Human Resources

Payroll Forms

State Withholding Form WT-4 (2015)
Direct Deposit Authorization Form
I-9 Employment Eligibility Verification Form (2017)
Federal Withholding Form W-4 (2017)

Life Insurance

Group Term Life Certificate-Teachers
Group Term Life Certificate-All Other Eligible Employees
Group Term Life Certificate-Administrator
Employee Enrollment Form
Life Insurance Beneficiary Info
Change of Beneficiary Request
Supplemental Life Enrollment (Optional)


Short Term Disability Insurance
Short Term Disability Certificate of Insurance
Long Term Disability Insurance (All Full-Time Active Employees)
Long Term Disability Certificate-Teachers
Long Term Disability Certificate-Support
Long Term Disability Certificate-Administrator

Health Insurance

Health Insurance Application/Change Form ET-2301 (Rev 11/11/16)
Health Plan Options and Rates(2016)
Health Plan Options and Rates (2017)
It's Your Choice 2017 Decision Guide
State of Wisconsin Pharmacy Benefits Program Fact Sheet
Pharmacy Benefits Presentation Handout

Dental Insurance

Delta Dental Enrollment Form
Delta Dental-Summary Plan Description
Summary of Dental Benefits/Allowances
Delta Dental Website

Wisconsin Retirement Fund

Beneficiary Designation Form (ET-2320)
Election to Participate in the Variable Trust Fund (ET-2356)
How Participation in the Variable Trust Affects Your WRS Benefits (ET-4930)
WI Retirement Benefit Handbook
Department of Employee Trust Funds (ETF)

Flexible Spending Account (FSA)

2017 Important Plan Information
DBS Direct Deposit Application
DBS Employee Guide
Flexible Benefit Plan Enrollment Form
FSA-125 claim form
Diversified Benefit Services, Inc. (DBS) Website
DBS Online Filing Instructions
Summary Plan Description

Tax Sheltered Annuities (TSA)

Employee Savings Plan 403(b)
Deferred Compensation Plan 457(b)
Approved Employee Savings Plan List
Salary Reduction Agreement-SDOJ

Family & Medical Leave Act (FMLA)

Family & Medical Leave Policy (GBGA)
Notice of Rights & Responsibilities When Taking FMLA
Request for Leave of Absence
FMLA Healthcare Provider Certification
Not to be used for Maternity Leave
Estimated Functional Capabilities Form
Return to Work Physicians Statement
  • Jefferson School District
  • 206 South Taft Ave. Jefferson, WI 53549
  • Phone: 920 675-1000 · Fax: 920 675-1020