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
ET-2319
Form Retiree / Local Employer / State Employer

Rehired Annuitant

WRS annuitants who have met all terms and conditions associated with having a valid termination and meeting the minimum break in service requirement may return to work for a WRS employer.

ET-7282
Form Active Employee / Retiree / Other Benefit Recipient

Direct Deposit Authorization

Authorize ETF and the financial institution you name to deposit funds such as annuity payments directly into your bank account.

ET-2321
Form Active Employee / Retiree

Beneficiary Designation - Alternate

If you wish to specify who shall receive a primary beneficiary’s share of a death or life insurance benefit if a primary beneficiary is deceased, you must use this alternate beneficiary designation form.

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.