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Employers should submit this form when first aware that an insured employee is unable to work due to illness or injury and will be unable to perform any work or to engage in any occupation for an indefinite period.
The annual open enrollment period starts Sept. 30 and ends Oct. 20, 2024. Learn more about what’s new for 2025, and attend an online Insurance Benefits Forum.
Report
Active Employee /
Board Member /
Local Employer /
State Employer
Submit your Well Wisconsin Award nominations and wellness grant applications. Help promote new classes and events and share updated program information.
Employer certification that a WRS annuity or lump-sum payment made to the survivor of the member named in this form may be eligible for an income tax exemption.