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.
A resolution for the employer to offer the Wisconsin Public Employers Group Health Insurance program to eligible personnel through the program of the State of Wisconsin Group Insurance Board, and agrees to abide by the terms of the program.
Save on a wide variety of everyday medical, dental, vision, day care, parking, and transit expenses with a pre-tax savings account. It’s a tax break that’s simple to use.
Plan Year
2024
Program Option
State Employee and Retiree Health Plan & Supplemental Benefits
ET-2331
Form
Retiree /
Other Benefit Recipient /
Local Employer /
State Employer