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.

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan (PO17) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Traditional Health Plan (PO12) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Health Plan (PO16) & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    State Employee and Retiree Health Plan & Supplemental Benefits

Medicare Plan Designs Quick Comparison

Learn about the key differences between plan designs such as how much you'll pay per month, how much you can expect to pay when you visit the doctor, and if you will have nationwide coverage.
Plan Year
    2025
Program Option
    Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits