Number Title Description Audience
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-2319L Return to Work

This form is for employers returning to Wisconsin Retirement System employment after taking a lump-sum separation benefit.

 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
ET-2440 County Jailer Election of Protective or General Category Status

Local county employers, please distribute this form to your jailers so they can record their decision to be either a general category employee or a protective category employee for WRS benefit purposes.

Active Employee, Local Employer