ET-4427
Form Active Employee / Retiree / Other Benefit Recipient

Statement of Incapacity for Finances and Property

Form for the member’s physician to complete if the member cannot manage property, finances or business affairs because of an impairment in the ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance.

Your Spouse or Dependent Dies

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 Annuitant Health Program (LAHP)
  • 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

Aspirus Health Plan

Major Health Systems
  • Advocate Aurora Health
  • Aspirus Health 
  • Bellin Health
  • Children's Wisconsin
  • ThedaCare
  • UW Health 
Full Service Areas
  • Forest County
  • Langlade County
  • Lincoln County
  • Marathon County
  • Oneida County
  • Portage County
  • Shawano County
  • Taylor County
  • Vilas County
  • Waushara County
  • Wood County
Limited Service Areas
  • Clark County
  • Florence County
  • Iron County
  • Price County