Income Continuation Insurance Report of Employment and Earnings

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Summary

Employers, complete this form to notify ETF of a claimant’s change in work status and/or earnings paid to the individual after the elimination period.

If you would like to complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.

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