Employee Premium Refund Request Form
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1EMPLOYEES BENEFITS COUNCIL
120 N. Robinson, Suite 1100
Oklahoma City, Oklahoma
73102
405-232-1190 or 1-800-219-8115
EMPLOYEE PREMIUM REFUND REQUEST
Date received by EBC Accounting: _________________
Name ______________________________________________________ SSN ____________________
Agency Name________________________________________________ Agency#/Loc ____________
Period & specific reason for refund: _____________________________________________________
Enrolled
Refund
Refund to
Name of
Premium
Refund to
Premium
Amount
Agency
Carrier
Amount Paid
Employee
Amount
Due
HB2928
Health
Dental
Life
Supp Life
Dep Life
Disability
Vision
Spending
Account
Total Refund Due per Period:
$___________ $__________ $___________
Total Refund requested:
for _________ period(s) x $ ____________ = $ _________
Total Employee Refund requested: for _________ period(s) x $ ____________ = $ _________
Total Agency Refund requested:
for _________ period(s) x $ ____________ = $ _________
In accordance with Title 87:20-31-2 of the rules of the Oklahoma State Employees Benefits Council, here are the rules
that apply to receiving refunds for premiums: (A) Responsibility of participant to notify the Coordinator of changes in
eligibility. It is the participant’s duty to notify his/her coordinator of any changes in eligibility for himself, his spouse, or
his dependents. Any refund of payment for any over deduction shall be made only when the Council is notified in
writing no later than sixty (60) days from the actual date of the over deduction. No refund will be made for over
deductions which occurred more than sixty (60) days prior to the date written notification is received by the Council. (B)
Refunds for over deductions due to administrator error. Refunds for over deductions due to administrator error of the
agency shall be made at 100%.
□
□
Is the employee participating in Premium Conversion?
Yes or
No
__________________
_________________________________ _______________________
Date Benefits Coordinator notified
Coordinator Signature
Telephone Number
I, the undersigned, do depose and say that the above request for refund of insurance premium is just, correct, and due,
according to the regulation stated above.
Claimant’s signature ______________________________________Date: ________________
□
□
For EBC Use Only:
Is the employee Eligible for Refund:
Yes or
No
Date: ______________ EBC Coordinator Signature: _______________________________
Revised July 2006
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