Notice of Privacy Practices

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

General Privacy Notice

The Wisconsin Department of Employee Trust Funds is a state agency. ETF administers Wisconsin Retirement System and other benefits for state and local government employees. Benefits include retirement, health, and sick leave benefits; disability benefits; life insurance; income continuation insurance; and pre-tax savings accounts.

To provide you with these services, ETF maintains certain personal information about you. The purpose of this document is to help you understand what types of information we have, why we have it, and how we use and protect it.

ET-6301
Form Other Benefit Recipient

Notice of Death

Notify the third party administrator of the group life insurance program of a member death.

ET-2314a
Form Local Employer / State Employer

Model COBRA Subsidy Notice

This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed. 

ETJ0060 Request for Proposals (RFP)

Federal Tax Counsel

Request for Proposals for the State of Wisconsin Department of Employee Trust Funds ETF RFP ETJ0060 – Federal Tax Counsel

***DO NOT use the eSupplier Portal to submit questions or to submit a proposal. Instructions for submitting questions and proposals are included in the RFP.***

ET-2311
Form Active Employee / Local Employer / State Employer

COBRA Continuation - Conversion Notice

Under federal law, known as COBRA, you and your qualified beneficiaries may continue group health insurance coverage, if eligible.

National Medical Support Notice

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

Notice of Creditable Coverage for Medicare Part D

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

ACA: Marketplace Health Insurance Coverage Options Notice

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