ET-4938
Form Active Employee / Retiree / Other Benefit Recipient

Appeal Form

Submit this completed form to ETF to appeal a determination regarding your ETF-administered benefit(s).

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

Account Minimums

To ensure accounts are being engaged with each year, ETF has set a minimum annual contribution and account balance for certain pre-tax savings accounts.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2024

Insurance Administration System (IAS) for Local Employers

A resource to keep local employers informed about the new Insurance Administration System project and the status of the implementation. Local employers can learn about the project, register for upcoming meetings, and view past meeting recordings.

ET-8108
Flyer Active Employee / Retiree / Other Benefit Recipient / Local Employer / State Employer

Nondiscrimination and Language Access

ETF complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.