| Number | Title | Description | Audience |
|---|---|---|---|
| ET-2301 | Health Insurance Application/Change Form | Enroll in health insurance or change your coverage. |
Active Employee, Local Employer, State Employer |
| ET-2304 | Life Insurance Application/Cancellation/Refusal | Enroll in, cancel or decline group life insurance coverage. |
Active Employee, Local Employer, State Employer |
| ET-2305 | Evidence of Insurability | Employees who did not enroll for group life insurance coverage during their initial enrollment period, or insured employees who wish to apply for more insurance for themselves or their spouse or dependents, may apply using this form. |
Active Employee, Local Employer, State Employer |
| ET-2306 | Conversion Information - Life Insurance | If any portion of your group life insurance coverage terminates, you may be able to continue your life insurance protection. Your right to do this is called a conversion privilege, and its features are described here. |
Active Employee, Local Employer, State Employer |
| ET-2307 | Income Continuation Insurance Application - State | Complete and then submit to your employer to apply for income continuation insurance. |
Active Employee, Local Employer, State Employer |
| ET-2311 | COBRA Continuation - Conversion Notice | Under federal law, known as COBRA, you and your qualified beneficiaries may continue group health insurance coverage, if eligible. |
Active Employee, Local Employer, State Employer |
| ET-2314 | Request for Treatment as an Assistance Eligible Individual | The American Rescue Plan Act of 2021 (ARP) subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1, 2021 through September 30, 2021. |
Local Employer, State Employer |
| ET-2314a | Model COBRA Subsidy Notice | This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed. |
Local Employer, State Employer |
| ET-2319 | Rehired Annuitant | WRS annuitants who have met all terms and conditions associated with having a valid termination and meeting the minimum break in service requirement may return to work for a WRS employer. |
Retiree, Local Employer, State Employer |
| ET-2331 | Health Insurance Application/Change for Retirees | Retirees, enroll in health insurance or change your coverage. |
Retiree, Other Benefit Recipient, Local Employer, State Employer |