Form Erd-12193 - Cessation Of Health Care Benefits Complaint
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1
2Office Use Only
Cessation of Health Care Benefits
State of Wisconsin
Complaint
Department of Workforce Development
Equal Rights Division
Personal information you provide may be used for secondary purposes.
[Privacy Law, Section 15.04(1)(m) Wisconsin Statutes]
•
This law applies to businesses with 50 or more employees in the State of
Wisconsin
•
Businesses who employ fewer than 50 employees do not have to give notice
when deciding to cease providing health care benefits to their employees.
•
If the law applies, employers must give 60-day’s advance notice to employees, retirees, and their
dependents before terminating a health care benefit plan.
•
The law does not require that employers notify employees who are terminated or who quit that their health
care benefits will cease. Notice is only required when a health care benefit plan is being terminated for an
entire class of employees.
•
The law does not require that employers give notice before making changes to an existing plan.
For more detailed information, please refer to publication ERD-11054-P, “Notification Required for Cessation of
Health Care Benefits.”
Please Type or Print In Black Ink All Applicable Information
Complainant Information
Employer Information
Mr.
Print your name
Business Name
Ms.
Mrs.
Your Street Address
Owner/Corporation Name
City, State, Zip Code
Business Street Address
City, State, Zip Code
Home Telephone Number (
)
Work Telephone Number (
)
Your Social Security Number
Business Telephone Number
(
)
Date of Birth
Type of Business
Filing Information
Are you
currently employed by the business?
retired from the business?
a former employee of the business?
a Union Representative?
a dependent of an employee or retiree?
You Must Also Complete Page 2 Of This Form
ERD-12193 (R. 03/2001)
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Parent category: Legal