Fillable City of Creve Coeur Defined Benefit Plan (CCDB) (City of Creve Coeur)

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City of Creve Coeur Defined Benefit Plan (CCDB) (City of Creve Coeur)

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-Acknowledgement Continues on Back- Page 1 of 2
City of Creve Coeur
Defined Benefit Plan (CCDB)
300 North New Ballas Rd
Creve Coeur, MO 63141
(314)-432-6000
PUBLIC SAFETY OFFICER AUTHORIZATION FOR INSURANCE PREMIUM DEDUCTION
INSTRUCTIONS:
• Please do not fax this form, only original forms will be accepted. Please print or type all information.
• Complete the entire form and follow the specific instructions for each section.
• You must submit a separate copy of this form for each insurance policy you are designating for direct payment by CCDB.
• Premium payments will only be made by CCDB if your insurance carrier or its agent has entered into an agreement with CCDB to
participate in this program.
SECTION 1: RETIREE
The purpose of this form is to elect to have third-party insurance premiums paid to your insurance carrier or its designated agent and the cost
deducted from your CCDB benefit.
Please read Page 2 before completing this form.
/ /
Member’s First Name Middle Last Today’s Date (mm/dd/yyyy) Social Security Number
Mailing Address City State Zip
( ) - ( ) -
Daytime Area Code and Telephone Number Evening Area Code and Telephone Number Email Address
SECTION 2: AGENT/INSURANCE CARRIER INFORMATION
Check all that apply: New Designation Change to Previously Designated Policy Stop Previously Designated Payments
Legal Name of Agent of Insurance Carrier Insurance Company Name Policy Number
(Complete only if payment is made to an agent.)
Payment Address City State Zip
( ) - Insurance Type: Medical Dental Long-Term Care
Telephone Number
Enter the monthly premium amount………………………………………………………………………………………………………$ .
SECTION 3: RETIREE ACKNOWLEDGMENT
• I have read and I understand the information on Page 2 and agree to all of the conditions for this election including the Waiver of Claims.
• I understand the eligibility requirements under the Pension Protection Act of 2006 (PPA) and anticipate claiming the income tax exclusion
for this program.
• I authorize CCDB to pay the insurance premiums directly and deduct the amount from my monthly benefit.
• I understand that the maximum amount of insurance premiums excludable from gross income under the PPA from all retirement plans is
$3,000 per year.
• I understand that it is my responsibility and obligation to inform CCDB of any change related to my insurance premium deduction including,
but not limited to, coverage, insurance carrier or agent, or premium changes.
• I understand CCDB is only performing an administrative function permitted by federal law in withholding insurance premiums from my
pension benefits.
• I understand that CCDB is not responsible for lapsed premiums or lapsed insurance policy coverage or any other coverage or benefit
issues that may arise.
• I understand that any and all tax implications of my election are my responsibility alone and I agree that I will make no claim against CCDB
for consequences of my election.
• I understand that this program is not transferable to my beneficiary upon my death.
RETAIN A COPY OF THIS ENTIRE FORM FOR YOUR RECORDS Page 2 of 2
CCDB Public Safety Officer Authorization for Insurance Premium Deduction
• I understand that CCDB does not provide tax advice and I should contact my personal tax advisor or CPA if I have questions on filing for this benefit
on my tax return.
• I understand that this is not a CCDB sponsored group insurance plan.
WAIVER OF CLAIMS
By signing this form, I agree that I will not make any legal claim of any kind against CCDB,the City of Creve Coeur or their respective staff and advisors
should my participation in this program result in unexpected tax liability to me, including interest and penalties. I understand that my ability to
participate in this program is a valuable benefit for which I am willing to agree to this waiver of all claims. I further release CCDB, the City of Creve
Coeur or their respective staff and advisors from any liability arising from the administration of payments to any insurer or its agent.
/ /
Retiree Signature Today’s Date (mm/dd/yyyy)
………………………………………………………………………………………………………………………………………………………………………
ABOUT THIS FORM
INSTRUCTIONS
1. Complete “Section 1: Retiree Information” and “Section 2: Agent/Insurance Carrier Information.”
2. Attach a copy of the insurance policy bill or coupon from the insurance carrier or its agent.
3. Sign the form and mail or deliver it to CCDB.
Note: Resubmit this form if you have presented any changes to your insurance carrier or its agent, there is a change to your premium information as
previously designated, or to stop insurance premium payments previously designated on this form.
IMPORTANT NOTICE
By participating in the program, you may be eligible for tax advantage treatment. Such treatment is determined under federal law and is subject to
compliance with certain requirements. Requirements may change from time to time. CCDB has no obligation to notify you of the requirements or
changes to the requirements
.
ELIGIBILITY FOR DISTRIBUTIONS FOR HEALTH AND LONG-TERM INSURANCE
• Public Safety Officer means an individual serving a public agency in an official capacity, with or without compensation including but not limited to, a
law enforcement officer, a firefighter, a chaplain for a police or fire department, or a member of a rescue squad or ambulance crew. See §1204(9)(A)
of the Omnibus Crime Council Control and Safe Streets Act of 1968 (42 U.S.C. § 3796b(9)(A)) for more information.
• Eligible Retired Public Safety Officer means an individual who, by reason of disability or attainment of normal retirement age, is separated from
service as a public safety officer with the employer who maintains the eligible retirement plan from which distributions are made.
• Normal retirement age for determination of eligibility means a member who has retired with an unreduced benefit or a deferred compensation
participant who has reached at least age 50.
AGENT / INSURANCE CARRIER PARTICIPATION
• Section 845 of the Pension Protection Act allows public safety officers to elect to exclude up to $3,000 of distributions from a government qualified
retirement plan or deferred compensation plan from taxable income as long as the payments are made directly to an insurance carrier or its agent to
purchase health or long-term care insurance for the officer or the officer’s spouse and/or defined dependents.
•
• Retirement plans may elect whether or not to participate. CCDB has elected to participate, but only with insurance carriers or agents that have
completed and filed the CCDB form: Retired Public Safety Officers Agent/Insurance Carrier Agreement with CCDB. Requests from members for
payment of premiums to insurance carriers or agents who have not filed the form will be referred to the insurance carrier or its agent who may
contact CCDB to order the form. Members are encouraged to contact their insurance carrier or its agent to complete the CCDB form: Retired Public
Safety Officers Agent/Insurance Carrier Agreement. Upon request, CCDB will provide a list of insurance carriers and agents that have filed the form.
NOTES ABOUT DISTRIBUTIONS FOR INSURANCE PREMIUMS
• The insurance premiums you designate on this form will be paid to the insurance carrier or its agent by CCDB and the premium will be deducted
from your benefit.
• You can use income from more than one retirement plan to pay insurance premiums, but the maximum income exclusion the IRS allows for all plans
combined is $3,000 per year. You are responsible for complying with this federal limit.
• Premium payments will only be made by CCDB if your insurance carrier or its agent has entered into an agreement with CCDB to participate in this
program. If CCDB does not have a prior approved agreement with the insurance carrier or its agent, implementation may be delayed or may not be
possible.
• Premium payments will begin after CCDB receives a completed and signed form. Incomplete and unsigned forms will not be processed
• You are responsible for contacting your insurance carrier or its agent should an over/underpayment of premiums occur due to CCDB not being
notified of premium changes or policy cancellations.
• All notices to CCDB must be received by the 10
th
of the month in order to be processed that month. Payments will be made by the end of
each month. It is the member’s responsibility to coordinate payment timing with the insurance carrier or its agent’s billing cycle.
• CCDB will not make the payment to the insurance carrier or its agent if the premium exceeds the retirement benefit.
RETAIN A COPY OF THIS ENTIRE
FORM FOR YOUR RECORDS
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City of Creve Coeur Defined Benefit Plan (CCDB) (City of Creve Coeur)

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Completed 22 January 2021

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