You Have a Job Change Where You Lose a Significant Share of Employer Contribution Toward Your Coverage (Active Employees Only)

Experiencing this life event may allow you to make changes to your accident plan or health, dental, vision, or long-term care insurance.

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits
ET-7414
Form Active Employee / Retiree / Other Benefit Recipient

Authorization to Disclose Medical Information

This form gives ETF and entities that perform contracted services for ETF permission to release your designated medical information to a person or entity specified by you.

COBRA: Continuation of Coverage Rights for the Group Health Insurance Program

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits
ET-4307
Form Active Employee / Retiree

Medicare Eligibility Statement

You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.

ET-4925
Brochure Active Employee / Retiree / Other Benefit Recipient

How Divorce Can Affect Your WRS Benefits

Information on how a divorce may affect WRS benefits, beneficiary designations as well as information for the alternate payee.

HSA Eligibility

There are a number of requirements you must meet in order to be eligible for an HSA.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2024

COBRA / Continuation of Health Coverage FAQs

Program Option
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
Plan Year
  • 2024