District Of Columbia Government Health Insurance printable pdf download

District Of Columbia Government Health Insurance

DISTRICT OF COLUMBIA GOVERNMENT

HEALTH INSURANCE PRE-TAX WAIVER/ELECTION FORM

Purpose of This Form:

This form is used to elect or waive pre-tax treatment of employee health insurance premium contributions to the

District’s health insurance program. Pre-tax treatment is automatic. You do not need to complete this form unless you

elect not to have your health insurance 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

SSN

Agency

Office Phone

Home Phone

II. ELECTION TO WAIVE PARTICIPATION IN PRE -TAX HEALTH INSURANCE PROGRAM

I elect to waive participation in the pre-tax health insurance program. I would like to have my health insurance premiums

deducted from my paycheck on an after-tax basis.

Signature

Date

o This is my initial opportunity to waive participation in the pre-tax health insurance program.

o I am making this election to waive participation during Open Season.

o I wish to waive participation in the pre-tax health insurance program on account of and in accordance with a Qualifying

Life Event.

III. ELECTION TO RESTORE PARTICIPATION IN PRE -TAX HEALTH INSURANCE PROGRAM

I elect to have my health insurance premiums deducted from my pay on a pre-tax basis. I understand that I may only

change my pre-tax health insurance premiums deductions to an after tax basis during subsequent Open Season or upon a

Qualifying Life Event.

Signature

Date

o I am making this election to participate during the Open Season.

o I wish to participate in the pre-tax health insurance program on account of and in accordance with a Qualifying Life

Event.

IV. TO BE COMPLETED BY DC OFFICE OF PERSONNEL STAFF

Approved

Disapproved o

Effective Date________________________________________________________________________

Authorized Agency Official ________________________________________ ___________________

Signature

Date

District Of Columbia Government Health Insurance