Employers must issue this notice to employees within 14 days of becoming aware of a qualifying event that will cause an employee to lose eligibility to participate in the FSA or limited purpose FSA program(s).
Employers should submit this form when first aware that an insured employee is unable to work due to illness or injury and will be unable to perform any work or to engage in any occupation for an indefinite period.
If you are an employee of the state, UW Hospitals and Clinics, or the Universities of Wisconsin (including Craft Workers), you may be eligible to receive up to $2,000 from your employer if you opt out of health insurance coverage under the State of Wisconsin Group Health Insurance Program.
Program Option
State Employee and Retiree Health Plan & Supplemental Benefits
