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ET-5350

Form Active Employee

Income Continuation Insurance Medical Report

Physician report to verify eligibility for an income continuation insurance claim.

You or Your Dependent Involuntarily Lose Eligibility or All Employer Contribution for Other Group Medical Coverage

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

You or Your Dependent Gain Eligibility for Other Group Medical Coverage

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

You Have a New Dependent

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

Life Change Events and Documentation Requirements

If you are eligible to enroll in or change plans due to a qualified life change event, you may be asked to provide documents (employees to your employer, retirees to ETF) to confirm your eligibility.

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

ET-1119a

Brochure State Employer

State of Wisconsin Income Continuation Insurance Plan Language

This plan language is intended to be used with the state and local income continuation insurance manuals.

Report Active Employee / Board Member / State Employer

State Income Continuation Insurance Plan Actuarial Valuation 2007

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the State Income Continuation Insurance Plan as of December 31, 2007.

Report Active Employee / Board Member / Local Employer

Local Income Continuation Insurance Plan Actuarial Valuation 2007

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Local Income Continuation Insurance Plan as of December 31, 2007.

ET-2405

Form Active Employee / Retiree

ETF Insurance Complaint Form

If you filed a grievance with the plan or benefit administrator and are dissatisfied with the final decision, you can request an administrative review from ETF.

ET-4943

Brochure Active Employee / Retiree / Other Benefit Recipient

Administrative Appeal Process

This brochure is designed to assist you in understanding the administrative appeals process as it relates to ETF. It is not intended to substitute for the legal advice or assistance of an attorney.