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Get the free Premium Conversion Enrollment/Stop Form - groupbenefits

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This document serves as an enrollment and stop form for the Premium Conversion under the Flexible Benefits Plan, outlining eligibility for tax-free insurance premium deductions for State employees.
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How to fill out Premium Conversion Enrollment/Stop Form

01
Obtain the Premium Conversion Enrollment/Stop Form from your HR department or online portal.
02
Fill in your personal information, including your name, employee ID, and contact information.
03
Indicate whether you want to enroll in or stop premium conversion by checking the appropriate box.
04
If enrolling, provide the necessary details about your current health insurance plan.
05
Review the form for accuracy to ensure all information is correct.
06
Sign and date the form.
07
Submit the completed form to your HR department or the designated office by the deadline.

Who needs Premium Conversion Enrollment/Stop Form?

01
Current federal employees who want to start or stop their premium conversion for health insurance.
02
Employees who are making changes to their health insurance coverage.
03
Individuals who are eligible for premium conversion benefits under their employer’s program.
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People Also Ask about

Comments Section If you waive premium conversion you will have the flexibility, without giving any reason whatsoever, either to drop your health insurance altogether or change from a Self and Family enrollment to Self Only. Premium conversion may result in somewhat lower Social Security benefits.
In most cases, you'll also save on State income tax and local income tax. How much? You save a percentage of your premium. If your annual premium is $1800, and you pay 35% in taxes on that amount of salary, you save 35% of $1800.
You should obtain, complete and return a waiver/election form to your employing office. You may waive participation in premium conversion (or elect to participate, if you previously waived) during the annual FEHB Open Season.
Annuitants who are enrolled in the Federal Employees Health Benefit (FEHB) Program can cancel or suspend their enrollment. The form, RI 79-9, ensures that an individual is fully informed about the effect of a cancellation of FEHB coverage.
Allowing Federal Employees to Pay their Health Benefits Premiums with Pre-tax Dollars. Federal employees can use pre-tax dollars to pay health insurance premiums to the Federal Employees Health Benefits Program under the "Premium Conversion" program.

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The Premium Conversion Enrollment/Stop Form is a document used by employees to enroll in or discontinue their participation in a premium conversion plan, which allows them to pay for certain health insurance premiums using pre-tax dollars.
Employees who wish to enroll in or stop their participation in a premium conversion plan are required to file the Premium Conversion Enrollment/Stop Form.
To fill out the Premium Conversion Enrollment/Stop Form, employees must provide personal information such as their name, address, employee identification number, and indicate their choice to enroll or discontinue participation along with any required signatures.
The purpose of the Premium Conversion Enrollment/Stop Form is to enable employees to manage their participation in a premium conversion plan and ensure that their health insurance premium payments are correctly processed as pre-tax deductions.
The information that must be reported on the Premium Conversion Enrollment/Stop Form includes the employee's personal details (name, address, employee ID), the selection of enrollment or stop, the name of the health plan, and the employee's signature.
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