State Group Health Insurance
How to add a domestic partner and his/her eligible children:
Review Domestic Partner Benefits, ET-2166, a detailed brochure.
Review the Imputed Income and Health Insurance Benefits page.
Complete the Affidavit of Domestic Partnership form to establish a domestic partnership for State of Wisconsin (Chapter 40) benefit purposes, including health insurance 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 | Submit to ETF
Complete this affidavit with date, signatures and notarization:
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.
Retain a copy of the notarized affidavit for your records.
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.
You will need to attach a copy of the Affidavit to your new health insurance application in the next step.
Complete and submit a new health insurance application along with a copy of the Affidavit to your benefits coordinator or your campus benefits office. Retain a copy of your health application to later submit with your acknowledgement letter (see step 5). Retain copies of these documents for your records.
Application | Submit to your Payroll & Benefits Office
Use Adobe Reader to open and complete PDF forms.
MAC Users: Do not use "Preview", a PDF reader.
Section 1 - Applicant Information
- Complete all applicable fields.
- For 'Marital or Domestic Partnership Status', check the box 'Domestic Partnership'. For the date, enter the ETF Affidavit acceptance date. Enter your Domestic Partner's name, Social Security Number and Date of Birth.
- For 'Coverage Desired', select 'Family'.
Section 2 - Reason for Application
- If you have had Single coverage, check the box 'Change to Family Coverage-43' - or - If you already have Family coverage, check the box 'Other' and select "Domestic Partnership" from the drop-down box.
- Check the box 'Domestic Partner'
- For the Event Date, enter the ETF Affidavit acceptance date.
Section 3 - Enrollment Information
- Complete all applicable fields.
- List your domestic partner and all eligible dependents.
- For 'Tax Dep?' 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 a domestic partner and his/her children that are not dependent on you for at least 50% of their support.
Sections 4, 5, and 6
- Answer all questions (check boxes) and complete applicable fields.
Section 7 - Signature
- Read the TERMS AND CONDITIONS.
- Check the first box, 'I apply for the insurance under the indicated health insurance contract made available to me through the State of Wisconsin and have read and agree to the TERMS AND CONDITIONS. A copy of this application is to be considered as valid as the original.'
- Sign and date the application, indicating agreement with the terms and conditions.
Note: Submit your completed health insurance application with a copy of the Affidavit. Following the submission of the original Affidavit to ETF, ETF will send you an acknowledgement letter that you will use in the final step.
After you receive your acknowledgement letter, submit a copy of your health application with a copy of your acknowledgement letter to your benefits coordinator or your campus benefits office. Retain copies of these documents for your records. Health insurance coverage for your domestic partner and his/her eligible children will start on the effective date of the domestic partnership.