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.

What Your Agent Can Do

Your financial power of attorney document determines the scope of your agent's authority. You may give your agent the ability to make many changes to your WRS account or limit them to a few actions.