The Wisconsin Public Employers Group Life Insurance program provides continuation of your group life insurance after retirement if you meet the eligibility requirements.
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.
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