Form Active Employee / Local Employer / State Employer

Health Care Provider Form

Complete this form using results from your most recent health care provider visit to earn credit for the Well Wisconsin Program.

25ET-2180
Brochure Active Employee / Retiree / Other Benefit Recipient / Local Employer / State Employer

2025 Uniform Benefits Certificate of Coverage

This Certificate of Coverage is your Summary Plan Description and contains the Uniform Benefits offered under the Group Health Insurance Program.

24ET-2180
Brochure Active Employee / Retiree / Other Benefit Recipient / Local Employer / State Employer

2024 Uniform Benefits Certificate of Coverage

This Certificate of Coverage is your Summary Plan Description and contains the Uniform Benefits offered under the Group Health Insurance Program.