State Agencies & Local ICI Employers
Vol. 22, No. 8
May 19, 2005
The Department of Employee Trust Funds (ETF) recently revised
Income Continuation Insurance (ICI) brochures and applications.
State of Wisconsin Income Continuation Insurance brochure (ET-2106)
and Wisconsin Local Government Employees Income Continuation Insurance
The State and Local ICI brochures are updated to clarify current
policy and include reference to the new supplemental ICI coverage.
The revised brochures include the following policy changes:
- Supplemental ICI coverage – The Group Insurance Board
(GIB) approved offering supplemental coverage for employees with
annual salaries exceeding $64,000 and up to a maximum of $120,000.
- Employees may continue or elect coverage while on military leave.
Should coverage lapse while on military leave, the employee may
reinstate the coverage by filing an ICI enrollment application
instead of filing through evidence of insurability.
- The GIB also approved the following changes to the ICI plan
benefit provisions: (These revisions apply to both the State and
Local ICI plans unless otherwise indicated.)
- Issue short-term disability benefits on a monthly basis
instead of biweekly. (State employees only.)
- Base monthly ICI benefits on 30 days regardless of the
number of days in a month. Partial monthly ICI benefits are
pro-rated using 30 days in a month.
- Offer direct deposit of short-term disability claim payments
for claimants who have received ICI short-term disability
benefits for a minimum of six (6) months.
- Require direct deposit of long-term disability payments.
- Increase the maximum monthly ICI benefit to $7,500 for
claimants with supplemental ICI coverage.
- Offset paid vacation, paid holiday and paid compensatory
time at 100% if payment is made after the elimination period
and before returning to part-time employment. (State employees
- Offset paid vacation, paid holiday and paid compensatory
time at 75% if payment is made after the elimination period
and after returning to part-time employment. (Local employees
- Offset part-time earnings from the ICI benefit payment
based on the date of the earnings check.
The brochures also include GIB-approved premiums for supplemental
ICI coverage. Premiums for supplemental coverage are added to the
standard premium to determine the total monthly employee premium.
In early June you will receive a supply of the ICI brochures (ET-2106
or ET-2129) to distribute to all insured employees. You will
also receive an additional supply to use for new hires. After
receipt of the revised brochures, discard any ICI brochures with
a revision date prior to 04/2005.
Questions regarding plan changes should be directed to Broadspire
at 1-800-960-0052. Questions regarding ICI coverage (eligibility
and coverage reporting questions from employers) should be directed
to ETF’s Employer Communication Center at (608) 264-7900.
ICI Evidence of Insurability Application (ET-2308)
Revisions to the ICI Evidence of Insurability Application (EOI)
include minor language changes and selection boxes for the new supplemental
You will receive a supply of this form in early June, along with
the revised state and local ICI brochures. After receipt of the
revised form, discard any EOIs with a revision date prior to 04/2005.
As of July 1, 2005, Broadspire will return, to the employee, applications
received with a revision date prior to 04/2005.
Income Continuation Insurance Employer Statement (ET-5351)
Revisions to the ICI Employer Statement require that State and
Local employers indicate whether the employee is covered under supplemental
ICI. Eligibility for supplemental ICI benefits requires that the
employee become disabled after the supplemental ICI coverage effective
date. In the event the ICI supplemental coverage effective date
is later than the first date of disability, ICI benefits are based
on the standard ICI coverage only.
State Agencies Only
State agencies must indicate whether a seasonal/academic, Limited
Term Employee (LTE), or project employee worked fewer than 12
months in the calendar year prior to the employee’s last
day worked. For most State employees, the ICI benefit is based
on the basic salary, excluding overtime, for the last complete
payroll period prior to the employee’s first date of disability.
ICI benefits for a seasonal/academic, LTE or project employee
who worked fewer than 12 months in the calendar year prior to
the employee’s last day worked are based on the State earnings
from the prior calendar year rounded to the next higher thousand
and divided by twelve. ICI benefits for an employee with an interruption
of three consecutive months or more are based on estimated earnings.
In these cases, employers use the earnings expected to be received
during the ensuing twelve months rounded to the next higher thousand
and divided by twelve to determine the monthly basis for the ICI
The most current revision of the ICI Employer Statement (ET-5351)
can be found on ETF’s Internet site at http://etf.wi.gov.
Additional ICI Forms
After you receive your initial order, you may order additional
State and Local ICI brochures (ET-2106 and ET-2129), Evidence of
Insurability Applications (ET-2308) and other ICI forms, by either
of the following methods:
- Photocopy and complete the ICI Forms/Booklets Order Form available
on ETF’s Internet site at http://etf.wi.gov. This form is
also located in Subchapter 110 of the ICI Administration Manual
– Local Government Employers. Fax the form to Broadspire
at (781) 270-8666.
- Complete the ICI Forms/Booklets Order Form available on ETF’s
Internet site at http://etf.wi.gov, and e-mail it to
Should an emergency need for ICI forms arise, call Broadspire at
1-800-960-0052 and provide the following:
- Employer Name
- Four-digit employer identification number (EIN) starting with
- Mailing Address
- Contact Name
- Contact Phone Number
- Form Name and Number
- Quantity of the form or brochure
The Broadspire Correspondence Unit will contact the employer to
confirm receipt of the request for forms and provide an estimated
Contact Broadspire’s Customer Service team designated for
the State of Wisconsin at 1-800-960-0052 for follow-up if orders
are not received within 10 business days of the estimated shipping
date. Provide the following information:
- Date the order was first placed and the estimated shipping date.
- Employer name, EIN and telephone number
Employers with questions about this bulletin should contact ETF’s
Employer Communication Center at (608) 264-7900.