Instructions: The purpose of this form is to enroll as an insurance carrier in the Retired Public Safety Officers Insurance Payment Program
for direct payment of insurance premiums as allowed under Internal
Revenue Code Section 402(
) and WV Code § 5-10D-6a. Read “About
the ICA Form” on page 2 before completing this form.
Section 1: Insurance Carrier Information
Authorized Signature Date Signed
Legal Name of Insurance Carrier Federal EIN Number
Contact Name Contact Email Address
Payment Mailing Address City State
Zip Code
Physical Location Address City State Zip Code
Section 3: Certification of Insurance Carrier Information
Insurance Carrier Officer’s Signature
Insurance Carrier Officer’s Name Title
Daytime Telephone Number
( )
Section 2: Terms of Agreement Between Insurance Carrier and CPRB
Retired Public Safety
Officer Insurance
Carrier Agreement (ICA)
4101 MacCorkle Avenue, SE
Charleston, WV 25304
304-558-3570 or 800-654-4406
Consolidated Public Rerement Board
Section 4: CPRB Certification
CPRB has reviewed this application and approved the insurance carrier named in Section 1.
This agreement is between CPRB and the insurance carrier named above.
The insurance carrier, identified in Section 1, agrees to participate in the Retired Public Safety Officers’ Insurance
Payment Program. Under the “Program”, CPRB retirees who retired as public safety officers may elect to have CPRB
deduct their medical, dental, vision, and long-term care insurance premiums from their retirement benefit and pay
the insurance carrier above directly.
The insurance carrier above certifies that all premiums are qualified health insurance premiums under Internal
Revenue Code 402(l).
The insurance carrier above will accept one payment of premiums of multiple retirees accompanied by an itemized
report showing name, social security number, and payment amount for each retiree.
CPRB’s only responsibility under the Program is to deduct and remit the premium payment as directed by the insured
member on the applicable PSOA form.
The insurance carrier above agrees to promptly notify CPRB of any changes in the applicable premiums, including,
but not limited to, termination of the policy and agrees to promptly return any overpayments to CPRB.
Either the insurance carrier above or CPRB can terminate this agreement by written notice received no less than 45
days in advance of the termination date.
I certify that I am an officer of the named insurance carrier in Section 1 who is authorized to bind the company or corporation
in this matter and hereby agree to abide by the terms of agreement state above.
Section 3: Certification of Insurance Carrier Information
Date Signed
Page 1 of 2
May 2015
1. Complete Section 1: Insurance Carrier Information.
2. Read Section 2: Terms of Agreement between Insurance Carrier and CPRB and place a check mark beside each bulleted item.
3. Complete Section 3: Certification of Insurance Carrier by an officer of the company or corporation.
About the ICA Form
Page 2 of 2
) AND WV CODE § 5-10D-6a
Note About Payments to Insurance Carriers: CPRB will send a printed report of names, social security numbers, and payment
amounts with payments. These payments will be sent by CPRB no later than the 25
of each month.
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 governmental qualified
retirement plan, 403(b) plan, or 457(b) plan from income each year as long as the distributions are paid directly to an insurer to
purchase health or long-term care insurance for the officer or the officer’s spouse and/or dependents for such year.
CPRB will only participate with insurance carriers that have completed and filed this form for approval. Requests from members for
payment of premiums to non-participating insurance carriers will be referred to the insurance carrier. CPRB may provide to
members a list of insurance carriers that have filed this agreement.
Internal Revenue Code Section 402(l)(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)).”
Title 26 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
(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) of 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
(i) Paragraph (1)(B) shall not apply to expenses which are reimbursable under Title XVIII of the Social Security Act only as
(ii) No provision of law shall be construed or applied so as to prohibit the offering of a qualified long-term care insurance
(C) Refunds of premiums. --
a secondary payor.
contract on the basis that the contract coordinates its benefits with those provided under such title.
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 cancellation of the contract shall be includable in gross income to the extent that any deduction or
exclusion was allowable with respect to the premiums.
(ii) borrowed, other than as provided in subparagraph (E) or paragraph (2)(C),
(B) Special rules relating to Medicare. --