ET-1330
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Summary

Local government employers participating in the Income Continuation Insurance (ICI) Program must contribute toward ICI premiums for all employees who elect coverage. Employers should fill out and submit this form to:

  • Change the elimination period for which the employer pays the gross premium, or
  • Indicate the elimination period for which the employer pays the gross premium currently for the Insurance Administration System implementation.

If you would like to complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.

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