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May 22, 2017

Income Continuation Insurance (ICI) Employer Statement (ET-5351) Form Revised

The Income Continuation Insurance (ICI) Employer Statement (ET-5351) form has been updated and simplified. In addition, the following information has been added:

  • Clarification that the employee’s last day paid is not the date of the last check.
  • A new salary period option along with instructions for situations when the ICI claimant was previously on unpaid a leave of absence, or returns to work and then files a new ICI claim.

You will receive this form for completion from Aetna, the third party administrator, when an employee files an ICI claim. This form is also available on the ETF Employer forms page.

Please direct questions or comments to the Aetna case owner who sends you the form. They will forward feedback to ETF.

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