To submit this form, scan or upload your completed PDF to the designated submission portal. You can also fax your application to 608-267-4549. For mail submissions, send your application to the Wisconsin Department of Employee Trust Funds, PO Box 7931, Madison WI 53707-7931. Ensure all documents are clear and legible for processing.

Important dates include open enrollment periods for health insurance, generally occurring in late fall. Ensure to submit your application before deadlines to secure coverage for the next calendar year. Keep a lookout for specific dates communicated by the ETF.

The purpose of this form is to facilitate the enrollment of Wisconsin employees and retirees into health insurance plans. It ensures that individuals can apply for coverage or modify their existing plans efficiently. Accurate completion of this form is crucial for ensuring the proper processing of health insurance applications.

• 1. First Name: The applicant's first name as per official documents.
• 2. Last Name: The applicant's last name as per official documents.
• 3. Telephone Number: Contact number without hyphens or dashes.
• 4. Email Address: A valid email address for communication.
• 5. ETF ID or SSN: Unique identification number or social security number.

Failing to submit this form will result in the inability to enroll or modify your health insurance coverage. Missing submission deadlines can lead to a lapse in coverage.

• Inactiveness in Coverage: Failure to submit may result in being uninsured or unable to access health benefits.
• Delayed Processing: Incomplete or late submissions lead to delays in processing your application.
• Loss of Benefits: Not submitting on time can result in losing eligibility for specific benefits.

• 1. Open Enrollment: Use this form when the annual open enrollment period is active.
• 2. COBRA Coverage Changes: Submit this form if you are a COBRA participant making updates.
• 3. Beneficiary Information Updates: When personal information or beneficiaries change, use this form.