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Form Active Employee / Local Employer / State Employer

Health Care Provider Form

Complete this form using results from your most recent health care provider visit to earn credit for the Well Wisconsin Program.

Local Employers with Supplemental Options

Program Option

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

ET-8929

Fact Sheet Active Employee / Retiree / Local Employer / State Employer

Accumulated Sick Leave Conversion Credit Program & Supplemental Health Insurance Conversion Credit Program Fact Sheet

The ASLCC and SHICC programs were created by Wis. Stat. § 40.05 (4) (b). The ASLCC Program was first authorized in 1972; the SHICC program was first authorized in 1995.

ET-4702

Brochure Active Employee / Retiree / Other Benefit Recipient / Local Employer / State Employer

Post Retirement Benefit Adjustments Historical Summary

Historical summary of retirement fund adjustments and dividends.

Report Active Employee / Board Member / Local Employer / State Employer

WRS Annual Actuarial Valuation of Active Lives 2007

This report presents the annual actuarial valuations of non-retired members covered by the Wisconsin Retirement System as of December 31, 2007.

Report Active Employee / Retiree / Board Member / Local Employer

Local Income Continuation Insurance Plan Actuarial Valuation 2023

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Local Income Continuation Insurance Plan as of December 31, 2023.

ET-2314

Form Local Employer / State Employer

Request for Treatment as an Assistance Eligible Individual

The American Rescue Plan Act of 2021 (ARP) subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1, 2021 through September 30, 2021.

Report Active Employee / Retiree / Board Member / Local Employer

Local Income Continuation Insurance Plan Actuarial Valuation 2021

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Local Income Continuation Insurance Plan as of December 31, 2021.

Report Active Employee / Retiree / Board Member / Local Employer

Local Income Continuation Insurance Plan Actuarial Valuation 2024

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Local Income Continuation Insurance Plan as of December 31, 2024.

ET-2166

Brochure Active Employee / Retiree / Other Benefit Recipient / Board Member / Local Employer / State Employer

As of Sept. 23, 2017, the State of Wisconsin no longer allows the establishment of new domestic partnerships under Chapter 40 of the Wisconsin statutes. This brochure provides information about the benefit changes for established domestic partnerships.