ET-4109
Form Active Employee / Retiree

Medicare Enrollment for Retiring Employees

The following information is for employees who will retire in the next three months and will be transitioning into Medicare under the State or the Wisconsin Public Employers Group Health Insurance Programs.

What Your Agent Can Do

Your financial power of attorney document determines the scope of your agent's authority. You may give your agent the ability to make many changes to your WRS account or limit them to a few actions.

Disclaimer of Liability

Neither the state of Wisconsin, the Department of Employee Trust Funds (ETF), nor any of its programs nor any of its employees, shall be held liable for any improper or incorrect use of, or inability to use, the information described and/or contained herein.

ET-7406
Form Active Employee / Retiree / Other Benefit Recipient

Authorization to Disclose Non-Medical Information

Wisconsin law allows ETF to release personal information to a third party if the member has first provided ETF with a valid written authorization. Use this form to authorize the release of non-medical information.

You Are Laid off or Start a Leave of Absence (Active Employees Only)

Experiencing this life event may allow you to make changes to your accident plan or health, dental, vision, or long-term care insurance.

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
  • State Employee and Retiree Health Plan & Supplemental Benefits