Employees who did not enroll for group life insurance coverage during their initial enrollment period, or insured employees who wish to apply for more insurance for themselves or their spouse or dependents, may apply using this form.
The State of Wisconsin Group Insurance Board contracts with a Pharmacy Benefit Manager to provide administrative services to State of Wisconsin and Wisconsin Public Employer group health insurance program participants.
24ET-2128
Brochure
Active Employee /
Retiree /
Local Employer