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.
This application allows you to apply to enroll in the Income Continuation Insurance (ICI) Program if you did not enroll when originally eligible or if coverage was canceled.
ET-2340
Form
Active Employee /
Local Employer /
State Employer