| Authorizations |
Title |
Format |
Revision
Date |
Form
Number |
| Authorization to Disclose Medical Information
|
PDF |
05/2006 |
ET-7414 |
| Request to Copy or Inspect Medical Information |
PDF |
05/2006 |
ET-2421 |
| Disability Insurance |
Title |
Format |
Revision
Date |
Form
Number |
| Disability Benefits |
PDF |
4/2008 |
ET-5102 |
| Income Tax Withholding Election |
PDF |
9/2001 |
ET-4310 |
| Long-Term Disability Insurance |
PDF
HTML |
3/2007 |
ET-5314 |
| s. 40.65 Duty Disability and Survivor Benefits |
PDF |
4/2008 |
ET-5103 |
| Health Insurance |
Title |
Format |
Revision
Date |
Form
Number |
| Group Health Insurance for Retirees |
HTML |
6/2005 |
ET-4112 |
| Group Health Insurance Application/Change
Form |
PDF |
03/2008 |
ET-2301 |
| Group Health Insurance Application/Change
Form-UW |
PDF |
06/2008 |
ET-2302 |
| It's Your Choice 2008 - State Employees |
PDF |
10/2007 |
ET-2107 |
| It's Your Choice 2008 - UW Graduate Assistants |
PDF |
10/2007 |
ET-2127 |
| It's Your Choice 2008 - Annuitants/Continuants |
PDF |
10/2007 |
ET-2108 |
| It's Your Choice 2008 - Local Employees
and Annuitants |
PDF |
10/2007 |
ET-2128 |
| Local Annuitant Health Progam |
PDF |
11/2007 |
ET-9019 |
| Sick Leave Escrow Application |
PDF |
1/2002 |
ET-4305 |
| Standard Plan - State Employees |
PDF |
1/2008 |
ET-2112 |
| State Medicare Plus $1,000,000 -- State
|
PDF |
1/2008 |
ET-4113 |
| WPE Standard Plan Booklet |
PDF |
1/2008 |
ET-2131 |
| WPE Standard PPP Plan Booklet |
PDF |
1/2008 |
ET-2160 |
| WPE Deductible Standard Plan Booklet |
PDF |
1/2008 |
ET-2161 |
| WPE Deductible Standard PPP Plan Booklet |
PDF |
1/2008 |
ET-2162 |
| WPE SMP Plan Booklet |
PDF |
1/2008 |
ET-2165 |
| WPE Deductible SMP Plan Booklet |
PDF |
1/2008 |
ET-2163 |
| Income Continuation
Insurance |
Title |
Format |
Revision
Date |
Form
Number |
| Income Continuation Insurance - Local |
PDF
|
5/2007 |
ET-2129 |
| Income Continuation Insurance - State |
PDF
|
5/2007 |
ET-2106 |
| Income Continuation Insurance Forms/Booklets
Order Form |
PDF |
2/2005 |
|
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 |
| Beneficiary Designation |
PDF |
6/2007 |
ET-2320 |
| Conversion Information - Life Insurance |
PDF |
11/2005 |
ET-2306 |
| Converting Your Group Life Insurance to
Pay Health or Long-Term Care Insurance Premiums |
HTML |
3/2004 |
ET-2325 |
| Continuation Application |
PDF |
8/2004 |
ET-2154 |
| Evidence of Insurability |
PDF |
6/2008 |
ET-2305 |
| Group Life Insurance After You Terminate
Employment |
HTML |
1/2003 |
ET-4104 |
| Group Life Insurance Plan Monthly Rates |
PDF |
11/2007 |
ET-2164 |
| Life Insurance Application/Cancellation/Refusal |
PDF |
4/2008 |
ET-2304 |
| Living Benefits Brochure |
PDF
HTML |
3/2004 |
ET-2327 |
| Notice of Death for Spouse or Dependent
Child |
PDF |
6/2006 |
ET-6303 |
| Wisconsin Public Employers Group Life Insurance
Plan |
PDF |
5/2005 |
ET-2101 |
| Spectera |
Title |
Format |
Revision
Date |
Form
Number |
| Benefit Reference Guide - State Employees |
PDF |
|
|
| Benefit Reference Guide - Retirees |
PDF |
|
|
| Commonly Asked Questions - Retirees |
PDF |
|
|
| Commonly Asked Questions - State Employees |
PDF |
|
|
| Employee Benefit Summary |
PDF |
|
|
| Employee Enrollment Form |
PDF |
1/2002 |
|
| Retiree Benefit Summary |
PDF |
|
|
| Retiree Enrollment Form |
PDF |
|
|
| Patient Options List - State Employees |
PDF |
|
|
| Patient Options List - Retirees |
PDF |
|
|
