ET-2305
Form Active Employee / Local Employer / State Employer

Evidence of Insurability

Employees who did not enroll for group life insurance coverage during their initial enrollment period, or insured employees who wish to apply for more insurance for themselves or their spouse or dependents, may apply using this form.

Sick Leave Credit Calculations

Learn how your sick leave credits are calculated for Accumulated Sick Leave Credit Conversion (ASLCC) and Supplemental Health Insurance Conversion Credit (SHICC).

ET-4427
Form Active Employee / Retiree / Other Benefit Recipient

Statement of Incapacity for Finances and Property

Form for the member’s physician to complete if the member cannot manage property, finances or business affairs because of an impairment in the ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance.

Your Unmarried Dependent Over Age 26 Becomes Disabled and Gains Eligibility

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 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