ET-4110
Form Retiree

Health Insurance - Integrated with Medicare

The following information is for those retirees who are transitioning into Medicare under the State or the Wisconsin Public Employers Group Health Insurance Programs.

ET-4322
Form Active Employee / Retiree

QDRO - Military Service Certification and Affidavit 

Wisconsin law requires the WRS participant to complete this form and submit it ETF when a portion of the participant’s account is awarded to an alternate payee via a Qualified Domestic Relations Order (QDRO).

HSA Eligibility

There are a number of requirements you must meet in order to be eligible for an HSA.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2024
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.

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

Duty Disability Program Actuarial Valuation 2014

This report presents the results of the annual actuarial valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2015.

ET-4307
Form Active Employee / Retiree

Medicare Eligibility Statement

You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.

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

Duty Disability Program Actuarial Valuation 2015

This report presents the results of the Annual Actuarial Valuation of benefit liabilities and costs of the Duty Disability Program as of January 1, 2016.

ET-7414
Form Active Employee / Retiree / Other Benefit Recipient

Authorization to Disclose Medical Information

This form gives ETF and entities that perform contracted services for ETF permission to release your designated medical information to a person or entity specified by you.

ET-4111
Form Retiree

Medicare Enrollment for Disability Retirees

If you retired due to a disability, you may be eligible for Medicare benefits. Medicare eligibility related to disability is available to persons who have received Social Security disability benefits for at least 24 months, who have End Stage Renal Disease (ESRD), or Lou Gehrig’s Disease (ALS).