| Commuter Benefits |
Title |
Format |
Revision
Date |
Form
Number |
| Commuter Benefits Users Guide |
PDF |
6/2007 |
|
| Commuter Benefits Transit Enrollment Form |
PDF |
6/2007 |
|
| Commuter Benefits Parking Enrollment Form |
PDF |
6/2007 |
|
|
| Employee Reimbursement
Account |
Title |
Format |
Revision
Date |
Form
Number |
| 2009 ERA Enrollment Form |
PDF |
9/2008 |
|
| Authorization to Disclose Non-Medical
Individual Personal Information |
PDF |
3/2004 |
ET-7406 |
Medical Expense Account Continuation
Election Form |
PDF
|
5/2006 |
ET-1518 |
|
Remittance Report
|
PDF
Word |
8/2002 |
ET-1516 |
| |
| Health Insurance |
Title |
Format |
Revision
Date |
Form
Number |
| 2010 Health Plan Contacts |
PDF |
9/2009 |
ET-1728 |
| 2009 Monthly Coverage Report -
State Employees |
PDF
Word |
11/2008 |
ET-1607 |
| 2009 Monthly Coverage Report -
Annuitants |
PDF
Word |
11/2008 |
ET-1645 |
| 2009 Monthly Coverage Report -
WPE Annuitants Deductible HMO/ Deductible Standard PPP |
PDF
Word |
11/2008 |
ET-1646 |
| 2009 Monthly Coverage Report -
WPE Annuitants Traditional HMO/ Standard PPP |
PDF
Word |
11/2008 |
ET-1658 |
| 2009 Monthly Coverage Report -
WPE Annuitants Traditional HMO/Classic Standard Plan |
PDF
Word |
11/2008 |
ET-1657 |
| 2009 Monthly Coverage Report -
WPE Deductible HMO/ Deductible Standard PPP |
PDF
Word |
11/2008 |
ET-1648 |
| 2009 Monthly Coverage Report -
WPE Deductible HMO/Deductible Standard Plan |
PDF
Word |
11/2008 |
ET-1647 |
| 2009 Monthly Coverage Report -
WPE Traditional HMO/ Classic Standard Plan |
PDF
Word |
11/2008 |
ET-1630 |
| 2009 Monthly Coverage Report -
WPE Traditional HMO/Standard PPP |
PDF
Word |
11/2008 |
ET-1643 |
| Accumulated Leave Certification
|
PDF |
3/2009 |
ET-4306 |
| Authorization to Disclose Non-Medical
Individual Personal Information |
PDF
Word |
3/2004 |
ET-7406 |
| COBRA Continuation Conversion Supplemental
Notice |
PDF |
3/2009 |
ET-2314 |
| Continuation - Conversion Notice |
PDF
Word |
2/2008 |
ET-2311 |
| Group Health Insurance Application/Change
Form |
PDF |
9/2009 |
ET-2301 |
| Health Insurance Election for Military
Service Personnel - State |
PDF
Word |
10/2001 |
ET-2350 |
| Health Insurance Monthly Additions
Report |
PDF
Word |
11/2005 |
ET-2610 |
| Health Insurance Monthly Changes
Report |
PDF
Word |
11/2005 |
ET-2614 |
| Health Insurance Monthly Deletions
Report |
PDF
Word |
11/2005 |
ET-2612 |
| Health Insurance Summary –
2009 - WPE Traditional HMO/ Classic Standard Plan |
PDF
Word |
11/2008 |
ET-1631 |
| Health Insurance Summary –
2009 - WPE Annuitants Deductible HMO/Deductible Standard Plan |
PDF
Word |
11/2008 |
ET-1653 |
| Health Insurance Summary –
2009 - WPE Annuitants Deductible HMO/Deductible Standard PPP |
PDF
Word |
11/2008 |
ET-1654 |
| Health Insurance Summary –
2009 - WPE Annuitants Traditional HMO/Classic Standard Plan |
PDF
Word |
11/2008 |
ET-1655 |
| Health Insurance Summary –
2009 - WPE Deductible HMO/ Deductible Standard Plan |
PDF
Word |
11/2008 |
ET-1649 |
| Health Insurance Summary –
2009 - WPE Deductible HMO/ Deductible Standard PPP |
PDF
Word |
11/2008 |
ET-1650 |
| Health Insurance Summary –
2009 - WPE Traditional HMO/ Standard PPP |
PDF
Word |
11/2008 |
ET-1652 |
| Health Insurance Summary
– 2009 - State |
PDF
Word |
11/2008 |
ET-1608 |
| Health Insurance Summary –
2009 - Wisconsin Public Employers |
PDF
Word |
11/2008 |
ET-1644 |
| Health Insurance Transfer
Report |
PDF
(Fill-In Form)
Word |
4/2007 |
ET-1615 |
| How to Become a Participating Employer
Under the Wisconsin Public Employers' Group Health Insurance
Program |
PDF |
8/2009 |
ET-1139 |
| Sick Leave Escrow Application |
PDF |
9/2005 |
ET-4305 |
| |
| Income Continuation |
Title |
Format |
Revision
Date |
Form
Number |
| Authorization to Disclose Non-Medical
Individual Personal Information |
PDF |
3/2004 |
ET-7406 |
| Claim Filing Instructions for the
Income Continuation Insurance (ICI) and Long-Term Disability
Insurance (LTDI) Plans |
PDF |
5/2008 |
ET-5106 |
| How to Become a Participating Employer
Under the Wisconsin Public Employers' Group Income Continuation
Insurance Program |
PDF
HTML |
3/2007 |
ET-1140 |
| Income Continuation Insurance (ICI)
Employer Statement |
PDF
Word |
2/2007 |
ET-5351 |
| Income Continuation Insurance Forms/Booklets
Order Form |
PDF |
4/2007 |
|
| Income Continuation Insurance Report
of Employment and Earnings |
PDF
Word |
12/2004 |
ET-5901 |
| Income Continuation Monthly Premium
Report - State |
PDF |
7/2005 |
ET-1611 |
| Income Continuation Monthly Premium
Report - UW Faculty |
PDF |
7/2005 |
ET-1612 |
| Income Continuation Monthly Premium
Report - Local |
PDF |
1/2005 |
ET-1629 |
ICI Contract and Plan Language
ICI Contract - Attachment A & B
ICI Contract - First Amendment
ICI Contract - Second Amendment
ICI Contract - Third Amendment
ICI Contract - Fourth Amendment
ICI Contract - Fifth Amendment
ICI Contract - Sixth Amendment
ICI Contract - Seventh Amendment
ICI Contract - Eighth Amendment
ICI Contract - Nineth Amendment
ICI Contract - Proposed 2005 Changes |
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF
PDF |
|
|
| |
| Life Insurance |
Title |
Format |
Revision
Date |
Form
Number |
| 2009 Local Government Employees
Monthly Life Insurance Premium Rate Chart |
PDF |
7/2009 |
ET-1706 |
| 2009 State Employees Monthly Life
Insurance Premium Rate Chart |
PDF |
7/2009 |
ET-1705 |
| 2007 State and Local Employees
Monthly Life Insurance Premium Rate Chart - Age 70 and Over |
PDF |
4/2007 |
|
| Authorization to Disclose Non-Medical
Individual Personal Information |
PDF |
4/1999 |
ET-7406 |
| Beneficiary Designation |
PDF |
6/2007 |
ET-2320 |
| Evidence of Insurability |
PDF |
6/2008 |
ET-2305 |
| Group Life Insurance Collection
Report - State |
PDF |
9/2003 |
ET-1610 |
| How to Become a Participating Employer
Under the Wisconsin Public Employer's Group Life Insurance Program |
PDF |
11/2008 |
ET-1107 |
- Employer Resolution to Pay Entire Premium
|
PDF |
4/1999 |
ET-1301 |
- Resolution for Inclusion Under Group Life
Insurance
|
PDF |
10/2007 |
ET-1303 |
| Life Insurance Application/Cancellation/Refusal |
PDF |
4/2008 |
ET-2304 |
| Notice of Death |
PDF |
11/2002 |
ET-6301 |
| Notice of Death for Spouse or Dependent
Child |
PDF |
6/2006 |
ET-6303 |
| Request for Disability Premium
Waiver |
PDF |
9/2002 |
ET-5306 |
| |
| Long-Term Disability |
Title |
Format |
Revision
Date |
Form
Number |
| Claim Filing Instructions for the
Income Continuation Insurance (ICI) and Long-Term Disability
Insurance (LTDI) Plans |
PDF |
5/2008 |
ET-5106 |
| |
| Wisconsin Retirement
System |
Title |
Format |
Revision
Date |
Form
Number |
| Additional Contributions Report |
PDF |
1/2009 |
ET-2535 |
| Agent Designation Form |
PDF
(Fill-In Form) |
9/2000 |
ET-1313 |
| Authorization to Disclose Non-Medical
Individual Personal Information |
PDF |
3/2004 |
ET-7406 |
| Authorization for Plan-to-Plan
Transfer to Purchase Wisconsin Retirement System Service Credit |
PDF |
7/2003 |
ET-1323 |
| Automated Clearing House (ACH)
Direct Withdrawal Authorization |
PDF |
9/1999 |
ET-1734 |
| Beneficiary Designation |
PDF |
6/2007 |
ET-2320 |
| Distribution Code/Address Specifications
for Statement of Benefits |
PDF |
1/2009 |
ET-9060 |
| Distribution Code/Address Option
Selection for January 1, 2009 WRS Statement of Benefits |
PDF |
1/2009 |
ET-9061 |
| Distribution Code/Employee Address
Report (CDAD) |
PDF |
1/2008 |
ET-9066 |
| Election to Participate in the
Variable Trust Fund |
PDF |
1/2009 |
ET-2356 |
| Electronic Reporter Transmittal |
PDF
Word |
10/2006 |
ET-2536 |
| Employee Identification Correction
Change |
PDF
(Fill-In Form) |
3/2006 |
ET-2810 |
| On-Line Network for Employers Security
Agreement |
PDF |
02/2009 |
ET-8928 |
| Employer Options for Providing
Increased Retirement Benefits |
PDF |
8/2005 |
ET-1137 |
| Employee Transaction Report |
PDF |
10/2007 |
ET-2533 |
| How to Become a Participating Employer
Under the Wisconsin Retirement System |
PDF |
12/2008 |
ET-1129 |
|
|
PDF
(Fill-In Form) |
9/2000 |
ET-1313 |
- Prior Service Cost Study Employees Eligible for WRS
|
PDF |
10/2001 |
ET-1321 |
- Resolution of Inclusion Under the Wisconsin Retirement
System
|
PDF |
9/2000 |
ET-1319 |
| Income Tax Withholding Election |
PDF |
3/2006 |
ET-4310 |
| Limited Power-of-Attorney for Appeal |
PDF |
4/1999 |
ET-4944 |
| Maximum Additional Contributions
Worksheet |
PDF |
1/2009 |
ET-2566 |
| New Employee Benefit Checklist |
PDF |
5/2007 |
ET-2572 |
| Rehired Annuitant Election |
PDF |
3/2006 |
ET-2319 |
| WRS Enrollment |
PDF
(Fill-In Form) |
3/2006 |
ET-2316 |
| WRS Previous Service Checks |
PDF |
6/2005 |
ET-1715 |
