et4317.pdf
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Summary

Re-enroll for group health insurance coverage during the annual health benefits open enrollment period or after an involuntary loss of your comparable non-state coverage, if eligible.

To complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.

  • Once you click on the "Submit your completed application securely here" link below, you will be taken to the Box website, which is a secure and confidential way to send your information to ETF. You don’t need an account with Box to submit forms with this link. Basic contact information is required in case the form is not readable.
  • It will take a few days to be uploaded into your records.
  • After you submit, you'll see "Success! Your file has been submitted." 

Submit your completed application securely here.

Note: ETF is unable to assist with Adobe Acrobat Reader technical or compatibility issues. If you need assistance, please visit Adobe’s help site.