ET-2314a
Form Local Employer / State Employer

Model COBRA Subsidy Notice

This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed. 

Breakdown of Your Costs by Plan Design

Learn how much you can expect to pay when you visit the doctor, get an X-ray and more.
Plan Year
    2024
Program Option
    Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits

Breakdown of Your Costs by Plan Design

Learn how much you can expect to pay when you visit the doctor, get an X-ray and more.
Plan Year
    2024
Program Option
    Local Deductible Health Plan (PO14) & Supplemental Benefits

State and Federal Notifications

Program Option
  • Local Annuitant Health Program (LAHP)
  • 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

Breakdown of Your Costs by Plan Design

Learn how much you can expect to pay when you visit the doctor, get an X-ray and more.
Plan Year
    2024
Program Option
    Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits

Breakdown of Your Costs by Plan Design

Learn how much you can expect to pay when you visit the doctor, get an X-ray and more.
Plan Year
    2024
Program Option
    Local Traditional Health Plan (PO12) & Supplemental Benefits
ET-5103
Brochure Active Employee

Duty Disability and Survivor Benefits

The Duty Disability Insurance Program is an income replacement program. Duty disability benefits may be payable to protective occupation participants if you have been injured while performing your duties or contracted a disease due to your occupation.

Notice of Creditable Coverage for Medicare Part D

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