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
RETAIN A COPY FOR YOUR RECORDS
Page 2 of 2
ABOUT I.R.C. SECTION 402(
) 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. --