State Group Life Insurance

How to Enroll 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 (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, 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; 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 for Domestic Partnership has been received and accepted. Your domestic partnership is effective on the date your Affidavit is received and accepted by ETF.
d.i. If you already have Spouse and Dependent life insurance coverage, no additional application is necessary; however, an affidavit must be on file at ETF before coverage for domestic partners and their children is effective. 
d.ii. If you do not have Spouse and Dependent life insurance coverage in effect, attach a copy of your affidavit and acknowledgement letter to your new life insurance application.

3. Complete a new life insurance application. General instructions are provided on page 1 of the application. Specific instructions follow.

Application | Submit to your Payroll & Benefits Office
Life Insurance Application / Cancellation / Refusal, ET-2304
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.

Section 2 - Reason for Application (check all that apply)
Subsection 'Spouse & Dependent'
- Check the subsection box 
- Check the 'Coverage Enrollment Due to Qualifying Event' box
- For 'Qualifying event', enter "Domestic Partnership"
- Date field: Enter your ETF affidavit acceptance date; enrollment must be within 30 days of this date.

Section 3 - Coverage Selection
- Select the level of coverage you wish to elect for yourself (Basic, and optionally Supplemental and Additional).
- Under 'Spouse & Dependent Coverage', select the check box for either '1 Unit' or '2 Units' for desired level of coverage.

Section 4 - Signature
- Sign and date the application.

4. Submit the completed application with a copy of your ETF acknowledgement letter to your benefits coordinator or your campus benefits office. Retain a copy of the documents for your records. Enrollment must be within 30 days of your ETF affidavit acceptance date. Coverage will be effective on the first day of the calendar month that begins on or after the date the life insurance application is received by the employer (provided an accepted affidavit is on file at ETF).