RETAIN A COPY OF THIS ENTIRE FORM FOR YOUR RECORDS Page 2 of 2
ABOUT THIS FORM
INSTRUCTIONS FOR AGENT/INSURANCE CARRIERS
1. Complete “Section 1: Agent/Insurance Carrier Information.”
2. CCDB will send a printed report of names, policy numbers, and payment amounts with payment. These payments will be sent by CCDB
by the end of each month.
3. Read “Section2: Terms of Agreement Between Agent/Insurance Carrier and CCDB” and place a check mark in the box for each item.
4. Complete “Section 3: Certification of Agent/Insurance Carrier: by two officers of the company or corporation.
5. Upon approval by CCDB; a copy of the agreement, will be returned to the contact person listed in Section 1 and a CCDB representative
will call the contact person to finalize premium payment procedures and the start date for making such payments.
ABOUT SECTION 845 OF THE PENSION PROTECTION ACT OF 2006
Effective for distributions made in taxable years beginning after December 31, 2006, Section 845 of the Pension Protection Act allows retired
public safety officers to make an election to exclude up to $3,000 of distributions from a government qualified retirement plan, 403(b) plan, or
457(b) plan from income each year as long as the distributions are paid directly to an agent/insurance carrier for payment to purchase
health or long-term care insurance for the officer or the officer’s spouse and/or dependents for such year.
Retirement Plans may opt to participate or not. CCDB has opted to participate, but only with agents/insurance carriers that have completed
and filed this agreement with CCDB. Request from members for payment of premiums to non-participating agents/insurance carriers will be
referred to the agents/insurance carriers. CCDB may provide to members a list of agents/insurance carriers that have filed this agreement.
Section 845(a)(4)(D) of the Pension Protection Act defines Qualified Health Insurance Premiums as “premiums for coverage for the eligible
retired public safety officer, his spouse, and dependents, by an accident or health insurance plan or qualified long-term care insurance
contract (as defined in Section 7702B(b)).”
With respect to long-term care insurance contracts, Title 526 U.>S.>C.> Section 7702B(b) states:
1. In general
The term “qualified long-term care insurance contract” means any insurance contract if:
a. The only insurance protection provided under such contract is coverage of qualified long-term care services,
b. Such contract does not pay or reimburse expenses incurred for services or items to the extent that such expenses are
reimbursable under Title XVIII of the Social Security Act or would be so reimbursable but for the application of a deductible or
coinsurance amount,
c. Such contract is guaranteed renewable,
d. Such contract does not provide for a cash surrender value or other money that can be:
i. Paid, assigned or pledged as collateral for a loan, or
ii. Borrowed, other than as provided in subparagraph (e) or paragraph (2)(c),
e. All refunds of premiums, and all policy holder dividends or similar amounts, under such contract are to be applied as a
reduction in future premiums or to increase future benefits, and
f. Such contract meets the requirements of subsection (g).
2. Special rules
a. Per diem, etc. payments permitted
A contract shall not fail to be described in subparagraph (a) or (b) or paragraph (1) by reason of payments being made on a per
diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.
b. Special rules relating to Medicare
i. Paragraph (1)(b) shall not apply to expenses, which are reimbursable under Title XVIII of the Social Security Act only
as a secondary payor.
ii. No provision of law shall be construed or applied so as to prohibit the offering of a qualified long-term care insurance
contract on the basis that the contract coordinates its benefits with those provided under such title.
c. Refund of premiums
Paragraph (1)(e) shall not apply to any refund on the death of the insured, or on a complete surrender or cancellation of the
contract, which cannot exceed the aggregate premiums paid under the contract. Any refund on a complete surrender or
cancelation of the contract shall be includable in gross income to the extent that any deduction or exclusion was allowable with
respect to the premiums.
