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Open Enrollment: Health Insurance Application/Change Form

Open Enrollment: Health Insurance Application/Change Form - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWHC Open Enrollment, Health Insurance, Resources

ET-2301 (REV 10/2/2017) Page 1 of 7

Please complete the requested information (signature required on Page 4) and return to your employer. Retirees and
continuants, return this form to the Department of Employee Trust Funds. Only the subscriber applying for coverage
should complete this form. For eligibility and online enrollment information, visit etf.wi.gov to see the It’s Your Choice
web pages. To elect the opt-out incentive if declining health insurance, complete Applicant Information and see Section
14. You must indicate whether you want dental coverage (Section 7) as part of your insurance, for an additional cost.
Your health insurance deductions will be taken pre-tax unless you request they be taken post-tax. Contact your
employer to make this change or submit the Employee Reimbursement Accounts Program Automatic Premium
Conversion Waiver/Revocation of Waiver (ET-2340) to your employer.
1. Applicant Information Information on this page required unless otherwise stated.
Name First M.I. Last Member ID SSN
Former/Maiden (if applicable) Telephone
( )
Email (not required)
Mailing address (Street) City State ZIP code Country
Birth date Gender
Male Female
Check here if your name, phone, address, email or marital status has changed:
Check your marital status:
Single (no change date required) Married Divorced Widowed Marital status change date: ______________
Please check which applies to you (this determines your eligibility)
Employee Non-WRS graduate assistant Retiree/LTDI COBRA recipient Surviving dependent
2. Spouse Information
Name First M.I. Last Former/Maiden SSN
Birth date Gender
Male Female
Check here if your spouse’s name has changed: Is your spouse a tax dependent? Yes No
3. Dependent Information (does not include spouse) Check to only update dependent information
Name You may attach additional pages
if more space is needed
SSN Birth
(child, stepchild,
legal ward,
dependent of minor
First M.I. Last
Health Insurance Application/Change
Employee ID: _________
Pay Group:
Reason for App:



Return completed forms to Human Resources by October 27 deadline:
Fax: 608-263-5778 | Ask HR form in ServiceNow
Open Enrollment 2018
**If enrolling in HDHP, must enroll in HSA for 2018**
Residents/Interns are NOT eligible to enroll in the HDHP/HSA

Name: _________________________________________ Member ID: ________________
ET-2301 (REV 10/2/2017) Page 2 of 7
4. Complete if you are a New Hire Selecting or Declining Health Insurance Coverage
New hires or employees returning from leave (lapsed coverage) only: When do you want your coverage to be effective?
When my employer contributes to my premium
As soon as possible (you will pay the entire monthly premium until you are eligible for your employer contribution)
I choose to decline/waive coverage (to decline health insurance & elect the opt-out incentive, go to section 14)
I choose to decline/waive coverage because I have other health insurance coverage
5. Complete if you are Not a New Hire Enrolling or Making a Change
Reason for Application: Select a reason for enrolling or changing your coverage or health plan:
It’s Your Choice open enrollment
Eligible move to a new service area
(may only change health plan)
Eligible life event change (select change below)
Event date for move or life event change: ________________
Eligible life event changes, which allow you to make a change outside of the annual It’s Your Choice open enrollment,
include birth/adoption, marriage and divorce. Visit etf.wi.gov for a Life Change Event Guide.
Select the event that allows you to enroll or make a change outside of your initial hire period. You may be required to
provide supporting documentation (the * indicates that you must provide proof of the selected event). See more
information on Page 6. If adding dependents, please list them in Section 3. If removing, list them, in Section 8.
Change Health Plan New health plan selected (full health plan name required): _____________________________
Select one reason to add coverage/dependent or remove dependent(s):
Add coverage/dependent(s)
Transfer to a new state agency
(state only)
Former agency name:
Birth or adoption*
LTE new hire (state only)
COBRA (Continuation-Conversion
Notice (ET-2311) also required)
National Medical Support Notice*
Spouse to spouse transfer
Loss of employer contributions or
loss of other coverage*
State retiree re-enroll*
Paternity acknowledgment*
Legal ward/guardianship*
Disabled, age 26+*
Eligible dependent not on initial
enrollment (excludes adult
Other: ___________________
Remove dependent(s)
It’s Your Choice open enrollment
Death of dependent
Legal ward/guardianship end*
Disabled dependent disability end
or support/mainenance less than
Grandchild’s parent age 18
Adult dependent eligible for other
Other: ___________________
Event date: ________________ (the * indicates that you must provide proof of the selected event)
6. Complete to Elect Your Health Insurance Coverage
Single or family coverage?
Single Family
Are you selecting an HDHP?
Yes No
Health plan selected (Quartz UW, Quartz Community, Dean, etc.)
UWHC employees: Most UWHC employees are eligible for the High Deductible Health Plan (HDHP). You must indicate if
you choose the HDHP option. If you elect the HDHP, you must also enroll in a state-sponsored health savings account
Residents/Interns are not eligible for the High Deductible Health Plan (HDHP).
7. Complete if you are Enrolling in or Declining Dental Coverage
UWHC employees: Indicate whether you are choosing Uniform Dental Benefits.
Do you want dental coverage?
Yes No
You may only choose dental if you are also enrolling, or are already enrolled in, health
Note: If you are not currently enrolled in dental and do not want dental coverage for the next plan year, you do not need to
decline dental coverage again.
If you are not a new hire and only wish to decline dental (and make no other changes to your health insurance) you
do not need to complete the remainder of this form. You must sign in Section 15.

Name: _________________________________________ Member ID: ________________
ET-2301 (REV 10/2/2017) Page 3 of 7
8. Complete if you are Removing a Spouse or Dependent(s)
Include address, if different than your address on Page 1
Name of person(s) you are removing (first, m.i., last) Birth date Address of person(s) you are removing
9. Complete if you are Changing from Family to Single Coverage
If your employee monthly premium share is pre-tax, IRC Section 125 restricts midyear changes to your coverage. (All
retirees and continuants are post-tax.) For more information on IRC Section 125 limitations, visit www.irs.gov
My employee-required monthly premium contribution is deducted (check one):
Pre-tax and my employee premium contribution has increased significantly
Pre-tax eligible status change event – Change event: ____________________
Pre-tax change to single during annual It’s Your Choice (January 1)
Post-tax (midyear changes to coverage level can be made at any time) – Event date: _____________
10. Complete if you are Cancelling Health Insurance Coverage
If your premiums are deducted on a post-tax basis (all retirees and continuants are post-tax), you may cancel coverage at
any time. If they are deducted on a pre-tax basis, you must provide the event allowing midyear cancellation.
Please select your reason for cancelling coverage:
My premiums are deducted: Pre-tax (select an event below) Post-tax (no event required to cancel coverage)
It’s Your Choice open enrollment
Retiree sick leave depleted – Effective end date of coverage: _____________
I am terminating employment
I am going on an unpaid leave of absence
My employee premium share has increased significantly
I and all eligible dependents are now eligible for, and enrolled in, other coverage* – Event date: _____________
(the * indicates that you must provide proof of the selected event)
Spouse to spouse transfer – Event date: _____________
11. Complete if you are Covered by Medicare
Are you, or any person you insure, covered by Medicare? Yes No
If yes, please check why you are eligible for Medicare: Age Disabillity End stage renal disease
Note: State employees are not eligible for HDHP if they have other coverage.
List all persons covered by Medicare, including yourself, Medicare claim number and Medicare Parts A and B
effective dates:
Name (first, m.i., last) Medicare claim number
Medicare Part A
effective date
Medicare Part B
effective date

Name: _________________________________________ Member ID: ________________
ET-2301 (REV 10/2/2017) Page 4 of 7
12. Complete if you Have Additional Health Insurance/Coverage
Note: State employees are not eligible for HDHP if they have other coverage.
Do you or any of your dependents have other medical or health care Flexible Spending Account coverage that has a
balance available as of the effective date of this coverage? (excludes dental or vision) Yes No
If yes, provide:
Company Policy number Group number
Name(s) of insured (first, m.i., last)
13. Complete if you Listed Dependent(s) on Page 1
Is any dependent listed on Page 1 your, or your spouse’s, grandchild? Yes No
If yes, name of parent: ___________________________________________________
14. Complete to Decline Health Insurance and Elect the Opt-Out Incentive
State of Wisconsin active employees only
Are you electing to receive the opt-out incentive for 2018? Yes No
If yes, you certify that you are eligible for the opt-out stipend and are not currently, nor will be this program year, a covered
dependent under the State Group Health Insurance Program, and that you did not decline or waive coverage in 2015.
15. Signature Required
By signing this application, I apply for the insurance under the indicated health insurance contract made available to me
through the state of Wisconsin and I have read and agreed to the Terms and Conditions (see Page 5). A copy of this
application is considered as valid as the original. In addition, to the best of my knowledge, all statements and answers in
this application are complete and true. Providing false information is punishable under Wis. Stat. § 943.395. Additional
documentation may be required by ETF at any time to verify eligibility.
Signature Date signed
Submit completed form to your employer. (Retirees and continuants, submit to ETF.)
Employer Completes
Employers: Coding instructions are in the Employer Health Insurance Administration Manual.
EIN Employer name Payroll representative email
Group number Employee type Coverage type
Single Family
Health plan name/suffix
Business Unit (if applicable) Employment status of applicant
Full time Part time LTE
Employee deductions
Pre-tax Post-tax
Hire date or date WRS-eligible employment or
graduate appointment began
Employer received
Event date Prospective coverage
Are you a WRS-participating employer? Yes No
Previous service check completed? Yes No
Source of previous service check? Online Network for Employers (ONE) ETF
Did employee participate in the WRS prior to being hired by you? Yes No
Payroll representative signature Phone number
( )
Date signed
0001-183 UWHC Authority hr@uwhealth.org
( 608( 263-6500

ET-2301 (REV 10/2/2017) Page 5 of 7
Terms and Conditions
To the best of my knowledge, all statements and
answers in this application are complete and true. I
understand that if I provide false or fraudulent
information, misrepresentation or fail to provide complete
or timely information on this application, I may face
action, including, but not limited to, loss of coverage,
employment action, and/or criminal charges/sanctions
under Wis. Stat. § 943.395.
I authorize the Department of Employee Trust Funds to
obtain any information from any source necessary to
administer this insurance.
I agree to pay in advance the current premium for this
insurance, and I authorize my employer (the remitting
agent) to deduct from my wages or salary an amount
sufficient to provide for regular premium payments that
are not otherwise contributed. The remitting agent shall
send the premium on my behalf to ETF.
I understand that eligibility for benefits may be
conditioned upon my willingness to provide written
authorization permitting my health plan and/or ETF to
obtain medical records from health care providers who
have treated me or any dependent(s). If medical records
are needed, my health plan and/or ETF will provide me
with an authorization form. I agree to respond to
questions from health plans and ETF, including, but not
limited to, audits, in a timely manner.
I have reviewed and understand the eligibility criteria for
dependents under this coverage and affirm that all listed
dependents are eligible. I understand that children may
be covered through the end of the month they turn 26.
Children may also be covered beyond age 26 if they:
have a disability of long standing duration, are dependent
on me or the other parent for at least 50% of support and
maintenance, and are incapable of self-support; or are
full-time students and were called to federal active duty
when they were under the age of 27 years and while they
were attending, on a full-time basis, an institution of
higher education.
I understand that it is my responsibility to notify the
employer, or if I am a retiree or continuant to notify ETF, if
there is a change affecting my coverage, including but not
limited to, a change in eligibility due to divorce, marriage
or an address change due to a residential move.
Furthermore, failure to provide timely notice may result in
loss of coverage, delay in payment of claims, loss of
continuation rights and/or liability for claims paid in error.
Upon request, I agree to provide any documentation that
ETF deems necessary to substantiate my eligibility or that
of my dependent(s).
I understand that if there is a qualifying event in which a
qualified beneficiary (me or any dependent(s)) ceases to
be covered under this program, the beneficiary(ies) may
elect to continue group coverage as permitted by state or
federal law for a maximum of 18, 29, or 36 months,
depending on the type of qualifying event, from the date
of the qualifying event or the date of the notice from my
employer, whichever is later. I also understand that if
continuation coverage is elected by the affected qualified
beneficiary(ies) and there is a second qualifying event
(i.e, loss of eligibility for coverage due to death, divorce,
marriage but not including non-payment of premium) or a
change in disability status as determined by the Social
Security Administration, continuation coverage, if elected
subsequent to the second qualifying event, will not extend
beyond the maximum of the initial months of continuation
coverage. I understand that timely notification of these
qualifying events must be made to ETF.
I understand that if I am declining enrollment for myself
or my dependent(s) (including spouse) because of other
health insurance coverage, I may be able to enroll myself
and my dependent(s) in this plan if I or my dependent(s)
lose eligibility for that other coverage (or if the employer
stops contributing toward that other coverage). However,
I must request enrollment within 30 days after my or my
dependents’ other coverage ends (or after the employer
stops contributing toward the other coverage). In addition,
if I have (a) new dependent(s) as a result of marriage,
birth, acknowledgement of paternity, adoption, or
placement for adoption, I may be able to enroll myself
and my dependent(s) if I request enrollment within 30
days after the marriage or within 60 days after the birth,
acknowledgement of paternity, adoption, or placement for
adoption. To request special enrollment or obtain more
information, I should contact my employer (or ETF if I am
a retiree or continuant).
I understand that I am responsible for enrolling in
Medicare Parts A and B when I am first eligible and
required by this coverage, and that as the subscriber I am
responsible for ensuring my spouse and any other eligible
dependents also enroll in Medicare Parts A and B when
they are first eligible, to ensure proper coordination of
benefits with Medicare. In the event I or any eligible
dependent does not enroll in Medicare Parts A and B
when first eligible and required by this group health
insurance program, I understand that I will be financially
liable for the portion of claims Medicare would have paid
had proper Medicare enrollment been attained.
I agree to abide by the terms of my benefit plan, as
explained in any written materials I receive from ETF or
my health plan, including, without limitation, the It’s Your
Choice materials.

ET-2301 (REV 10/2/2017) Page 6 of 7
Documentation Requirements
Reason for Change or Enrollment Type of Documentation
*Adoption Recorded copy of court order granting adoption or letter of placement for
* Cancel coverage/remove adult
dependent due to enrollment in
other health insurance coverage
when premium contributions are
deducted per-tax
Copy of medical ID card or letter from health plan indicating effective date of
other coverage. Must be received within 30 days of enrollment in other coverage.
Does not apply to retirees or post-tax deductions.
*Death Original death certificate.
*Disabled, age 26+ Copy of letter from health plan approving disabled status
*Divorce (Family coverage remains
in place when more dependents
than spouse/stepchildren covered.)
Copy of Continuation-Conversion Notice (ET-2311) sent to ex-spouse of the
subscriber (ETF may request copy of divorce decree from clerk of courts
showing date of entry of divorce if needed per the Terms and Conditions.)
*Eligible and enrolled in Medicare
Copy of Medicare card and Medicare Eligibility Statement (ET-4307).
(Note: If you are on COBRA Continuation and the subscriber or dependents
become Medicare eligible after the COBRA effective date, subscriber or
dependent is no longer eligible to continue on COBRA.)
*Family to single because all
dependents enrolled in other
Copy of medical ID card or letter from health plan indicating effective date of
other coverage. Must be received within 30 days of enrollment in other coverage.
Does not apply to retirees or post-tax deductions.
*Legal change of name (other than
due to marriage or divorce) Copy of court order.
*Legal ward Court Order (Letters of Guardianship) granting permanent guardianship of
*Loss of other coverage or loss of
employer contribution to premiums
(applies to member and
The following items on letterhead from the previous insurer or former employer,
dated and issued after termination of coverage. Materials providing prospective
termination dates are not acceptable.
1. Who was covered (must list the name of the member who is requesting
this special, late enrollment)
2. Name of Health Insurer
3. Subscriber number and name
4. Date coverage was terminated
5. Reason for the cancellation (that is voluntary such as due to non-
payment of premium vs. involuntary such as due to job loss).
COBRA notice is acceptable if the coverage end date, covered individuals and
health plan are indicated. If loss of employer premium contributions, letter from
employer indicating they no longer contribute towards their employee’s premium.
*National Medical Support Notice Copy of National Medical Support Notice.
*Paternity Court order declaring paternity, Voluntary Paternity Acknowledgement filed with DHS or birth certificate.
*Social Security number change Copy of card or letter from Social Security Administration.
*State retiree re-enroll Same as loss of other coverage and a Sick Leave Re-enrollment Application
(ET-4317). During It’s Your Choice, no documentation required.
Birth Original birth certificate not required. (ETF may request documentation per the Terms and Conditions.)
Change of address/telephone No documents required but ETF may request per the Terms and Conditions.
Divorce (family to single) No documents required but ETF may request per the Terms and Conditions.
Marriage Original marriage certificate is not required. (ETF may request per the Terms
and Conditions.)
*Documentation required/must be submitted to ETF.

ET-2301 (REV 10/2/2017) Page 7 of 7
Discrimination is Against the Law 45 C.F.R.
§ 92.8(b)(1) & (d)(1)
The Wisconsin Department of Employee Trust Funds
complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, color,
national origin, age, disability or sex. ETF does not
exclude people or treat them differently because of
race, color, national origin, age, disability or sex.
ETF provides free aids and services to people with
disabilities to communicate effectively with us, such as
qualified sign language interpreters and written
information in other formats. ETF provides free
language services to people whose primary language
is not English, such as qualified interpreters and
information written in other languages. If you need
these services, contact ETF’s Compliance Officer, who
serves as ETF’s Civil Rights Coordinator.
If you believe that ETF has failed to provide these
services or discriminated in another way on the basis
of race, color, national origin, age, disability or sex,
you can file a grievance with: Compliance Officer,
Department of Employee Trust Funds, 801 West
Badger Road, P.O. Box 7931, Madison, WI 53707-
7931; 1-877-533-5020; TTY: 711; Fax: 608-267-4549;
Email: ETFSMBPrivacyOfficer@etf.wi.gov. If you need
help filing a grievance, ETF’s Compliance Officer is
available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for
Civil Rights, electronically through the Office for Civil
Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail
or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue, SW, Room
509F, HHH Building, Washington, D.C. 20201; 1-800-
368-1019; TDD: 1-800-537-7697. Complaint forms are
available at www.hhs.gov/ocr/office/file/index.html.
Spanish: ATENCIÓN: si habla español, tiene a su
disposición servicios gratuitos de asistencia lingüística.
Llame al 1-877-533-5020 (TTY: 711).
Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov
kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-
(TTY: 711).
Chinese: 注意:如果您使用繁體中文,您可以免費獲得
語言援助服務。請致電 1-877-533-5020
German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen
Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-877-533-5020 (TTY: 711).

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Russian: ВНИМАНИЕ: Если вы говорите на русском
языке, то вам доступны бесплатные услуги перевода.
Звоните 1-877-533-5020 (телетайп: 711).
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원
서비스를 무료로 이용하실 수 있습니다.
1-877-533-5020 (TTY: 711)번으로 전화해 주십시오.
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các
dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
1-877-533-5020 (TTY: 711).
Pennsylvania Dutch: Wann du [Deitsch (Pennsylvania
German / Dutch)] schwetzscht, kannscht du mitaus Koschte
ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf
selli Nummer uff: Call 1-877-533-5020 (TTY: 711).
Laotian/Lao: ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ
ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ,
ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທ
ຣ 1-877-533-5020 (TTY: 711).
French: ATTENTION : Si vous parlez français, des
services d'aide linguistique vous sont proposés
Appelez le 1-877-533-5020 (ATS : 711).
Polish: UWAGA: Jeżeli mówisz po polsku, możesz
skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod
numer 1-877-533-5020 (TTY: 711).
Hindi: ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में
भाषा सहायता सेवाएं उपलब्ध हैं। 1-877-533-5020 (TTY:
711) पर कॉल करें।
Albanian: KUJDES: Nëse flitni shqip, për ju ka në
dispozicion shërbime të asistencës gjuhësore, pa pagesë.
Telefononi në 1-877-533-5020 (TTY: 711).
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog,
maaari kang gumamit ng mga serbisyo ng tulong sa wika
nang walang bayad. Tumawag sa 1-877-533-5020 (TTY: