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									Sample insurance self-pay letter



Instructions for the agency for use of this sample letter: (The instructions in this box are not
intended to be included with the letter to the employee.) If an employee is in leave without pay
the agency (generally Payroll) sends this letter. Put this letter on your agency letterhead.


DATE:

TO:              Name:
                 Employee’s Address:

FROM:            Name:
                 Benefits Specialist

SUBJECT:         Self-paying Optional Insurances and Voluntary Deductions While on Leave
                 Without Pay
Agency Payroll has been notified that as of (date)__________________, you are in a leave
without pay (LWOP) status. Your voluntary deductions ended as of (date) _____________.
PEBB Insurances
Continuation of Health and Dental Insurances while on LWOP
If you are on Federal Family and Medical Leave (FMLA), Continued Benefit of Injured Worker
(CBIW), or 24 months of active duty military leave, you are eligible for your agency to continue
to pay your health, vision, and basic life premiums because of your protected leave status.
If the agency is paying your premiums and you have health or dental insurance coverage for
your domestic partner and, or your partner’s eligible children, and they are not tax dependents
for the purpose of receiving pre-tax health benefits, you must still pay the federal and state
taxes on the imputed value of the domestic partner insurance. See the table below.
If you are no longer eligible for agency-paid premiums, you will receive information about
continued health and dental insurances through self-pay COBRA coverage. The Public
Employee’s Benefit Board’s (PEBB) third-party administrator for COBRA will send you this
information.
Optional Insurances
If you are on leave without pay (LWOP) and want your optional PEBB insurances to continue,
you may be able to self-pay premiums to the agency. The following table provides a summary of
the optional PEBB insurances and the LWOP types that would allow you to self-pay.
Note: Only the insurances that are eligible as self-pay and were in effect before the start date of
your LWOP status may be self-paid.

You may only self-pay any of the allowable optional premiums up to 12 months, some of
the insurances may be converted for longer coverage. Contact your insurance carrier.

                             The key for the table is as follows
LWOP=Leave without Pay            FMLA=Federal Family and Medical Leave Act
OFLA=Oregon Family Leave Act      CBIW= Continued Benefit of Injured Worker
Military=Military Leave           Military Caregiver=FMLA Military Caregiver Leave
Exigency=FMLA Exigency Leave Yes=you may self-pay your premiums
No=you may not self-pay your premiums


DAS Sample Insurance Self-Pay Payroll Letter (01/28/09)                                           1
Sample insurance self-pay letter



                               Protected LWOP
       Optional               (FMLA, OFLA, CBIW,                Unprotected          Monthly Premium
      Insurance               Military, FMLA Military
                               Caregiver or FMLA                  LWOP                  Amounts
         Plan
                                     Exigency)
Optional                     Yes                          Yes
Employee Life

Spouse or Domestic           Yes                          Yes
Partner Life

Dependent Life               Yes                          Yes


AD&D                         Yes                          Yes


Long Term Care               Yes                          Yes


Short Term Disability        Yes                          No
                             Military No                  Yes, if a claim is filed
                                                          and awaiting
                                                          approval.
Long Term Disability         Yes                          No
                             Military No                  Yes, if a claim is filed
                                                          and awaiting
                                                          approval.
Domestic Partner             Yes, if DP insurance         Yes, if DP insurance
Insurance Tax                for partner or children      for partner or children
Liability                    who are not tax              who are not tax
                             dependents                   dependents

Self-Pay Premiums
If you choose to continue your optional PEBB benefits or the domestic partner insurance, your
total monthly payment is $_________________. You may pay for more than one month at a
time. Please pay the exact amount.
To prevent a break in your optional insurance coverage you need to make the premium
payment to this office. This is the only notice you will receive. Please keep this notice for your
records.
If you choose to self-pay the above insurances, send a cashiers check or money order made
payable to Department of Administrative Services Joint Payroll Account. Please mail your
payment by ______________ to: (agency name and address)
___________________________________________________.
Send payment to the attention of: (name and title of Payroll
representative)_________________________________________.



DAS Sample Insurance Self-Pay Payroll Letter (01/28/09)                                              2
Sample insurance self-pay letter


If you have short-term or long-term disability and Standard approves your claim, your premiums
for those insurances are waived. Upon approval, your agency will refund premiums paid by you
from the time of the claim filing to the approval.
Deferred Compensation
If you have a deferred compensation deduction you will need to contact the deferred
compensation coordinator at 503-378-3730.
(If applicable) Union Name __________________
The table below indicates which deductions you have through (union name) _________.
Contact your union at ________________________, for more information about self-paying
these premiums or for a waiver of premiums.

Deduction Type                     Yes, you may self-pay      No



Upon Return to Work from an Un-Protected LWOP:
You are required to work at least 80 hours in the month you return to qualify for basic benefits
the following month. (Medical, dental, and employee-only basic life)
If you have any questions please do not hesitate to contact the agency payroll office at (phone)
_______________.




DAS Sample Insurance Self-Pay Payroll Letter (01/28/09)                                            3

								
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