You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.
This document, “Long-Term Care Insurance Standards,” serves as a resource for insurers interested in offering state employees and retirees long-term care insurance (LTCI).
ET-2301
Form
Active Employee /
Local Employer /
State Employer