calculators
Member Education
forms and publications
news
about etf
frequently asked questions
contact etf
site map
related links
home
top of page
home
members retirees employers governing boards careers at etf
 
Publications

Employer Forms and Brochures

Some documents on this site are in Adobe Acrobat PDF format. Download a free version. Adobe Reader does not allow users to save completed fillable PDFs to their computer. Refer to the Adobe Web site for more information on fillable PDFs.

Annual Processing
Commuter Benefits
Disability Benefits
Employee Reimbursement Account
Health Insurance
Income Continuation Insurance
Life Insurance
Other Insurance Programs
Wisconsin Retirement System

Manuals
Member Forms and Brochures Alphabetically
Member Forms and Brochures by ET- Number

Benefit Request Form (ET-7301)

Commuter Benefits

Commuter Benefits Users Guide

Commuter Benefits Transit Enrollment Form

Commuter Benefits Parking Enrollment Form

 
Disability Benefits

Claim Filing Instructions for the Income Continuation Insurance (ICI) and Long-Term Disability Insurance (LTDI) Plans (ET-5106)

Disability Retirement Benefits Folder (ET-5107)

Disability Retirement Benefits Reference Guide (ET-5102)

Long-Term Disability Insurance Folder (ET-5108)
Long-Term Disability Insurance Reference Guide (ET-5109)
 
Employee Reimbursement Account

Authorization to Disclose Non-Medical Individual Personal Information (ET-7406)   

Medical Expense Account Continuation Election Form (ET-1518)

FSA/LPFSA/Transportation and Parking Remittance Report (ET-1516)

 
Health Insurance

Authorization to Disclose Non-Medical Individual Personal Information (ET-7406) (PDF Version) (Fillable Word Version)

Benefit/Health Fair Request Form (ET-7117) (Fillable Word Version)

Continuation - Conversion Notice (ET-2311) (Fillable Word Version)

Employer Verification of Health Insurance Coverage (ET-4814)

Existing Employer Option Selection Resolution WPE Health Insurance (ET-1152)

Group Health Insurance Application/Change Form (ET-2301)

Health Insurance Benefit Change (ET-2171) 

Health Insurance Election for Military Service Personnel - State (ET-2350) 

Health Plan Carrier Codes and Display Names (ET-1159)

Health Plan Contacts (ET-1728)

How To Join The Wisconsin Public Employers Group Health Insurance Program For Non-WRS Employers (ET-1156)

How to Become a Participating Employer Under the Wisconsin Public Employers' Group Health Insurance Program (ET-1139)

Notice of Nondiscrimination (ET-8108)

Sick Leave Escrow Application (ET-4305) 

Online Network for Health Plans Security Agreement (ET-8937) 

 
Income Continuation Insurance (ICI)

Authorization to Disclose Non-Medical Individual Personal Information (ET-7406)  

Claim Filing Instructions for the Income Continuation Insurance (ICI) and Long-Term Disability Insurance (LTDI) Plans (ET-5106)

Evidence of Insurability Instructions--Income Continuation Insurance (ICI) (ET-2308)

How to Become a Participating Employer Under the Wisconsin Public Employers' Group Income Continuation Insurance Program (ET-1140) 

Income Continuation Insurance (ICI) Employer Statement (ET-5351) (PDF Version) (Fillable Word Version)

Income Continuation Insurance Application--Local Employee (ET- 2366)

Income Continuation Insurance Application--State Employee (ET- 2307)

Income Continuation Insurance - Claim Packet (Local)
Income Continuation Insurance Booklet (ET-2129)
Income Continuation Insurance Medical Report (ET-5350)
Income Continuatiion Insurance Claim Instructions (ET-5352)

Income Continuation Insurance - Claim Packet (State)
Income Continuation Insurance Booklet (ET-2106)
Income Continuation Insurance Medical Report (ET-5350)
Income Continuatiion Insurance Claim Instructions (ET-5352)

ICI Premium Table (2017 State)
ICI Premium Table (2016 State)

ICI Premium Rates - Local Government (2011)
There will be a premium holiday in 2017 for local ICI participants.

Income Continuation Insurance Report of Employment and Earnings (ET-5901) (PDF Version) (Fillable Word Version)

Income Continuation Monthly Premium Report - State (ET-1611)

Income Continuation Monthly Premium Report - Local (ET-1629)

ICI Contract and Plan Language
ICI Contract - Attachment A & B
ICI Contract - First Amendment
ICI Contract - Second Amendment
ICI Contract - Third Amendment
ICI Contract - Fourth Amendment
ICI Contract - Fifth Amendment
ICI Contract - Sixth Amendment
ICI Contract - Seventh Amendment
ICI Contract - Eighth Amendment
ICI Contract - Nineth Amendment
ICI Contract - Proposed 2005 Changes
  
 
Life Insurance

Authorization to Disclose Non-Medical Individual Personal Information (ET-7406)

Beneficiary Designation (ET-2320)

Employee/Employer Certification Annuitant Continuant Coverage--Private Pension Fund (ET-4620)

Evidence of Insurability (ET-2305)

Group Life Insurance Collection Report - State (ET-1610)

Group Life Insurance Continuation Application (ET-2154)

Group Life Insurance Local Overview

Group Life Insurance State Overview

How to Become a Participating Employer Under the Wisconsin Public Employer's Group Life Insurance Program (ET-1107)

Employer Resolution to Pay Entire Premium (ET-1301)

Resolution for Inclusion Under Group Life Insurance (ET-1303)

Life Insurance Application/Cancellation/Refusal (ET-2304)

Life Suite - Summary

Notice of Death (ET-6301)

Notice of Death for Spouse or Dependent Child (ET-6303)

Request for Disability Premium Waiver (ET-5306) 

 
Other Insurance Programs

Anthem DentalBlue Continuation

Dental Wisconsin Continuation

Epic Benefits+ Continuation

Vision Service Plan (VSP) Continuation

 
Wisconsin Retirement System

Agent Designation Form (ET-1313)

Authorization to Disclose Non-Medical Individual Personal Information (ET-7406)

Authorization for Plan-to-Plan Transfer to Purchase Wisconsin Retirement System Service Credit (ET-1323)

Automated Clearing House (ACH) Direct Withdrawal Authorization (ET-1734)

Beneficiary Designation (ET-2320)

Distribution Code/Address Specifications for Statement of Benefits (ET-9060)

Distribution Code/Address Option Selection for January 1 WRS Statement of Benefits (ET-9061)

Election to Participate in the Variable Trust Fund (ET-2356)

Electronic Reporter Transmittal (ET-2536)

Employee Identification Correction Change (ET-2810)

Employer Certification of Eligibility for Public Safety Officer Survivor Benefit Tax Exemption (ET-6329)

Employer Options for Providing Increased Retirement Benefits (ET-1137)

Employee Transaction Report (ET-2533)

Federal Withholding Requirements & Direct Rollover Option (ET-7289)

How to Become a Participating Employer Under the Wisconsin Retirement System (ET-1129)  

Designation of Agent (ET-1313)

Prior Service Cost Study Employees Eligible for WRS (ET-1321)

Resolution of Inclusion Under the Wisconsin Retirement System (ET-1319)

Waiver/Election of Participation in the Wisconsin Retirement System (ET-2300)

Income Tax Withholding Election (ET-4310)

Information for Rehired Annuitants (ET-4105)

Limited Power-of-Attorney for Appeal (ET-4944)

Maximum Additional Contributions Worksheet (ET-2566) 

New Employee Benefit Checklist (ET-2572)

On-Line Network for Employers Security Agreement (ET-8928)

Post Retirement Benefit Adjustments Historical Summary (ET-4702)

Rehired Annuitant Form (ET-2319)

Resolution to Increase Prior Creditable Service (ET-1311)

USERRA Certification (ET-4560)

Federal USERRA Notice

USERRA Make-up Contributions Montly Tracking Report (ET-2573)

 

supporting excellence in Wisconsin public service