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Gov/benefits-by-employer to learn more about choices available to you, view an eLearning and see instructions

Gov/benefits-by-employer to learn more about choices available to you, view an eLearning and see instructions 2025

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4.4 out of 5

168 votes

The document is a health insurance application/change form from the Wisconsin Department of Employee Trust Funds. It outlines the process for enrolling in or changing health insurance coverage, including eligibility criteria, required information, and documentation needed for various life events. The form also provides contact information for different health plans and emphasizes the importance of timely notification regarding changes in coverage.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Applicant Information section. Ensure that your name, contact details, and ETF ID are accurate. If there have been any changes, check the appropriate box and provide updated information.
If applicable, complete the Spouse Information section if you are adding a spouse or updating their details. Include their name, birth date, and primary care physician.
In the Dependent Information section, list any dependents you wish to add or update. Make sure to indicate if any dependents are grandchildren.
Select your reason for application in the Eligibility section. This could be due to open enrollment or a life event change. Be sure to provide dates where required.
Choose your It’s Your Choice (IYC) Plan Design based on your preferences for coverage levels and monthly payments.
Complete any additional sections as necessary based on your specific situation, such as Medicare coverage or removing dependents.
Finally, review all information for accuracy before signing and dating the application at the end of the form.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (146 Votes)
2020	4.4 Satisfied (161 Votes)
2019	4.4 Satisfied (168 Votes)

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What benefits does the State of Illinois offer?

10-25 Days of Paid Vacation time annually - (10 days in year one of employment) 10 Weeks Paid Maternity/Paternity Leave. Deferred Compensation Program - A supplemental retirement plan. Optional Pre-Tax Programs such as Medical Care Assistance Plan (MCAP), Dependent Care Assistance Plan (DCAP)

What assistance can I get in Illinois?

Illinois: Financial Assistance Resources for Families Child Care Financial Assistance. Temporary Assistance for Needy Families (TANF) Childrens Health Insurance Program (CHIP) Women, Infants, and Children (WIC) Supplemental Nutritional Assistance Program (SNAP formerly Food Stamps) Low Income Energy Assistance Program.

What is the benefit choice in Illinois?

Benefit Choice is your annual opportunity to make changes to your State of Illinois benefits: Health, dental, ADD and life insurance. Dependent coverage. Opt out (full-time employees) of State of Illinois health and dental insurance coverage.

What benefits are offered by Illinois?

State of Illinois Benefit Programs Health Insurance. Health Insurance (Part-Time Employees) Dental Insurance. Vision Plan. Life Insurance. Accidental Death Dismemberment. Flexible Spending Accounts. 457(b) Deferred Compensation Plan.

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