CCR2022.090-WPE Group Health Ins ProgramResolution #090-2022
Wisconsin Employee
in Department
Resolution for Inclusion Under the POBoxI 931TrustFunds
Wisconsin Public Employers' Madison W1 53707-7931
1-877-533-5020 (toll free)
Group Health Insurance Program Fax608-267-4549
p etf.wi.gov
RESOLVED, by the Cvr?A[o� C'oUN�il of the
(Governing Body) (Employer Legal Name)
that pursuant to the provisions of Wis. Stat. § 40.51 (7) hereby determines to offer the Wisconsin Public Employers (WPE)
Group Health Insurance Program to eligible personnel through the program of the State of Wisconsin Group Insurance
Board (Board), and agrees to abide by the terms of the program as set forth in the Local Employer Health Insurance
Standards, Guidelines and Administration Manual (ET-1144).
All participants in the WPE Group Health Insurance Program will need to be enrolled in a program option. An employer
may elect participation in program options listed below, with each program option to be offered to different employee
classifications (pursuant to collective bargaining). Individual employees cannot choose between program options.
We choose to participate in the (check applicable options):
❑ Traditional HMO -Standard PPO W/ Dental, P02
❑ Deductible HMO -Standard PPO W/ Dental, PO4
❑ Coinsurance HMO -Standard PPO W/ Dental, P06
❑ High Deductible Health Plan HMO -Standard HDHP PPO
W/ Dental, P07
Send resolution(s) to:
Department of Employee Trust Funds
Division of Insurance Services
PO Box 7931
Madison WI 53707-7931
or
❑ Traditional HMO -Standard PPO W/O Dental, P12 I ETFSMBESSNewEmployer(o.etf.wi.gov
❑ Deductible HMO -Standard PPO W/O Dental, P14
❑ Coinsurance HMO -Standard PPO W/O Dental, P16
High Deductible Health Plan HMO -Standard HDHP PPO W/O Dental, P17
The large group (50 or more employees) underwriting and enrollment process takes 120 days. (Small groups of 49 or less
employees do not go through underwriting and take 60 days.) All groups are eligible to enroll effective January 1, April 1, July 1,
or October 1.
RESOLUTION EFFECTIVE DATE: (select one date): of
The proper officers are herewith authorized and directed to take all actions and make salary deductions for premiums and
submit payments required by the Board to provide such Group Health Insurance.
CERTIFICATION
I hereby certify that the foregoing resolution is a true, correct and complete copy of the resolution duly and regularly passed
by the above governing body on the lZ day of 6-_W6e2 , year and that said resolution has not been repealed
or amended, and is now in full force and effect.
further certify that we offered insurance to our employees immediately prior to joining this program.
Dated this 1� day of (' c l0 a z2 , year .20a .
I understand that Wis. Stat. § 943.395 provides criminal penalties for knowingly making false or fraudulent statements, and
hereby certify that, to the best of my knowledge and belief, the Mf on is true and correct.
Federal tax identification number (FEIN/TIN) Au loy presentative signature
69-036- "t —00 Q
2r � � .�✓L J �. (fie -TA9 Z S 'e(
ETF employer identification number Authorized employer representative printed name
Number of eligible employees
Ckb-) JKe-S1la-
E toyer coun
Employer benefit contact email address
Ole
Authorized representative title
Mailing address (�f
For ETF use only -EFFECTIVE DATE
OF COVERAGE ENTERED BY ETF:
ET-1324 (REV 6/8/2022) * E T- 1 3 2 4* Page 1 of 1