Download PDF


Employers, please use this form to verify that you viewed the employee’s original required document(s) to verify the employee or dependent(s) is eligible for benefit coverage, as administered by the Department of Employee Trust Fund, and that the date provided is what was on the viewed document.

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.
  • After you submit, you'll see "Success! Your file has been submitted." 
  • It will take a few days to be uploaded into your records, at which point ETF staff will be able to view your document. If you have any questions, please contact ETF at 1-877-533-5020.

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 at