Request for Treatment as an Assistance Eligible Individual

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Summary

This form is only used by former State of Wisconsin employees or local government employees who participated in the Wisconsin Public Employers Group Health Insurance Program.

This must be provided with the Model COBRA Subsidy Notice (ET-2314a).

President Biden signed H.R. 1319, the American Rescue Plan Act of 2021 (ARP), on March 11, 2021. This law subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1, 2021 through September 30, 2021.

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.