Form Et 5351 – Fill Out and Use This PDF

Department of Employee Trust Funds (ETF)

INCOME CONTINUATION INSURANCE (ICI)

EMPLOYER STATEMENT

Wis. Stat. § 40.61 and 40.62

The employee named below is applying for an ICI benefit. Please follow

the detailed instructions on the back of this form and return it to the Department of Employee Trust Funds (ETF) promptly. Benefits cannot be computed until this form is received and processed.

Occupation (Title)

Previous Calendar Years Salary

Last Day Worked

Last Day Paid

Seasonal/Academic Yr

(MM/DD/CCYY)

(MM/DD/CCYY)

Projected Salary:

Permanent

Project

New Hire

LTE

Per Diem

Change in Appointment

Change in Hourly Rate*

Monthly Salary

Full Time

Has claim been filed for

Worker’s Comp. Effective

Weekly Worker’s

Part Time

Worker’s Comp?

Date

Comp Amount

$

Part Time Percent

%

Yes

No

Paid Thru

$

Denied

Pending

(State Only) Total Sick Leave Shown to hundredths of

(State Only) Date Sick Leave is

Premium Category/Elimination Period

an hour–2 Decimal Places

Exhausted (MM/DD/CCYY)

Year

Year

Year

Current Year

Accumulated Hrs

Earned Hours

Total Hours

(Locals Only) Percentage of Premium Paid by Employer in Prior Years:

20					20					20					Current Year
				%					%					%		%
Claimant has elected the supplemental ICI Coverage.								Yes		No

Employer (CIRCLE: STATE OR LOCAL)

Division (STATE)

Central Payroll Code Number (STATE)

I understand Wis. Stat. § 943.395 provides penalties for knowingly making false or fraudulent claims on this form and hereby certify that, to the best of my knowledge and belief, the above information is true and correct.

ET-5351 (REV 02/2011) Mail to: ETF, PO BOX 7931, MADISON 53707-7931

FAX: (608)267-4549

Employer Instructions

1.Complete this form as quickly as possible and e-mail to this address: ETFWEB@etf.state.wi.us. If you are unable to e-mail it please fax to ETF at (608)267-4549 OR send it by mail to the address on page 1. No ICI benefits are payable to your employee until the completed form (and required medical) is received and processed.

2.For State or Local employees, report the last day paid for any vacation, holiday or compensatory time paid after the elimination period. For Local employees only, report last day paid for any sick leave paid in addition to any vacation, holiday or compensatory time paid after the elimination period.

3.Monthly Salary –

To determine benefits as of the date of disability, the average monthly salary is determined by using the:

Previous calendar year salary, rounded to the next higher thousand and divide by 12.

OR

If there is a new hire or a permanent change in appointment, estimate the base salary (including add-ons for certain educational degrees, certifications, licenses or credentials) to be received during the ensuing 12 months. Round to the next higher thousand and divide by 12.

* NOTE: If the employee has received a permanent change in the hourly rate (and is not a new hire or did not have a change in appointment), report the higher of:

Previous calendar year salary. OR

Projected salary.

4.For State employees, report the accumulated sick leave hours as of the employee’s last day worked, plus any additional sick leave earned while continuing in pay status. Report sick leave in hours and hundredths of hours (2 decimal places), not minutes.

5.For most State employees who work a standard Monday – Friday work week, sick leave is not utilized on paid legal holidays and thus extends the date sick leave is exhausted.

6.For State employees, an ICI claimant who has applied for a Wisconsin Retirement System disability, Long Term Disability Insurance (LTDI) benefit, or duty disability benefit may convert (bank) sick leave to pay for health insurance premiums and begin ICI benefits at an earlier date. Determine, with the employee, the date through which sick leave is to be used. If the permanent disability is not approved, the date through which sick leave was used will have to be adjusted. Attach written documentation to this form, which verifies the employee’s decision to bank sick leave after a specified date.

7.Continue to collect premiums, for eligible employees, until you receive written notice of approval of the claim. Note that no premiums can be accepted after employment is terminated.

8.Under “Premium Category,” fill in the premium category or selected elimination period for the year in which the disability began (current year) as well as the previous three calendar years.

9.Indicate whether the employee is enrolled in the supplemental ICI coverage.

10.After completion, please make a copy of this form for your records for future reference.

11.Please include your e-mail address.

ET-5351 (REV 02/2011)