EPIC Benefits+

How to add a domestic partner and his/her eligible children

1. Review Domestic Partner Benefits, ET-2166, a detailed brochure regarding domestic partnership benefits.

2. Complete the Affidavit of Domestic Partnership form to establish a domestic partnership for State of Wisconsin (Chapter 40) benefit purposes (as well as EPIC coverage). An Affidavit that is missing the signature of either partner or is not notarized will be rejected, and the domestic partnership will not become effective until ETF has received a properly completed Affidavit.

Affidavit for Domestic Partnership, ET-2371 | Submit to ETF
Affidavit for Domestic Partnership, ET-2371
Complete this affidavit with date, signatures and notarization:
a. Send the original notarized affidavit to ETF at the address on the top of the form. You may submit the notarized affidavit to ETF by fax at (608) 267-4549. The facsimile must be complete and legible; the notary seal must be visible in the electronic copy. ETF may request the original document if necessary.
b. Retain a copy of the notarized affidavit for your records.
c. ETF will send you an acknowledgement letter indicating that your Affidavit has been received and accepted. Your domestic partnership is effective on the date your Affidavit is received and accepted by ETF.
d. Attach a copy of the Affidavit and your acknowledgement letter to your new EPIC insurance application.

3. Complete a new EPIC application.

Application | Submit to your Payroll & Benefits Office
EPIC Benefits+ Plan Application, E11444
Use Adobe Reader to open and complete PDF forms.
MAC Users: Do not use "Preview", a PDF reader.

Section 1 - Information about You
- Complete all applicable fields.

Section 2 - Reason for Submitting Application
- Check the box 'Initial Enrollment'.
- For 'Coverage Requested' check the appropriate coverage box.

Section 3 - Information about Your Family
- Complete all applicable fields.
- List your domestic partner and all eligible dependents.
- For 'Federal Tax Dependent' indicate Y (Yes) or N (No) if your domestic partner and/or dependent child is considered a “tax dependent” under federal law. Note: There may be tax consequences to you when you cover dependents (i.e., domestic partners and children) that are not dependent on you for at least 50% of their support.

Section 4 - Information about Other Coverage
- Answer all questions; use applicable check boxes and text fields.

Section 5 - Signature
- Sign and date the application, indicating agreement with the signature statement.

4. Submit the completed application with a copy of your acknowledgement letter to your benefits coordinator or your campus benefits office. Retain a copy of the documents for your records. EPIC insurance coverage will start on the effective date of the domestic partnership.