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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

Employees who are eligible for pre-tax treatment of their FEHB premiums

Form

General Information

Further information on premium conversion may be obtained on the OPM website:

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 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 are events that may allow you to make a change in your premium conversion election

(QLEs)

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.

Page 2 of 2

form HUD-27012 (9/2000)

Form Hud-27012 - Instructions For Completing The Fehb Premium Conversion Election/waiver Form

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