RETIREMENT COUNSELING WORKSHEET Employee: Employee Spouse: SSN: Person ID: SSN: DOB: Age: DOB: Age: Appt Date/Time: State Employee: Yes No Retirement Date(s): Address: Phone Number: Seniority Date: Home: Work: Current Salary/Hourly Wage: $ Appt Type/Position Title: Basis/Appt % Department Code: Vacation hours: Sick Leave hours: Sabbatical/ALRA hours: Personal / Floating Comp Time hours: V: hrs/pay period Holiday hours: VN: Current Tax Filing Status: Federal- Additional- State- Additional- Monthly Coverage Comments Benefit Plan Deduction Levels/Plan/Type Employer paid coverage will end on . Coverage automatically continues at retirement and premiums will be paid by accumulated sick leave credits (see estimate) until exhausted. The currently monthly State Group Health Carrier: $ Insurance Type: premium to maintain your current coverage in retirement is . You will receive new ID cards for your retiree coverage. You (and/or spouse) is/are required to enroll in Medicare Part B effective . Group Life Coverage ends on . Insurance Basic $ $ Employee coverage automatically continues at retirement Supplemental $ $ and premiums are taken directly from your annuity until Addl: unit(s) $ $ age 65 (see estimate). Cost/Coverage: $ $ Spouse & Dependent coverage ends at termination but Spouse & Dependent: $ Spouse: $ can be converted to an individual policy at a higher unit(s) Dependent: $ premium. Income Continuation Elimination Insurance Coverage ends at termination. Period/Category: Standard $ Supplemental $ Coverage ends on . UW Employees, Inc. $ $ Life Insurance Can convert to an individual policy at a higher premium. Individual & Family Life Insurance Coverage ends on . Employee $ $ Spouse/Dom Partner $ $ Can convert to an individual policy at a higher premium. Children $ $ Total Cost: $ Coverage ends on . AD&D Insurance + $ $ Zurich Travel Assist Type: Can continue indefinitely through direct payment to carrier. Coverage ends Sept 30th following termination. University Insurance $24.00 / $ Assoc. Life Insurance Year Can continue indefinitely through direct payment to carrier. Coverage ends on . Can continue indefinitely through direct payment to carrier. EPIC Benefits+ $ Type: Required to pay monthly annuitant rate of as a retiree. Coverage ends on . Plan: Dental Wisconsin $ Type: Can continue indefinitely through direct payment to carrier.
RETIREMENT COUNSELING WORKSHEET Employee: Employee Spouse: SSN: Person ID: SSN: DOB: Age: DOB: Age: Appt Date/Time: State Employee: Yes No Retirement Date(s): Address: Phone Number: Home: Work: Seniority Date: Current Salary/Hourly Wage: $ Appt Type/Position Title: Basis/Appt % Department Code: Vacation hours: V: VN: Sick Leave hours: hrs/pay period Sabbatical/ALRA hours: Personal / Floating Holiday hours: Comp Time hours: Current Tax Filing Status: Federal- Additional- State- Additional- Benefit Plan Monthly Deduction Coverage Levels/Plan/Type Comments State Group Health Insurance $ Carrier: Type: Employer paid coverage will end on . Coverage automatically continues at retirement and premiums will be paid by accumulated sick leave credits (see estimate) until exhausted. The currently monthly premium to maintain your current coverage in retirement is . You will receive new ID cards for your retiree coverage. You (and/or spouse) is/are required to enroll in Medicare Part B effective . Group Life Insurance Basic Supplemental Addl: unit(s) Cost/Coverage: Spouse & Dependent: unit(s) $ $ $ $ $ $ $ $ $ Spouse: $ Dependent: $ Coverage ends on . Employee coverage automatically continues at retirement and premiums are taken directly from your annuity until age 65 (see estimate). Spouse & Dependent coverage ends at termination but can be converted to an individual policy at a higher premium. Income Continuation Insurance Standard Supplemental $ $ Elimination Period/Category: Coverage ends at termination. UW Employees, Inc. Life Insurance $ $ Coverage ends on . Can convert to an individual policy at a higher premium. Individual & Family Life Insurance Employee Spouse/Dom Partner Children Total Cost: $ $ $ $ $ $ $ Coverage ends on . Can convert to an individual policy at a higher premium. AD&D Insurance + Zurich Travel Assist $ $ Type: Coverage ends on . Can continue indefinitely through direct payment to carrier. University Insurance Assoc. Life Insurance $24.00 / Year $ Coverage ends Sept 30th following termination. Can continue indefinitely through direct payment to carrier. EPIC Benefits+ $ Type: Coverage ends on . Can continue indefinitely through direct payment to carrier. Required to pay monthly annuitant rate of as a retiree. Dental Wisconsin $ Plan: Type: Coverage ends on . Can continue indefinitely through direct payment to carrier.
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