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Complete this form to waive your participation in automatic premium conversion, or to revoke a waiver of premium conversion that you filed previously.

Employers may remit contributions and report adjustments for employee FSA/LPFSA/transportation and parking costs.

The income continuation insurance ICI benefit is a voluntary “income replacement” benefit payable if you become disabled.

This Summary Plan Description is a supplement to the Section 125 Cafeteria Plan Document (ET-1904), for members and employees. This publication summarizes the basic features of the plan.

Complete and then submit to your employer to apply for income continuation insurance.

Traditionally, flu clinics are held indoors. However, this year an outdoor clinic may better suit your needs.

For UWs use only, as a paper alternative for a member who cannot complete their HSA enrollment online.

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, 2019.

Certificate of Coverage for the Medicare Plus Plan for the 2024 plan year.

Certificate of Coverage for the Medicare Plus Plan for the 2025 plan year.