ET-1908
Form Local Employer / State Employer

Employer Attestation For Documentation Received

Employers, use this form to verify that you viewed the employee’s original required document(s) to verify the employee or dependent(s) is eligible for benefit coverage, as administered by ETF.

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 Have a Job Change Where You Gain a Greater Share of Employer Contribution Toward Your Coverage (Active Employees Only)

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 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 Job Change Where You Lose a Significant Share of Employer Contribution Toward Your Coverage (Active Employees Only)

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 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
Report Active Employee / Retiree / Board Member / Local Employer / State Employer

Duty Disability Program Actuarial Valuation 2010

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2011.

Report Active Employee / Retiree / Board Member / Local Employer / State Employer

Duty Disability Program Actuarial Valuation 2013

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2014.

Report Active Employee / Board Member / Local Employer / State Employer

Duty Disability Program Actuarial Valuation 2011

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2012.

Report Active Employee / Retiree / Board Member / Local Employer / State Employer

Duty Disability Program Actuarial Valuation 2012

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2013.

Report Active Employee / Retiree / Board Member / Local Employer / State Employer

Duty Disability Program Actuarial Valuation 2016

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2017.