not have provided more than half of his or her own support for the year. 5. The child is not filing a joint return for the year (unless that return is filed only as a claim for refund). 6. If the child meets the rules to be a qualifying child of more than one person, only one person can actually treat the child as a qualifying child. 7. Special rule for disabled: In the case of an individual who is permanently and totally disabled, as defined in section 22 (e)(3) which states an individual is permanently and totally disabled if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. An individual shall not be considered to be permanently and totally disabled unless he furnishes proof of the existence thereof in such form and manner, and at such times, as may be required.

OR

The IRC requires that a qualifying relative meet all of the following tests to qualify as your tax dependent:

1. The person cannot be your qualifying child or the qualifying child of any other taxpayer. 2. The person either (a) must be related to you in one of the ways listed under ‘Relatives

who do not live with you’, or (b) must live with you all year as a member of your household (and your relationship must not violate the law).

3. The person’s gross income for the year must be less than $3,700 (there is an exception if the person is disabled and has income from a sheltered workshop.

4. You must provide more than half of the person’s total support for the year (There are exceptions for multiple support agreements, children of divorced or separated parents or parents who live apart, and kidnapped children).

Additional information can be found at www.irs.gov/publications/p17/ch03.html

Section 2: Dependent Tax Status Information With the exception of your spouse, list the individuals over the age of 18 that you wish to enroll as a Qualifying Child or Qualifying Relative (including Domestic Partner, and indicate whether they qualify as your Federal and/or State tax dependent.

Qualifying Child or Relative Name Date of Birth SSN Relationship to Employee Federal and/or State Tax Status

I am part of a same sex marriage and was married in a state that recognizes same sex marriage.

Yes, this person qualifies as my IRC Section 152 dependent No, this person does not qualify as my IRC Section 152

dependent. Federal &/or State taxes will be applied to the cost of their coverage.

I am part of a same sex marriage and was married in a state that recognizes same sex marriage. Yes, this person qualifies as my IRC Section 152 dependent

No, this person does not qualify as my IRC Section 152 dependent. Federal &/or State taxes will be applied to the cost of their coverage.

Section 3: Signature - Required

I declare that the information I have provided is true, complete and correct. If it is not, or if I do not update this information within the timeliness in UWMF rules, I must repay any premiums that have been paid on my behalf. I understand that knowingly providing false, incomplete, or misleading information to UWMF for the purpose of defrauding the company will result in appropriate discipline. I understand that:

This declaration of responsibility may have legal implications under Federal and/or State law.

A civil action may be brought against me for any losses, including reasonable attorney’s fees, if I have made a false statement in this declaration.

I must notify UWMF human resources if there is a change in my domestic partnership or dependent status no later than 60 days after the change. Any change in my family status may directly impact the calculation of my taxable income.

UWMF’s Privacy Notice: We will keep your information private as allowed by law.

Employee’s printed name ____________________________________________________________ Employee ID_________________

Employee’s Signature _______________________________________________________________ Date________________________

Your Dental Benefits

Specially Prepared for the Employees ofU W Medical Foundation

The summary below does not cover all plan details. Further information can be found in the summary plan description or dental benefit handbook. That document provides a thorough explanation of your dental plan, including any limitations or exclusions that might apply. If there are any discrepancies between information found here and the group contract, the group contract shall govern.

Benefit Plan DesignDelta Dental

PPODelta Dental

PremierWhen you see a When you see a

Delta Dental Delta Dental PremierPPO dentist or any other dentist

Individual Annual Maximum $1,200 $1,200

Deductible Individual $50 $50

Family $100 $100

Dependent EligibilityDependents are eligible through the end of the month in which they attain age 25 and full-time students through the end of the month in which they attain age 25; except as noted for orthodontics

Diagnostic & Preventive Services Exams 100% 100% Cleanings 100% 100% Fluoride treatments 100% 100% X-rays 100% 100% Sealants 100% 100% Space maintainers 100% 100% Deductible applies No No

Basic & Major Services Emergency treatment to relieve pain 100% 100% Fillings 100% 100% Endodontics – nonsurgical 100% 100% Endodontics – surgical 100% 100% Periodontics – nonsurgical 100% 100% Periodontics – surgical 100% 100% Extractions - nonsurgical 100% 100% Extractions - surgical and other oral surgery 100% 100% Crowns, inlays, onlays 80% 80% Bridges and dentures 80% 80% Repairs and adjustments to bridges and dentures 80% 80% Implants 80% 80% Deductible applies Yes Yes

Orthodontic Services Coverage copayment 50% 50% Individual lifetime maximum $2,000 $2,000 Dependents eligible to age 25 25 Full-time students eligible to age 25 25 Adult ortho Yes Yes Deductible applies No No

Special Plan Provisions (see following pages for more information) Evidence-Based Integrated Care Plan Yes Yes

Specially prepared for the employees of U W Medical Foundation

A Better PPO from Delta Dental

Delta Dental is the nation’s largest and oldest dental-benefits specialist built on the guiding principle that dental benefits should be simple and hassle-free. Delta Dental of Wisconsin was founded in 1962 with the same goal. Combined, member companies of the Delta Dental Plans Association serve more than 59 million people in nearly 97,000 groups nationwide.

With some PPO plans, you don’t get much choice of providers. And if you go out of network, your provider may balance-bill you. But your Delta Dental PPO plan is different. The Delta Dental PPO network, with more than 165,000 dentist locations nationwide, is backed by the Delta Dental Premier network, with more than 247,000 dentist locations nationwide – almost 80% of the nation’s dentists. Your lowest out-of-pocket costs come from seeing a Delta Dental PPO dentist, but you’ll also enjoy cost advantages if you see a Delta Dental Premier dentist. That means savings on out-of-pocket costs and better choice. Here’s an example:

PPO Savings, With A “Safety Net” Delta Dental PPO Dentist

Delta Dental Premier Dentist

Out-of-Network Dentist

Dentist’s Normal Fee $720 $720 $720

Allowed Amount $590 $680 $680

Dentist Fee Adjustment Due to Delta Dental Agreement

$130 $40 None

50% Benefit Paid by Plan $295 $340 $340

Patient Responsibility $295 $340 $380

Advantages of Delta Dental Network Dentists

Noncontracted Dentists

Delta Dental Premier Network Dentists

Delta Dental PPO Network Dentists

Agreed-to fee ceilings (no balance-billing): Dentist agrees to fee ceilings. If his/her normal charge is higher than the fee ceiling, he/she can’t pass the balance on to you.

Additional fee schedule savings: Dentist agrees to a reduced fee schedule. Saves out-of-pocket expenses for you.

Convenient claims processing: Dentist is required to file claims on your behalf, saving you the hassle of doing so yourself. Claims payments go directly to the dentist.

Treatment guarantees: Examples -- Repair or replace dental restorations should they fail within 24 months.

Confirming Your Coverage

If you are not sure of the effective date of your coverage, please call Delta Dental at 800-236-3712 before you have any dental work done.

Also, before scheduling appointments for extensive dental care, you may ask your dentist to send the treatment plan to Delta Dental. The plan will be reviewed by Delta Dental and you and your dentist will receive a Predetermination of Benefits form. You and your dentist may then discuss the treatment and your out-of-pocket costs. Delta Dental encourages you to be informed about your dental care.

Delta Dental’s Websitewww.deltadentalwi.com has a lot to offer. You can use it to obtain coverage information under your plan, check the status of a claim, find a network dentist, evaluate your oral health and learn ways to improve and protect it.

Visit www.deltadentalwi.com for eligibility, claims or dentist information.Also, our Benefit Advisors are available every weekday from 7:30 a.m. to 5 p.m. (Central Time) to answer your questions. Call us at 800-236-3712. We look forward to talking with you!

Specially prepared for the employees of U W Medical Foundation

Special Plan Provisions

Your group dental plan from Delta Dental of Wisconsin includes one or more special features designed to encourage good oral health and promote overall health. Details of these provision(s) are addressed in the policy amendments provided with your dental plan handbook. Below is a brief summary.

Evidence-Based Integrated Care Plan: Expanded benefits for persons with medical conditions that have oral health implications

Delta Dental of Wisconsin’s Evidence-Based Integrated Care Plan (EBICP) option is included in your plan. It provides additional benefits for persons with medical conditions that have oral-health implications. Conditions include:

o Diabeteso Pregnancyo Specific heart conditions that pose a risk of certain types of infectiono Kidney failure or dialysiso Suppressed immune systemo Cancer therapyo Periodontal disease

EBICP’s unique enrollment mechanism requires no medical claims be filed. EBICP requires self-enrollment by the patient or his/her dentist at www.deltadentalwi.com, or by calling

800-236-3712. Learn more at www.deltadentalwi.com/EBICP.

GROUP LIFE AND LTD ENROLLMENT/CHANGE FORM EMPLOYER INFORMATION EMPLOYER’S FULL LEGAL NAME

UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION

GROUP POLICY#

036143

BILL UNIT LOSS UNIT

ENROLLMENT INFORMATION

PLEASE CHECK ONE OF THE FOLLOWING:

INITIAL ENROLLMENT

CHANGE TO EXISTING ENROLLMENT

NAME / ADDRESS CHANGE (FORMER NAME ) BENEFICIARY CHANGE ( LIFE/AD&D OR SUPP LIFE)

COVERAGE CHANGE (ADD DELETE EFFECTIVE DATE )

FAMILY STATUS CHANGE (TYPE EFFECTIVE DATE )

EMPLOYEE INFORMATION EMPLOYEE’S NAME (LAST, FIRST, MIDDLE INITIAL)

DATE OF BIRTH

GENDER

MARITAL STATUS

SOCIAL SECURITY NUMBER

EMPLOYEE’S HOME ADDRESS

CITY / STATE

MARRIAGE DATE

ZIP

SPECIALTY/OCCUPATION

EARNINGS (AS DEFINED BY THE POLICY) YR

# HOURS WORKED PER WEEK

DATE OF HIRE

BENEFICIARY INFORMATION PRIMARY LIFE BENEFICIARY NAME

RELATIONSHIP

DATE OF BIRTH

SOCIAL SECURTIY NUMBER

% OF BENEFIT

PRIMARY LIFE BENEFICIARY NAME

RELATIONSHIP

DATE OF BIRTH

SOCIAL SECURTIY NUMBER

% OF BENEFIT

CONTINGENT LIFE BENEFICIARY NAME

RELATIONSHIP

DATE OF BIRTH

SOCIAL SECURTIY NUMBER

% OF BENEFIT

Note: If additional space is needed, use back of form. Your beneficiary designation can be changed at any time. If you are married and/or divorced and reside in a community property state, you should consult with your legal counsel prior to changing your beneficiary. The designation takes effect as of the date the completed form is received and accepted by The Hartford.

APPLICABLE BENEFIT ELECTIONS Please make your benefit elections by checking the appropriate box. Contact your employer for plan details.

LONG TERM DISABILITY YES NO SUPPLEMENTAL LIFE AND AD&D* YES—$ NO

LIFE AND AD&D* YES NO SUPPLEMENTAL SPOUSE LIFE* YES—$ NO

SPOUSE LIFE YES NO SUPPLEMENTAL CHILD LIFE YES—$ NO

DEPENDENT LIFE YES NO If applicable, the accidental death benefit (AD&D) will equal the face amount of the life insurance elected.

SPOUSE INFORMATION SPOUSE’S NAME

SPOUSE’S GENDER

SPOUSE’S SOCIAL SECURITY NUMBER

SPOUSE’S DATE OF BIRTH

APPLICATION FOR COVERAGE I apply for the group insurance coverage checked above provided under my employer plan. I authorize deductions from my wages to cover my contribution, if required. If I have declined any contributory coverages for which I am eligible above, I understand that to later enroll for these coverages satisfactory medical evidence of insurability will be required and the insurance carrier will have the right to refuse my request. Any person who knowingly, and with the intent to defraud or deceive any insurance company, submits an insurance application containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law.

EMPLOYEE SIGNATURE

DATE

COMPLETE THIS FORM ONLY IF YOU DO NOT LIST YOUR SPOUSE AS PRIMARY BENEFICIARY.

Life Insurance Spousal Consent Form

I, the undersigned spouse of __________________________________________________________________named in the foregoing

(Participant/Employee Name – please print) “Designation of Beneficiary”, hereby certify that I have read the Designation of Beneficiary and fully understand the property subject to the designation is my spouse’s benefit under the Plan, in which I possess a beneficial interest, provided I survive my spouse. Being fully satisfied with the provisions of the designation, I hereby consent to and accept the beneficiary designation, without regard to whether I survive or predecease my spouse. This consent is irrevocable unless my spouse changes the designation. If my spouse changes the designated (choose either a or b)

_____ (a) I understand I must sign a similar consent to agree with any changes in the designation, or my consent is no longer effective; or

_____ (b) I waive my right to withhold my consent to a change in designation. I understand that I do have the right to limit my consent to the specific beneficiary designated on the life insurance or request for change form by checking line (a).

I have executed this consent this _________ day of ________________________________, 20_______. _____________________________________________ Signature of spouse of participant Witness by Plan Representative Signature of spouse for consent witnessed this ______ day of _________________________, 20______. ____________________________________________ Plan Representative

OR Witness by Notary STATE OF ___________

COUNTY OF _________

Before me, as the undersigned Notary Public, personally appeared _________________________________ who executed the above Spousal Consent as a free and voluntary act.

In witness whereof, I have signed my name and affixed by official notarial seal this _______ day of _______________________, 20_______. _____________________________________________ (SEAL) Notary Public My commission expires:__________________________

Note: If you are married and you do not name your spouse as your only primary beneficiary, your spouse’s signature must be notarized on this page. Return completed form to: Human Resources Department UW Medical Foundation 7974 UW Health Court Middleton, WI 53562

NNeeww EEmmppllooyyeeee

Revised 9/2007

Long Term Disability (LTD) Benefit

TTaaxx OOppttiioonn EEnnrroollllmmeenntt FFoorrmm Long Term Disability (LTD) Insurance is provided to UWMF employees with a minimum of 0.75 FTE (30 hours per week or more) and UWMF mid-level providers with a minimum of 0.50 FTE (20 hours per week or more). Eligibility is the first of the month following one month of employment. UWMF pays the premium for the LTD benefit; however, the employee must pay the tax on this benefit in one of two ways: Post-Tax Option UWMF will reimburse the employee for the cost of the premium in addition to their regular compensation. The pay code LTDAT will

appear on his/her paycheck as income, equal to the amount of the disability insurance premium. That amount is then subtracted from his/her paycheck. This process is simply to calculate the federal tax on the premium.

The amount of the premium is based on the employee’s prior year W2 wages. If newly eligible for the plan, the premium is based on the

employee’s annualized current rate of pay. The tax impact on the employee will be based on the LTD premium that UWMF is compensating the employee.

If the employee is disabled for more than 90 consecutive days and is approved to collect LTD benefits, he/she will not have income tax

deducted from his/her disability check. The disability check will not be income to the employee and therefore does not have to be claimed on the employee’s tax return at year-end.

Pre-Tax Option UWMF will pay the LTD premium on behalf of the employee. The pay code LTDBT will appear on his/her paycheck as an employer paid

benefit. The amount of the premium is based on the employee’s prior year W2 wages. If newly eligible for the plan, the premium is based on the

employee’s annualized current rate of pay. If the employee is ever unable to work due to a disability and is approved to receive LTD benefits, the disability benefit would be taxable

income. This is because the employee chose not to pay the taxes through payroll deduction. The employee would have to claim that money as taxable income on their annual tax return and pay taxes on it at the end of the year.

The employee may choose whichever option best suits their needs. However, UWMF strongly encourages employees to elect the Post-Tax Option. There may be less of a financial strain to an employee if he/she chooses to pay the tax on the benefit while working and receiving a steady paycheck rather than pay the tax through his/her annual tax return. Keep in mind that LTD Insurance is similar to car insurance – you don’t expect to use your car insurance, but it’s there if you need it. The same goes for LTD – you don’t expect to use your LTD benefit, but it is there if you need it. If you elect the Post-Tax Option, but do not use your LTD benefit, you do not get the taxes paid on the benefit back. Again, this is just like car insurance. If you don’t make a claim against your car insurance, you won’t get your premiums back. Changes can only be made to the employee’s election during the annual open enrollment period. Please choose the option you prefer below:

LTD Post-Tax Option: I elect to participate in the Post-Tax Option for the Long Term Disability benefit. I understand that UWMF will reimburse me for the premium, and that taxes will be calculated on that premium. I also understand that if I were to claim LTD and receive disability payments, I will not have to pay income tax on the disability income. LTD Pre-Tax Option: I elect to participate in the Pre-Tax Option for the Long Term Disability benefit. I understand that UWMF will pay for the LTD premium on a pre-tax basis. I will not see a premium deduction, nor the added compensation on my paycheck related to LTD. I also understand that if I were to claim LTD and receive disability payments, I will have to claim the disability income as taxable income on my annual tax return.

_______________ Employee Name (please print) Emp ID _______________ Employee Signature Date

Dependent Life Insurance HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Name Soc Sec No Title Date of Birth Date of Hire Effective Date

Basic Life Insurance – Spouse and Child(ren) You may elect life coverage for your Spouse/Domestic Partner and Child(ren). If you elect this coverage, your Spouse/Domestic Partner will be covered for $10,000 and each child for $5,000. Children under the age of 6 months are covered for $100. Child, for the purpose of this coverage, must be unmarried and under age 19 or under age 25, if a full time student. If both you and your spouse are employees of the University of Wisconsin Medical Foundation, only one of you may elect this coverage.

I elect to enroll my Spouse/Domestic Partner and/or Child(ren) in the Dependent Life plan at a monthly cost of $0.93

I elect to decline the Dependent Life plan for my Spouse/Domestic Partner and/or Child(ren)

I elect to decline this benefit, as I do not have a Spouse/Domestic Partner and/or Child(ren)

Employee Confirmation I have been given the opportunity to enroll in Basic Life Dependent Coverage for my eligible dependents. I understand that the beneficiary for this coverage is myself. __________________________________________ ______________ Signature Date _____________ Employee ID

Updated 09.25.14

Name:

Social Security Number:

Salary:

Date of Birth:

Date of Hire:

Effective Date:

Hours Worked/FTE

Occupation

The following costs should be calculated based on your age as of January 1 of the current year.

Supplemental Life/AD&D Insurance - Employee

You can purchase Supplemental Life/AD&D Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than $750,000. When you are newly eligible for this coverage the guaranteed issue amount is $250,000. If you elect an amount that exceeds the guaranteed issue amount of $250,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. Use the rate chart and calculation line below to determine your semi-monthly cost for this coverage. *

Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Rate .054 .054 .070 .089 .129 .193 .311 .467 .745 1.127 1.906 4.366

I elect to enroll in the Supplemental Life/AD&D plan at the semi-monthly cost below. *

÷ $1,000 = x X 12 ÷ 24 = $

Elected Benefit Amount Rate Above Your Semi-Monthly Cost*

I elect to decline the Supplemental Life/AD&D plan.

* Your cost may change if your age category changes as January 1.

*Note: Benefit reductions begin at age 65. Please see your benefits administrator for further information.

Supplemental Life Insurance – Spouse/Domestic Partner If you elect Supplemental Life Insurance for yourself, you may elect Spouse Supplemental Life Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than the lesser of $250,000 or 50% of your Supplemental Life Insurance. When your spouse or DP is newly eligible for this coverage, the guaranteed issue amount is $30,000. If you elect an amount that exceeds the guaranteed issue amount of $30,000, your spouse or DP will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. Supplemental Spouse or DP rates and premiums are based on the employee’s age, not the Spouse’s or DP’s age.

Use the rate chart and calculation line below to determine your semi-monthly cost for this coverage. *

Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Rate .034 .034 .050 .069 .109 .173 .291 .447 .725 1.107 1.886 4.346

I elect to enroll my Spouse in the Supplemental Life plan at the semi-monthly cost below. *

÷ $1,000 = x X 12 ÷ 24 = $

Elected Benefit Amount Rate Above Your Semi-Monthly Cost*

I elect to decline the Supplemental Life plan for my spouse/domestic partner.

First Name Last Name Gender Date of Birth Date of Marriage

Supplemental Life/AD&D Insurance Enrollment Form

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Child(ren) Supplemental Life Insurance

If you purchase Supplemental Life Insurance for yourself, you may purchase Child(ren) Supplemental Life Insurance for your Dependent Child(ren) between the ages of 2 weeks and 19* years and unmarried (25* years if a full time student and unmarried) in the amount of $10,000. *If your child is no longer eligible for this benefit it is your responsibility to notify HR they will assist you in making this change.

I elect to enroll my dependent child(ren) in the Supplemental Life plan for $10,000 at the semi-monthly cost below.

x .25 = $

# of Covered Children Cost Per Child Above Your Semi-Monthly Cost

I elect to decline to purchase the Supplemental Life plan for my dependent child(ren).

First Name Last Name Gender Date of Birth

Beneficiary Designation You must select your beneficiary – the person (or more than one person) or legal entity (or more than one entity) who receives a benefit payment if you die while covered by the plans. Please make sure that you also name a contingent beneficiary – who would receive your benefit if your primary beneficiary dies first. Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than one primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the information requested below. If your beneficiary is not related either by blood or by marriage, insert the words, “Not Related” as their stated relationship. If you need assistance, contact your benefits administrator or your own legal advisor.

Full Name Address Social

Security # Relationship

Date of Birth

Percent-age

Primary Beneficiary

Contingent Beneficiary

The beneficiary for insurance on the lives of your spouse and children will automatically be you, if surviving. Otherwise, the beneficiary will be the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon written request. NOTE: Spousal Consent For Community Property States Only: If you live in a community property state – Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin – you must complete a Supplemental Life Insurance Plan Spousal Consent Form, which allows your spouse to waive his or her rights to any community property interest in the benefit.

Employee Confirmation I acknowledge that I have been given the opportunity to enroll in University of Wisconsin Medical Foundation’s Group Supplemental Life/AD&D plans. I understand and agree that if I decline coverage now, but later decide to enroll, I will be required to provide evidence of insurability that is satisfactory to The Hartford and be approved for such coverage before it becomes effective. I understand my request for coverage may be denied by The Hartford. I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy. I understand and agree that only the insurance policy issued to the policyholder (your employer) can fully describe the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy. If I have life insurance coverage with The Hartford, I understand and agree that my life insurance benefit is reduced at a specified age stated in the policy. I authorize my employer to make the appropriate payroll deductions from my earnings. I understand that no insurance will be valid or in force if I am not eligible in accordance with the terms of the group policy as issued to my employer. Signature: Date:

Supplemental Life Insurance Plan

Spousal Consent Form

I, the undersigned spouse of __________________________________________________________________named in the foregoing

(Participant/Employee Name – please print) “Designation of Beneficiary”, hereby certify that I have read the Designation of Beneficiary and fully understand the property subject to the designation is my spouse’s benefit under the Plan, in which I possess a beneficial interest, provided I survive my spouse. Being fully satisfied with the provisions of the designation, I hereby consent to and accept the beneficiary designation, without regard to whether I survive or predecease my spouse. This consent is irrevocable unless my spouse changes the designation. If my spouse changes the designated (choose either a or b)

_____ (a) I understand I must sign a similar consent to agree with any changes in the designation, or my consent is no longer effective; or

_____ (b) I waive my right to withhold my consent to a change in designation. I understand that I do have the right to limit my consent to the specific beneficiary designated on the life insurance or request for change form by checking line (a).

I have executed this consent this _________ day of ________________________________, 20_______. _____________________________________________ Signature of spouse of participant Witness by Plan Representative Signature of spouse for consent witnessed this ______ day of _________________________, 20______. ____________________________________________ Plan Representative

OR Witness by Notary STATE OF ___________

COUNTY OF _________

Before me, as the undersigned Notary Public, personally appeared _________________________________ who executed the above Spousal Consent as a free and voluntary act.

In witness whereof, I have signed my name and affixed by official notarial seal this _______ day of _______________________, 20_______. _____________________________________________ (SEAL) Notary Public My commission expires:__________________________

Note: If you are married and you do not name your spouse as your only primary beneficiary, your spouse’s signature must be notarized on this page. Return completed form to: Human Resources Department UW Medical Foundation 7974 UW Health Court Middleton, WI 53562

Updated 10/2013

Flexible Spending Accounts

Enrollment Form

Submit form to: UWMF Human Resources ▪ 7974 UW Health Court ▪ Middleton, WI 53562 ▪ (ph) 608-821-4150 ▪ (fax) 608-821-4151

Part 1 EMPLOYEE INFORMATION (please print) Employee Name (Last, First MI) Social Security Number

Street Address City State Zip Home Telephone

Date of Birth Date of Hire Eligibility Date

Gender Male Female

Marital Status Number of Dependents

Part 2 DEPENDENT INFORMATION (please print) Dependent #1 Name (Last, First, MI) Date of Birth Dependent SSN

Relation to Employee Same Employer? Yes No

Dependent #2 Name (Last, First, MI) Date of Birth Dependent SSN

Relation to Employee Same Employer? Yes No

Dependent #3 Name (Last, First, MI) Date of Birth Dependent SSN

Relation to Employee Same Employer? Yes No

Dependent #4 Name (Last, First, MI) Date of Birth Dependent SSN

Relation to Employee Same Employer? Yes No

Part 3 FLEXIBLE SPENDING ACCOUNT (FSA) ELECTIONS FSA Type Yearly Deduction Amount Effective Date

Health Care Flexible Spending (annual maximum of $2,500)

Dependent Care Flexible Spending (annual maximum of $5,000)

I do not wish to participate in the Flexible Spending Account benefit at this time. I certify that I wish the above total amount deducted from each of my paychecks. I understand that this will lower my gross pay, and consequently, my tax base and Social Security base. ____________________________________________________________________ ____________________________ Employee Signature Date

Submit form to:

Flexible Spending Accounts WestLake Financial Group, Inc.

Direct Deposit Enrollment Form 1477Barclay Boulevard Buffalo Grove, IL 60089 (Fax) 866-509-7380

Part 1 EMPLOYEE INFORMATION (Please Print)

Employer Name Employer Location

Employee Name Last First Mi. Date of Birth SSN or Employee ID

Street Address City State Zip

Home Telephone

Part 2 BANK INFORMATION (Please Print)

Name of Financial Institution Branch Address

City State Zip

Checking or Savings? Checking Savings

Account number

Transit Routing Number (9 digits)

Part 3 JOINT ACCOUNT INFORMATION

Additional Account Holder(s)

Name

Name

I verify the accuracy of the above information and agree to refund WestLake Financial Group, Inc. any amounts found to

be overpayments as described in the following statement:

I hereby authorize you to deposit all Flexible Spending Account reimbursements directly into the account named above. This

authority will remain in effect until I have given you written notice that I have terminated it. I understand that I must give you enough

notice to allow you reasonable time to act on my instructions. In the event an overpayment should be credited to my account during or

after my lifetime I authorize you to direct my bank to refund same to you and charge such payment to my/our account.

EMPLOYEE SIGNATURE: DATE:

JOINT ACCOUNT HOLDER SIGNATURE: DATE:

KBG354

Text Box

Complete this application if you wish to enroll in flexible spending medical or dependent daycare for 2015.

Every 2 seconds, someone is a victim of identity theft.

®

†

and a Certified Resolution Specialist will handle your case every step of the

‡

2

1

3

17%Credit Card Fraud

34%Government

Benefits Fraud

6%Related Theft

14%Phone/

Fraud

4%LoanFraud

8%BankFraud

17%Other Identity Theft

The

the most available

rted crime to the Federal Trade

to 2 Identity theft is

your credit history3

state that

children are now the fastest growing segment of identi 4

in 2 122

happens every 2 sec3

Fastest growing segment

When a threat is detected, LifeLock notifies members

by phone, text or email.**

#1 REPORTED CRIMEto Federal Trade Commission¹

LifeLock Services & Benefit Pricing Details

Plan Options LifeLock LifeLock Ultimate

Employee Only [18 and over]

Employee + Spouse

Employee + Children*

Employee + Family*

LifeLock Standard

LifeLock Ultimate

LifeLock Junior

Need more detail?View the detailed product descriptions.

Service Features LifeLockLifeLock Ultimate

LifeLock Identity Alert® System†

Lost Wallet Protection

Address Change Verification

Black Market Website Surveillance

Reduced Pre-Approved Credit Card Offers

Live Member Support 24/7/365

Certified Resolution Support

$1 Million Total Service Guarantee‡

Fictitious Identity Monitoring

Court Records Scanning

Checking & Savings Account Application Alerts†

Bank Account Takeover Alerts†

Credit Inquiry Alerts†

Online Annual Credit Reports

Online Annual Credit Scores

Monthly Credit Score Tracking

File-Sharing Network Searches

Sex Offender Registry Reports

Priority Live Member Support 24/7/365

LifeLock standard identity theft protection uses innovative monitoring technology and alert tools to help proactively safeguard your credit and finances.†

LifeLock Ultimate service provides peace of mind knowing you have the most comprehensive identity theft protection available. Enhanced services include bank account application and takeover alerts, online credit reports and credit scores.†

LifeLock Junior service is a proactive system rolled into family plans that helps keep your child’s information safe. A child’s clean and unmonitored credit file is a gold mine for identity thieves, with critical misuse and damage potentially going completely undetected for years.††

*As LifeLock identity theft protection and LifeLock Ultimate service are available for adults 18 years of age and older, children under the age of 18 will receive a product designed specifically for minors LifeLock Junior service. Enrollment in LifeLock service is limited to employees and their eligible dependents.† Network does not cover all transactions. †† Must be enrolled with an adult member. ‡The benefits under the Service Guarantee are provided under a Master Insurance Policy underwritten by State National Insurance Company. Under the Service Guarantee LifeLock will spend up to $1 million to hire experts to help your recovery. As this is only a summary please see the actual policy for applicable terms and restrictions at LifeLock.com. ®

HOW TO ENROLL:

MEMBERSHIP ELECTION FORM

LifeLock® Identity Theft Protection Service

COVERAGE

Employee Only

Employee + Spouse

Employee + Children

Employee + Family

COVERAGE

Employee Only

Employee + Spouse

Employee + Children

Employee + Family

LifeLock Ultimate™ Service

Important Message. Without complete information, the LifeLock services for your dependents may be limited to new credit account and non-credit account identity alerts and remediation, and until the dependent information is provided to LifeLock, such dependents cannot receive any other LifeLock services. By enrolling your dependents, you understand and agree that if you do not provide this information you will be charged the full cost of the LifeLock service through your elected method of payment, and that you will not be entitled to a refund for such payments.†Network does not cover all transactions and scope may vary.*The benefits under the Service Guarantee are provided under a Master Insurance Policy underwritten by State National Insurance Company. Under the Service Guarantee LifeLock will spend up to $1 million to hire experts to help your recovery. As this is only a summary please see the actual policy for applicable terms and restrictions at LifeLock.com.Copyright © 2013, LifeLock. All Rights Reserved. LifeLock, the LockMan Icon and “Relentlessly Protecting Your Identity” are registered trademarks of LifeLock, Inc.

Please return this form to your HR team

Primary Account Holder:

Print Name: Address:

Email: Phone: ( ) -

DOB: / / Gender: M F SSN: - - Signature: Date:NOTE: By signing this form, you represent that you have the authority to enroll those dependents indicated below in LifeLock services and you further agree to LifeLock’s Terms and Conditions which can be found at www.lifelock.com/terms on behalf of yourself and any other members of your family you are enrolling as indicated below. Please see your HR department for the cancellation policy or a copy of LifeLocks Terms and Conditions.

Dependents:Spouse/Domestic Partner Name:

Dependent Name:

Dependent Name:

Dependent Name:

Dependent Name:

DOB: / / Gender: M F SSN: - -

DOB: / / Gender: M F SSN: - -

DOB: / / Gender: M F SSN: - -

DOB: / / Gender: M F SSN: - -

DOB: / / Gender: M F SSN: - -

All the protection of LifeLock® standard service plus:

Credit Application Alerts†

Lost Wallet Protection

Address Change Verification

Black Market Website Surveillance

Checking and Savings Account Alerts†

Priority Award Winnning Member Service

Monthly Credit Score Tracking

Online Annual Credit Reports & Scores

Enhanced Credit Application Alerts

Bank Account Takeover Alerts†

Employer:

Reduced Pre-Approved Credit Card Offers

Award-Winning Member Service 24/7/365

$1 Million Total Service Guarantee*

 UWMF Employee Health Risk Assessment Plan 

Notice of Privacy Practices 

UWMF’s Employee Health Risk Assessment Plan protects your protected health information (“medical information”) in all forms ‐‐ oral, written, and electronic. We keep your medical information private as required by law and our own policies. This Notice explains your rights, our legal duties and our privacy practices. 

Our Legal Duty 

We are required by applicable federal and state law to maintain the privacy of your medical information.  We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. 

We must follow the privacy practices that are described in this notice while it is in effect.  This notice takes effect October 21, 2010, and will remain in effect unless we replace it. 

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law.  We reserve the right to make any change in our privacy practices and the new terms of our notice applicable to all medical information we maintain, including medical information we created or received before we made the change. 

Your Medical Information  

We collect and use several types of medical information to carry out employee wellness activities. This includes information that you give us on applications or other forms, such as your name, address, age, family medical history, and certain biometric measurements to identify personal health risks.   

We use physical, technical and procedural methods to protect your medical information. We share it only with our employees, affiliates or others who need it to provide employee wellness services, or for other legally allowed or required purposes. 

Uses and Disclosures of Your Medical Information  

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

We collect, use and communicate medical information by and about you for operations purposes related to the UWMF Employee Wellness Plan, or when we are allowed or required by law to do so. 

For Health Care Operations: We may use and disclose your medical information about you, without your permission, for our operations.  Our operations include: 

• Health care benefits quality assessment and improvement activities;  

• Provision of wellness coaching and general health improvement services;   Page 1 of 4 

UWMF Employee Health Risk Assessment Plan Notice of Privacy Practices October 21, 2010 

 

• Business planning, development, management, and general administration of health care benefits activities.  

Health –related Benefits and Services:  We may contact you with information about health‐related benefits and services. For example, based on your answers to our Health Risk Assessment questionnaire, we may notify you about wellness coaching and other general health improvement services which you may become eligible, such as Medicare supplements or individual coverage. We may also send reminders about routine medical check‐ups and tests. 

Health‐Related Products and Services:  We may use your medical information to communicate with you about health‐related products, health care providers, health‐related benefits and services, and payment for those products, benefits and services.  We may use your medical information to communicate with you about treatment alternatives that may be of interest to you.   

Disclosures to another Health Plan or Health Care Provider:  We may disclose your medical information to another health plan or to a health care provider subject to federal privacy protection laws, as long as the plan or provider has or had a relationship with you and the medical information is for that plan’s or provider’s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention. 

As Allowed or Required by Law: Information about you may be shared for oversight activities required or allowed by law; for judicial or administrative proceedings; with public health authorities; for law enforcement purposes; with coroners, funeral directors or medical examiners (about decedents); for research purposes; to avert a serious threat to health or safety; for specialized government functions; and for workers' compensation purposes. 

Your Rights 

Access:  You have the right to examine and to receive a copy of your medical information, with limited exceptions.  You should submit your request in writing to our Contact Office (details provided below).   

We may charge you reasonable, cost‐based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request.  Contact our Contact Office for information about our fees. 

Disclosure Accounting:  You have the right to a list of instances after October 21, 2010, in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.  

You should submit your request for this information to the Contact Office.  We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before October 21, 2010.  If you request this accounting more than once in a 12‐month period, we may charge you a reasonable, cost‐

Page 2 of 4 UWMF Employee Health Risk Assessment Plan Notice of Privacy Practices 

October 21, 2010  

based fee for responding to your additional requests.  Contact our Contact Office for information about our fees. 

Amendment.  You have the right to request that we amend your medical information.  You should submit your request in writing to the Contact Office.  We may deny your request only for certain reasons.  If we deny your request, we will provide you a written explanation.  If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the un‐amended information to your detriment, as well as persons you want to receive the amendment. 

Restriction:  You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify.  We are not required to agree to your request.  If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law.  You should submit your request to the Contact Office.  Effective October 21, 2010 (or such later date specified by the U.S. Department of Health and Human Services) we will agree to a restriction request if:   

1.  except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment); and 

2.  the medical information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. 

Confidential Communication:  You have the right to request that we communicate with you about your medical information in confidence by means or to locations that you specify.  You should submit your request in writing to the Contact Office.  We will accommodate your request if it is reasonable, specifies the means or location for communicating with you, and continues to permit us to perform our functions as your Employee Wellness Plan.   

Breach Notification:  You have the right to receive notice of a breach of your unsecured medical information.  Notification may be delayed or not provided if so required by a law enforcement official.  You may request that notice be provided by electronic mail.  If there is a breach of your medical information after the time of your death, the notice will be provided to your next of kin or personal representatives if we know the identity and address of such individual(s). 

Your Authorization / Revocation of Authorization:  You may give us written authorization to use your medical information or to disclose it to anyone for any purpose.  If you give us an authorization, you may revoke it in writing at any time.  You should submit your revocation in writing to the Contact Office.  Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect.  Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than those purposes described in this notice. 

   

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October 21, 2010  

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Potential Impact of Other Applicable Laws  

The HIPAA Privacy Rule generally does not "preempt" (or override) state privacy or other applicable laws that provide individuals greater privacy protections. As a result, if any state privacy laws or other applicable federal laws provide for a stricter privacy standard, then we must follow the more strict state or federal laws with respect to your medical information. 

Complaints  

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information, about amending your medical information, about restricting our use or disclosure of your medical information, or about how we communicate with you about your medical information (including a breach notice communication), you may complain to our Contact Office. 

You also may submit a written complaint to the United States Department of Health and Human Services Office for Civil Rights: 

Office for Civil Rights / U.S. Department of Health and Human Services 233 N. Michigan Avenue, Suite 240 Chicago, IL  60601 Voice Phone:  (312) 886‐2359 Toll Free:  1‐800‐368‐1019 FAX:  (312) 886‐1807 TTD:  (312) 353‐5693 

We support your right to the privacy of your medical information.  We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. 

Contact Information / Contact Office 

If you want to exercise your rights under this notice, request a paper copy of this document, talk with us about privacy issues, or file a complaint, please contact our Contact Office at: 

Telephone:    (608) 821‐4150 

E‐mail:     hr@uwmf.wisc.edu 

Address:   UWMF Employee Health Risk Assessment Plan 7974 UW Health Court Middleton, WI  53562 

2015 EMPLOYEE CONFIDENTIALITY AGREEMENT

(Rev’d 05/2013 – UWMF & UWHC Legal)

As an employee of either the University of Wisconsin Medical Foundation, Inc. (“UWMF”), or the University of Wisconsin Hospitals & Clinics Authority (“UWHC”) (UWMF and UWHC may be collectively referred to as “UW Health”), I understand that I am required to abide by my employer’s guidelines and policies (“Policies”) and to ensure that all information regarding UW Health and/or the patients of UW Health is kept confidential to the greatest possible extent. I understand that during the performance of my job duties, I may have access to and be involved in the processing of confidential information, in any medium, pertaining to UW Health (“Confidential Information”). Confidential Information includes, but is not limited to: (1) Patient Health Care Records; (2) Indexes of medical information, patient demographics, patient billing and appointment history; (3) Confidential communications made for the purposes of diagnosis or treatment of patients’ physical, mental, or

behavioral health conditions; (4) Employees’ personnel records, including employee health records; (5) UW Health business, financial, corporate, and proprietary information; and (6) Other information protected by Nondisclosure or Confidentiality Agreements by UW Health.

I understand that Confidential Information is not confined to written materials or hard paper copies, but includes information derived from any source, including, but not limited to, electronic data (whether retrieved on screen or contained on technical storage devices), and oral communications and/or recordings. I understand that I should only access Confidential Information to the extent minimally necessary and as required in order to perform my job. If I access Confidential Information for any reason other than for the performance of my job duties, such access will be considered a violation of my employer’s Policies, and such access will result in sanctions as outlined in my employer’s Policies or as indicated by state or federal laws. I understand that Confidential Information is to be handled in the strictest confidence and will not be accessed, read, discussed, released, utilized, or disclosed by myself or to any other person or entity without appropriate written authorization or a legitimate, professional need to know such information for the performance of his or her job duties, as applicable. Further, I understand that releases or disclosures to persons both internal or external to UW Health may violate this Confidentiality Agreement. **If I have specific concerns about my access, use, or release of any Confidential Information, I will seek guidance about such access, use, or release from my direct supervisor or from my employer’s Privacy Officer.** Any employee found to be in violation of this Confidentiality Agreement and/or UW Health policies, state, or federal laws will be subject to disciplinary action by his or her employer, up to and including immediate termination and/or legal action as warranted by the severity of the violation or the type of Confidential Information accessed, read, discussed, released, utilized by, or disclosed by such employee. I understand that unauthorized modification or misrepresentation of patient records or other Confidential Information (i.e., misrepresentation of a medical procedure and/or diagnosis code information) is also a violation of this policy. I acknowledge that I have read and reviewed my employer’s Policies applicable to my position, including but not limited to policies regarding: ethical and professional behavior, business conduct, compliance, information services, acceptable use of my employer’s resources, e-mail, mobile devices, remote access to informational systems, security, wireless networking, employee performance, discipline, event/incident reporting, and releases of medical record information. I expressly acknowledge that the Policies may be found at the following intranet location: https://uconnect.wisc.edu/servlet/Satellite?c=Page&cid=1116249893336&pagename=B_EXTRANET_UWH_POLICIES/Page/Show_Policy_Landing I agree that I will immediately report knowledge of all suspected unethical, illegal, or unauthorized behavior or practices, or violations of Policies through the appropriate channels, and I fully understand that I am protected by law against retaliation for any such report. I agree to abide by this Confidentiality Agreement and my employer’s Policies applicable to my position. I will abide by and annually review my employer’s Policies in connection with annual Compliance Training. Employee Signature Employee Printed Name Date UWMF UWHC Employee Department & Title Employee Number Employer (Circle One)