CCR2024.057 Income Continuation Ins PlanRESOLUTION #057-2024
�� Resolution for Inclusion Under the
Income Continuation Insurance Plan
RESOLVED, by the Common Council
(Governing Body)
City of Muskego
(Employer Legal Name)
that pursuant to the provisions of Section 40.61 of the Wisconsin Statutes,
Common Council
(Governing Body)
Wisconsin Department
of Employee Trust Funds
PO Box 7931
Madison WI 53707-7931
1-877-533-5020 (loll free)
Fax 608-2674549
etfwi.gov
of the
hereby determines to offer the Income Continuation Insurance Plan
to eligible personnel through the program of the State of Wisconsin Group Insurance Board, and agrees to
abide by the terms of the plan as set forth in the contract between the Group Insurance Board and the
Administrator.
The resolution shall be effective on the later of the 1st of the month on or after 90 days following its receipt at
the Department of Employee Trust Funds, or
January 1, 2025 ; and
(specify a later effective date, 1 st of month only)
The proper officers are herewith authorized and directed to take all actions and make salary deductions for
premiums and submit payments required by the State of Wisconsin Group Insurance Board to provide such
Income Continuation Insurance.
Employers are required to pay a minimum contribution, which is equal to the gross premium for the 180-day
elimination period. Employers may choose to contribute more to employees' premiums to an amount equal to
the gross premium for a shorter elimination period. As elimination periods become shorter, the premium cost
increases.
An employee can choose a shorter elimination period than that offered by their employer, and pay the
difference in cost between their choice and the elimination period the employer for which the employer has
elected to pay the gross premium.
For example, if an employer elects to pay for the full 90-day elimination period, = their employees will not have
out-of-pocket premiums unless the employee elects the 60-day or 30-day elimination period. If the employee
elected a shorter elimination period, the employee will pay the premium difference between that and the 90-
day elimination period.
Elect one elimination period that your employer will pay the gross ICI premium for:
Q 30-day elimination period I-Ti 60-day elimination period
❑ 90-day elimination period Q 120-day elimination period
In 180-day elimination period (required minimum contribution)
Complete the Certification on the next page.
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Page 1 of 2
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 17th day of September 2024 and that said
resolution has not been repealed or amended, and is now in full force and effect.
Dated this 17th day of September
39-6006023
Federal tax identification number (FEIN1TIN)
69-036- 1194000
ETF employer identification number
Number of eligible employees
116
Waukesha
Employer county
kcroteau@muskego.wi.gov
Employer benefit contact email address
2024
u orize employer rf?"91entative signature
Rick Petfalski
Authorized employer representative printed name
Mayor
Authorized representative title
City of Muskego
W182S8200 Racine Ave., Muskego, WI 53150
Mailing address
Submit completed form to ETF at ETFSMBESSNewEmployer@etf.wi.gov or fax to 608-267-4549.
For ETF use only- EFFECTIVE DATE OF COVERAGE ENTERED BY ETF:
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