Attachment 3 

 

This form is used to elect or waive pre-tax treatment of employee premium contributions to the FEHB Program. 

Pre-tax treatment is automatic. You do not need to complete this form unless you elect not to have your FEHB premium contributions 

deducted on a pre-tax basis, or you previously waived this benefit and now elect to participate. 

I. PARTICIPANT INFORMATION 

Last Name First Name MI SSN 

Agency/Bureau Name Agency/Bureau Address Office phone 

II. ELECTION TO WAIVE PARTICIPATION IN PREMIUM CONVERSION 

I elect to waive participation in premium conversion and the pre-tax treatment of my FEHB premiums. I would like to 

have my FEHB premium contributions deducted from my pay on an after-tax basis. 

Signature Date 

This is my initial opportunity to waive participation in premium conversion 

I am making this election to waive participation during FEHB Open Season 

I wish to waive participation in premium conversion on account of and in accordance with a Qualifying Life Event 

III. ELECTION TO RESTORE PARTICIPATION IN PREMIUM CONVERSION 

I elect to have my FEHB premiums deducted from my pay on a pre-tax basis. I understand that I may only change my 

FEHB premium deductions to an after-tax basis during a subsequent Open Season or upon a Qualifying Life Event. See 

instructions for acceptable events. 

Signature Date 

I am making this election to participate during the FEHB Open Season 

I wish to participate in premium conversion on account of and in accordance with a Qualifying Life Event 

IV. TO BE COMPLETED BY PAYROLL/PERSONNEL STAFF 

 Approved Disapproved Effective Date: MM/DD/YYYY 

 Authorized agency official: -------------------------------------------- ------------------------ 

 Signature Date

Privacy Act Statement: This information is collected under 5 C.F.R. § 892 and will be used to process your decision 

to waive or restore the pre-tax treatment of your FEHB premiums. This information may also be used pursuant to 

routine uses promulgated by OPM under 5 U.S.C. § 552a(b)(3). Completion of this form is voluntary. However, if 

this information is not provided, we will be unable to process your waiver or restoration of premium conversion. 

Federal Employees Health Benefits Program (FEHB)

Premium Conversion Waiver/Election Form 

Purpose of This Form 
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 not use this form to Elect premium conversion UNLESS you have previously waived it 

Waive premium conversion if you have already waived it 

Enroll in the FEHB Program. A separate form is used for that purpose 

Who May Use This 

Form 

Employees who are eligible for pre-tax treatment of their FEHB premiums 

General Information Further information on premium conversion may be obtained on the OPM website: 

www.opm.gov 

Effective Dates 

For Waivers If you wish to waive pre-tax treatment when premium conversion becomes effective on 

October 1, 2000, this form must be completed by you and received by your employing office 

the earlier of: the date set by your employing agency; or the day before the first pay period 

that begins on or after October 1, 2000. 

Your decision to waive pre-tax treatment must be made during FEHB Open Season or within 

the specified time period after a Qualifying Life Event (QLE). If you change your participation 

during 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 Qualifying Life Event, the 

change will be effective the first full pay period after this form is received by your employing 

office. 

Newly hired employees who want to waive pre-tax treatment need to submit this form at the 

same time as SF-2809, Employee Health Benefits Election Form. Pre-tax waivers made by 

newly hired employees take effect at the same time that FEHB coverage is effective. 

Your decision will continue indefinitely unless you later submit a new election/waiver form to 

change the tax treatment of your contributions to FEHB. 

For Restorations IRS Guidelines—Restrictions on 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 pretax 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 be effective the first full pay period after this form is received 

by your employing office. 

Qualifying Life Events 

(QLEs)

QLEs are events that may allow you to make a change in your premium conversion election 

outside of open season. Ask your employing agency for more information on whether your 

event meets the criteria of a qualifying life event. 

With two exceptions (noted above), the rules for changing FEHB enrollment outside of Open 

Season do not change. The opportunities for you to enroll or change enrollment described in 

5 CFR Part 890, and in the FEHB Employee Health Benefits Election Form (SF 2809) will 

continue to be allowed under premium conversion. 

The IRS has additional events that will allow you to change your participation (election) in 

premium conversion. Please see OPM's website for more information.