Federal Employees Health Benefits Program (FEHB)
Premium Conversion Waiver/Election Form


Purpose of This Form -- This form is used to elect or waive premium conversion (pre-tax treatment) of employee premium contributions to the FEHB Program. Premium conversion 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 ____ SSN _______________________________

Bureau/Office __________________________ Bureau/Office Address _____________________________ 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

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

IV. TO BE COMPLETED BY PAYROLL/PERSONNEL STAFF

Date Received in Employing Office________________ Received by______________________________

Approved 9 Disapproved 9 Effective Date: _______________________
Authorized agency official:

________________________________
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 8, 2000, this form must be completed by you and received by your employing office by October 6, 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 pre-tax 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.