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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