Employees who did not enroll for group life insurance coverage during their initial enrollment period, or insured employees who wish to apply for more insurance for themselves or their spouse or dependents, may apply using this form.
This application allows you to apply to enroll in the Income Continuation Insurance (ICI) Program if you did not enroll when originally eligible or if coverage was canceled.
ET-4112
Brochure
Active Employee /
Retiree /
Local Employer /
State Employer
If you are an employee of the state, UW Hospitals and Clinics, or the Universities of Wisconsin (including Craft Workers), you may be eligible to receive up to $2,000 from your employer if you opt out of health insurance coverage under the State of Wisconsin Group Health Insurance Program.
Program Option
State Employee and Retiree Health Plan & Supplemental Benefits
