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Employer Bulletin

All Employers
Vol. 17, No. 18
September 21, 2000

Urgent Reminder for Income Continuation Insurance Claims

Ordering ICI Claim Form Packets

As of June 1, 2000, the Department of Employee Trust Funds (ETF) stopped accepting outdated Income Continuation Insurance (ICI) Claim forms (ET-5301 or ET-5310).

  • The February 16, 2000 Employer Bulletin (Vol. 17, No. 4) provided information on the new ICI claims process and advised that old claim forms (ET-5301 or ET-5310) be destroyed and only new forms would be accepted effective April 1, 2000.

  • The March 22, 2000 Employer Bulletin (Vol. 17, No 6) reminded employers to request new ICI claim packets and destroy the old claim forms. The deadline for using the new forms was extended from April 1 to June 1, 2000.

Despite the notices, some employers are still using the old claim forms. This is causing processing delays, as the claims administrator must reject these old claim forms and request the employee complete the revised form. The claimant gets the rejection notice (the employer does not). It is important to use new claim forms so the employee's claim will not be delayed.

Please order a supply of new claim form packets if you have not already done so. When you receive the new packets, destroy the old forms.

To order a claim form packet(s) from ETF, provide your employer name, Employer Identification Number (EIN), your name, title, address, phone number, city, state and zip code. Indicate whether you are a state or local government employer and the quantity of packets wanted. Use one of the following methods:

  • Call ETF Supply and Mail Services at (608) 266-3302.

  • E-mail ETF by clicking contact us on our Internet site,

  • FAX your request to ETF at (608) 267-4549.

Returning ICI Employer Statements to the Claims Administrator

Upon receipt of a claim form, the claims administrator sends an ICI Employer Statement (ET-5351) to the employer to complete. The employer must complete the statement and mail it to ETF. Unfortunately, not all ICI Employer Statements (ET-5351) are being returned to ETF. This delays the processing of claims. You can help avoid delays by immediately completing and returning the ICI Employer Statement to ETF at PO Box 7931, Madison, WI 53707-7931.

Please direct questions regarding this process to United Wisconsin Insurance Company toll free at 1-800-452-4250.


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