ET-4307
Form Active Employee / Retiree

Medicare Eligibility Statement

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.

HIPAA: Special Enrollment Opportunities

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

STAR Employees Enrollment

State of Wisconsin, Legislature, and Wisconsin Court System Employees covered by STAR

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025
ET-2327
Brochure Active Employee / Retiree / Other Benefit Recipient

Living Benefits

Living Benefits are the proceeds of your life insurance coverage under the Wisconsin Public Employers Group Life Insurance program that are paid to you while you are still living rather than to your beneficiaries after your death.

ET-8935
Brochure Active Employee / Retiree

Ombudsperson Services

The ETF ombudsperson staff attempts to resolve questions and issues on behalf of WRS members.