(FEHB) Premium Conversion Waiver/Election Form

Attachment 3
Federal Employees Health Benefits Program (FEHB)
Premium Conversion Waiver/Election Form
Purpose of This Form
This form is used to elect or waive pre-tax treatment of employee premium contributions to the FEHB Program.
Pre-tax treatment is automatic. You do not need to complete this form unless you elect not to have your FEHB premium contributions
deducted on a pre-tax basis, or you previously waived this benefit and now elect to participate.
I. PARTICIPANT INFORMATION
Last Name
First Name
MI
Agency/Bureau Name
Agency/Bureau Address
SSN
Office phone
II. ELECTION TO WAIVE PARTICIPATION IN PREMIUM CONVERSION
I elect to waive participation in premium conversion and the pre-tax treatment of my FEHB premiums. I would like to
have my FEHB premium contributions deducted from my pay on an after-tax basis.
Signature
Date
This is my initial opportunity to waive participation in premium conversion
I am making this election to waive participation during FEHB Open Season
I wish to waive participation in premium conversion on account of and in accordance with a Qualifying Life Event
III. ELECTION TO RESTORE PARTICIPATION IN PREMIUM CONVERSION
I elect to have my FEHB premiums deducted from my pay on a pre-tax basis. I understand that I may only change my
FEHB premium deductions to an after-tax basis during a subsequent Open Season or upon a Qualifying Life Event. See
instructions for acceptable events.
Signature
Date
I am making this election to participate during the FEHB Open Season
I wish to participate in premium conversion on account of and in accordance with a Qualifying Life Event
IV. TO BE COMPLETED BY PAYROLL/PERSONNEL STAFF
Approved
Authorized agency official:
Disapproved
Effective Date: MM/DD/YYYY
-------------------------------------------Signature
-----------------------Date
Privacy Act Statement: This information is collected under 5 C.F.R. § 892 and will be used to process your decision
to waive or restore the pre-tax treatment of your FEHB premiums. This information may also be used pursuant to
routine uses promulgated by OPM under 5 U.S.C. § 552a(b)(3). Completion of this form is voluntary. However, if
this information is not provided, we will be unable to process your waiver or restoration of premium conversion.
Instructions for Completing the FEHB Premium Conversion Election/Waiver Form
Use this form to
Waive premium conversion and the pre-tax treatment of FEHB premiums
Restore premium conversion if previously waived
Do not use this form to
Elect premium conversion UNLESS you have previously waived it
Waive premium conversion if you have already waived it
Enroll in the FEHB Program. A separate form is used for that purpose
Who May Use This
Form
Employees who are eligible for pre-tax treatment of their FEHB premiums
General Information
Further information on premium conversion may be obtained on the OPM website:
www.opm.gov
Effective Dates
For Waivers
If you wish to waive pre-tax treatment when premium conversion becomes effective on
October 1, 2000, this form must be completed by you and received by your employing office
the earlier of: the date set by your employing agency; or the day before the first pay period
that begins on or after October 1, 2000.
Your decision to waive pre-tax treatment must be made during FEHB Open Season or within
the specified time period after a Qualifying Life Event (QLE). If you change your participation
during Open Season, it will become effective on the first full pay period in the following
calendar year. If you change your participation as a result of a Qualifying Life Event, the
change will be effective the first full pay period after this form is received by your employing
office.
Newly hired employees who want to waive pre-tax treatment need to submit this form at the
same time as SF-2809, Employee Health Benefits Election Form. Pre-tax waivers made by
newly hired employees take effect at the same time that FEHB coverage is effective.
Your decision will continue indefinitely unless you later submit a new election/waiver form to
change the tax treatment of your contributions to FEHB.
For Restorations
IRS Guidelines—Restrictions on Changing Health Benefits Coverage (Pre-tax Treatment)
To make a change outside of the FEHB Open Season, (switch plans or options, cancel your
enrollment, or change from family to self-only) or to change your participation in premium
conversion you must have experienced a QLE and the change in coverage must be on
account of and in accordance with that QLE. This differs for employees covered by after-tax
treatment, who may reduce their level of coverage at any time. The difference is because pretax treatment is subject to Internal Revenue Service (IRS) guidelines. Keep this information in
mind when making your decision.
If your change is allowed, it will be effective the first full pay period after this form is received
by your employing office.
Qualifying Life Events
(QLEs)
QLEs are events that may allow you to make a change in your premium conversion election
outside of open season. Ask your employing agency for more information on whether your
event meets the criteria of a qualifying life event.
With two exceptions (noted above), the rules for changing FEHB enrollment outside of Open
Season do not change. The opportunities for you to enroll or change enrollment described in
5 CFR Part 890, and in the FEHB Employee Health Benefits Election Form (SF 2809) will
continue to be allowed under premium conversion.
The IRS has additional events that will allow you to change your participation (election) in
premium conversion. Please see OPM's website for more information.