| Number | Title | Description | Audience |
|---|---|---|---|
| ET-2307 | Income Continuation Insurance Application - State | Complete and then submit to your employer to apply for income continuation insurance. |
Active Employee, State Employer |
| ET-2311 | COBRA Continuation - Conversion Notice | Under federal law, known as COBRA, you and your qualified beneficiaries may continue group health insurance coverage, if eligible. |
Active Employee, Local Employer, State Employer |
| ET-2314 | Request for Treatment as an Assistance Eligible Individual | The American Rescue Plan Act of 2021 (ARP) subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1, 2021 through September 30, 2021. |
Local Employer, State Employer |
| ET-2314a | Model COBRA Subsidy Notice | This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed. |
Local Employer, State Employer |
| ET-2319 | Rehired Annuitant | WRS annuitants who have met all terms and conditions associated with having a valid termination and meeting the minimum break in service requirement may return to work for a WRS employer. |
Retiree, Local Employer, State Employer |
| ET-2331 | Health Insurance Application/Change for Retirees | Retirees, enroll in health insurance or change your coverage. |
Retiree, Other Benefit Recipient, Local Employer, State Employer |
| ET-2340 | Automatic Premium Conversion Waiver/Revocation of Waiver | Complete this form to waive your participation in automatic premium conversion, or to revoke a waiver of premium conversion that you filed previously. |
Active Employee, Local Employer, State Employer |
| ET-2366 | Income Continuation Insurance Application--Local Employee | Complete and then submit to your employer to apply for income continuation insurance. |
Active Employee, Local Employer |
| ET-2384 | Employee Reimbursement Accounts (ERA) Enrollment | For UWs use only, as a paper alternative for a member who cannot complete their ERA enrollment online. |
Active Employee, Local Employer, State Employer |
| ET-2385 | Health Savings Account (HSA) Enrollment | For UWs use only, as a paper alternative for a member who cannot complete their HSA enrollment online. |
Active Employee, Local Employer, State Employer |