ET-4938
Form Active Employee / Retiree / Other Benefit Recipient

Appeal Form

Submit this completed form to ETF to appeal a determination regarding your ETF-administered benefit(s).

Calculator and stethoscope

Accumulated Sick Leave Credit Program

Find out how this program allows state employees to convert unused sick leave to credits to pay for health insurance during retirement, including pharmacy and optional Uniform Dental benefits.

Nurse helping support a patient with a cane

Long-Term Care Insurance

Available to state employees and retirees. Long-term care insurance covers medical services, such as nursing care or therapies. It also includes supportive services, such as bathing, dressing, getting in and out of bed, taking medicines, or preparing meals.

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

You or Your Dependent Has a Medicare Coverage Change (Retirees and Survivors 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 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