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stopped accepting outdated Income Continuation Insurance (ICI) Claim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
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, http://etf.wi.gov
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.