# Instructions for Completing the FEHB Premium Conversion Election/Waiver Form

+----------------------+-----------------------------------------------+
| # Use this form to   | Waive premium conversion and the pre-tax      |
|                      | treatment of FEHB premiums.                   |
|                      |                                               |
|                      | Restore premium conversion if previously      |
|                      | waived.                                       |
+----------------------+-----------------------------------------------+
| ## Do                | Elect premium conversion UNLESS you have      |
| not use this form to | previously waived it.                         |
|                      |                                               |
|                      | Waive premium conversion if you have already  |
|                      | waived it.                                    |
|                      |                                               |
|                      | Enroll in the FEHB Program. A separate form   |
|                      | (SF-2809) is used for that purpose.           |
+----------------------+-----------------------------------------------+
| ##                   | Employees who are eligible for pre-tax        |
|                      | treatment of their FEHB premiums, send        |
| ## Who M             | completed forms to:                           |
| ay Use This Form and |                                               |
|                      | **Customs and Border Protection (New Hires)** |
| ###### W             |                                               |
| here do they send it | **Indianapolis Hiring Center/HRM**            |
|                      |                                               |
|                      | **6650 Telecom Drive, Suite 100**             |
|                      |                                               |
|                      | **Indianapolis, IN 46278**                    |
|                      |                                               |
|                      | **U.S. Citizenship & Immigration Services ICE |
|                      | (Investigations, Intelligence)**              |
|                      |                                               |
|                      | **CBP HRM - Burlington Office CBP HRM -       |
|                      | Dallas Office**                               |
|                      |                                               |
|                      | **70 Kimball Avenue 7701 North Stemmons       |
|                      | Freeway**                                     |
|                      |                                               |
|                      | **South Burlington, Vermont 05403 Dallas,     |
|                      | Texas 75247**                                 |
|                      |                                               |
|                      | **ICE (Detention & Removal, Federal           |
|                      | Protective Service) ICE Employees of          |
|                      | Organizations & Offices**                     |
|                      |                                               |
|                      | **CBP HRM - Laguna Niguel Office not listed   |
|                      | above**                                       |
|                      |                                               |
|                      | **24000 Avila Road, Room 5160 (See CBP HRM    |
|                      | Laguna Niguel Office)**                       |
|                      |                                               |
|                      | **Laguna Niguel, CA 92677**                   |
+----------------------+-----------------------------------------------+
| **General            | Further information on premium conversion may |
| Information**        | be obtained from the OPM web site at          |
|                      | www.opm.gov/insure/health/pretaxfehb. You may |
|                      | also contact your servicing CBP-Human         |
|                      | Resources                                     |
|                      |                                               |
|                      | Management office.                            |
+----------------------+-----------------------------------------------+
| ###                  | Premium conversion was initially implemented  |
|                      | October 1, 2000.                              |
| ### EFFECTIVE DATES  |                                               |
|                      | Newly hired employees who want to waive       |
| ##### For Waivers    | pre-tax treatment need to submit this form    |
|                      | along with their                              |
| ##                   |                                               |
| ### For Restorations | SF-2809, Health Benefits Election Form, but   |
|                      | within 60 days of their appointment. Pre-tax  |
| #####                | waivers made                                  |
|                      |                                               |
|                      | by newly hired employees take effect at the   |
|                      | same time the FEHB coverage is effective.     |
|                      |                                               |
|                      | You may waive pre-tax treatment during the    |
|                      | annual FEHB Open Season or within the         |
|                      | specified time                                |
|                      |                                               |
|                      | period after a Qualifying Life Event (QLE).   |
|                      | If you change your participation during the   |
|                      | FEHB                                          |
|                      |                                               |
|                      | Open Season, it will become effective on the  |
|                      | first full pay period in the following        |
|                      | calendar year.                                |
|                      |                                               |
|                      | If you change your participation as a result  |
|                      | of a QLE, the change will be effective the    |
|                      | first full                                    |
|                      |                                               |
|                      | pay period after this form is received by the |
|                      | Human Resources Management office.            |
|                      |                                               |
|                      | Your decision will continue indefinitely      |
|                      | unless you later submit a new election/waiver |
|                      |                                               |
|                      | form to change the tax treatment of your      |
|                      | contributions to FEHB.                        |
|                      |                                               |
|                      | ####                                          |
|                      |                                               |
|                      | #### IRS Guidelines-Restrictions o            |
|                      | n Changing Health Benefits Coverage (Pre-tax  |
|                      |                                               |
|                      | *Treatment*) To make a change outside of the  |
|                      | FEHB Open season, (switch plans or            |
|                      |                                               |
|                      | options, cancel your enrollment, or change    |
|                      | from family to self-only) or to change your   |
|                      |                                               |
|                      | participation in premium conversion, you must |
|                      | have experienced a QLE and the                |
|                      |                                               |
|                      | change in coverage must be on account of and  |
|                      | in accordance with that QLE. This             |
|                      |                                               |
|                      | differs for employees covered by after-tax    |
|                      | treatment, who may reduce their level of      |
|                      |                                               |
|                      | coverage at any time. The difference is       |
|                      | because pre-tax treatment is subject to       |
|                      |                                               |
|                      | Internal Revenue Service (IRS) guidelines.    |
|                      | Keep this information in mind when            |
|                      |                                               |
|                      | making your decision.                         |
|                      |                                               |
|                      | If your change is allowed, it will become     |
|                      | effective the first full pay period after     |
|                      | this form is                                  |
|                      |                                               |
|                      | received by your servicing CBP-Human          |
|                      | Resources Management office.                  |
+----------------------+-----------------------------------------------+
| ###                  | QLEs are events that may allow you to make a  |
|                      | change in your premium conversion             |
| ###### Qu            |                                               |
| alifying Life Events | election outside of open season. QLEs include |
|                      | marriage, child birth, divorce, etc. Contact  |
| **(QLEs)**           |                                               |
|                      | your servicing CBP-Human Resources Management |
|                      | Service Center or visit the OPM web site at   |
|                      |                                               |
|                      | http://www.opm.gov/ins                        |
|                      | ure/health/reference/premconversion/index.asp |
|                      | for more information on                       |
|                      |                                               |
|                      | whether your event meets the criteria of a    |
|                      | qualifying life event.                        |
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