SECTION 4: LIST SPOUSE/CHILD(REN) TO BE ENROLLED (Use additional paper if needed to list all dependents)
Please list all eligible dependents that you wish to have covered under your plan. Providing accurate information ensures claims
are able to be processed timely. Dependent children are eligible until the end of the month in which they turn 26.
Listing a beneficiary is necessary to pay an Accidental Death and Dismemberment claim to your designated beneficiary.
Name Date of Birth Gender
M F Y N Y N
M F Y N Y N
M F Y N Y N
Beneficiary: Last Name: First Name: Middle Initial: Relationship:
* Please use additional paper if needed to list additional dependents or beneficiaries. There is also a Beneficiary Designation
form at www.EPICBenefits.com
2018 EPIC BENEFITS+ ACTIVE EMPLOYEE SPECIAL ENROLLMENT FORM
Enrollment period of October 2 — October 27, 2017
Coverage Effective January 1, 2018
Please print clearly or type
SECTION 1: APPLICANT INFORMATION
Note: If you are a new employee with the State of WI within your eligibility period, please see your Payroll and Benefits office
for a new employee application.
Member Name (last, first, middle) Social Security Number
Street Address City State Zip Code
Email Address Daytime Telephone Number Date of Birth Gender
SECTION 2: ENROLLMENT INFORMATION
Requested Coverage: With Vision Insurance Without Vision Insurance For Existing Members: Add Vision Cancel Vision
SECTION 3: SPECIAL ENROLLMENT GRADUATED DENTAL MAXIMUM
Members who are enrolling during the 2018 Special Enrollment will be subject to the following Dental Maximum benefit per
member in calendar year:
• 2018 is $750 • 2019 is $1,000 • 2020 is $1,500 (full benefit amount) • 24 month waiting period on Orthodontics
SECTION 5: SIGNATURE (Sign here and return completed application to your employer)
Please indicate if you are applying for coverage or if you are going to cancel your existing Benefits+ coverage. If you are only canceling
your vision coverage, check only the “Wish to cancel Vision only” box in Section 2.
Your signature and date are required to indicate that you are making a choice and that if electing coverage, you are authorizing payments
to be deducted from your pay check. I understand that once enrolled this coverage must remain in force for the full calendar year
unless eligibility is lost.
I am applying for the coverage elected above. I understand that Wis. Stats. §943.395 provides criminal penalties for knowingly
making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the information
is true and correct. I agree to the provisions of the plan and hereby authorize deduction of the monthly premium from my
salary. I understand that once enrolled this coverage must remain in force for the full calendar year unless eligibility is lost.
Cancel my coverage as of December 31, 2017. I understand that I must submit the application to cancel coverage by
December 1st or coverage will remain in force for the following year.
29964-088-1706Underwritten by The EPIC Life Insurance Company
FOR OFFICE USE ONLY
Date Rec’d Received by Hire Date Cov Eff Date Agency/Campus Code
EPIC Group Number Division Number Premium
Open Enrollment 2018Return completed forms to Human Resources by October 27 deadline:
Fax: 608-263-5778 | Ask HR form in ServiceNow
Employee ID: _________