1. Complete Sections 1 and 2 of the PSOA-2021 Form.
2. Attach a copy of the invoice for all qualifi ed health insurance payments, except PEIA.
3. Sign the form in blue ink and mail it to CPRB.
Note: Resubmit the PSOA-2021 Form if you have changes to a previously designated insurance provider or premium
amount or to stop insurance premium paymen ts.
About the PSOA-2021 Form
RETAIN A COPY FOR YOUR RECORDS
Page 2 of 2
Retiree Signature
Date Signed
By signing this form, I agree that I will not make any legal claim of any kind against CPRB, its 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 CPRB, its staff and advisors
from any liability arising from the administration of payments to any insurer.
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This is a benefit enacted by congress and the IRS has not provided guidance to date on the application of this program. CPRB is
proceeding with implementation of the program based on its understanding of the information currently available, with the anticipation
that the program might require revisions and adjustments as the provisions of the Pension Protection Act of 2006 are interpreted and
clarified. By participating in the program, you acknowledge that changes may be required and that changes could affect your eligibility
or the eligibility of your insurance carrier or policy. It may also result in reversal of some transactions. You agree that any benefit or
privilege granted under this program is subject to change or revocation, that you will cooperate with any adjustments, and that CPRB is
not responsible for any consequence of any change to the program, including unexpected tax liability, interest and penalties.
Important Legal Notice
Instructions
Waiver of Claims
Eligibility for Tax-Free Distributions for Health and Long-Term Care Insurance
Notes About Tax-Free Distributions For Insurance Premiums
Public Safety Officer means an individual serving a public agency in an official capacity, with or without compensation, as a law
enforcement officer, firefighter, chaplain for a police or fire department, or member of a rescue squad or ambulance crew,
correction officers, probation officers, parole officers, judicial officers, and any other individuals involved in crime and juvenile
delinquency control or reduction or enforcement of the laws.
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.
Upon the death of a Public Safety Officer, IRC 402(l) does not allow a surviving spouse or other beneficiaries to receive this tax-
free distribution.
Section 845 of the Pension Protection Act of 2006 allows public safety officers to elect to exclude up to $3,000 of distributions
from a governmental qualified retirement plan from taxable income as long as the payments are made directly to an insurer to
purchase health or long-term care insurance for the officer or the officer’s spouse and/or dependents.
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Internal Revenue Code Section 402(l) and WV Code § 5-10D-6a authorize CPRB to offer this voluntary election, but only with
insurance carriers that have completed and filed the Retired Public Safety Officer Insurance Carrier Agreement (ICA) with the
CPRB. Requests from members for payment of premiums to insurance carriers who have not filed the ICA form will be referred
to the insurance carrier. CPRB may provide members a list of insurance carriers that have filed the ICA form upon request to
determine whether or not they will participate.
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You must submit a separate copy of this form for each insurance policy you are designating for direct payment by CPRB.
The insurance premiums you designate on this form will be paid directly to the named insurance company by CPRB and the cost
will be deducted from your monthly benefit.
The cost of insurance premiums, up to $3,000, is excluded from your taxable income for federal withholding purposes.
You can use income from more than one retirement plan to pay insurance premiums, but the maximum income exclusion the
I.R.S. allows for all plans combined is $3,000 per year. You are responsible for complying with this federal limit and for
consequences if your designated insurance premiums exceed the limit.
Premium payments will begin upon the CPRB’s approval of your insurance carrier and after CPRB receives a completed and
signed PSOA-2021 Form. Incomplete and unsigned forms will not be processed and you will be notified that you must resubmit
the form.
You are responsible for contacting your insurance carrier should an over/underpayment of premiums occur due to CPRB not
being notified of premium changes or policy cancellations.
The form must be signed and dated to be valid.
I have read and I understand the information in “About the 2021 PSOA Form” and agree to all of the conditions for this election including the Waiver of Claims.
Normal retrirement age for determination of eligibility means a member who has retired with an unreduced benefit.
Insurance Carrier Participation
PSOA-2016
WVAF0008 - Jan 2016
WVAF0008 Revised 11/30/2020
