SC Public Employee Benefit Authority
South Carolina Retirement Systems
Retired Public Safety Officers' Insurance Payment Program Deduction Form
SC Employee Insurance Program (EIP) Only
At the time of my separation from service immediately prior to retirement, I
Public Safety Officer Certification
or designated member of a legally organized volunteer fire department.
a rescue squad or ambulance crew.
control or reduction, or enforcement of the criminal laws, including, but not limited to, police, corrections, probation, parole, and judicial officers.
I understand that the Retirement Systems is not responsible for lapsed premiums or lapsed insurance policy coverage or any other coverage or benefit issues that may arise between EIP and me.
I authorize EIP to notify the Retirement Systems directly and authorize changes to premium amounts. I authorize the Retirement Systems to process changes and cancellations related to these insurance premiums upon notification from EIP.
If my monthly annuity check will not cover the entire premium payment, the Retirement Systems will not make the payment to EIP.
If I exhaust the $3,000 eligible for exclusion from taxable income, the Retirement Systems will continue to remit payment to EIP.
By participating in this program and authorizing the Retirement Systems to remit premium payments on my behalf, I cannot authorize another qualified retirement plan to also remit payments that will exceed the $3,000 maximum annual amount.
I understand that it will be my responsibility to report the premiums eligible for exclusion on my individual tax return in order to claim the exclusion from taxable income. If I receive a refund of qualifiied premiums during the calendar year, I understand the amount of qualified premiums reported on the SCRS annual statement must be adjusted to reflect the refund.
BY SIGNING THIS FORM, I AGREE THAT I WILL NOT MAKE ANY LEGAL CLAIM OF ANY KIND AGAINST THE SOUTH CAROLINA RETIREMENT SYSTEMS, ITS STAFF AND ADVISORS, AND THE EMPLOYER AS A RESULT OF MY PARTICIPATION IN THIS PROGRAM, INCLUDING, BUT NOT LIMITED TO ANY 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 SIGN THIS WAIVER OF ALL CLAIMS. I FURTHER RELEASE THE SOUTH CAROLINA RETIREMENT SYSTEMS, ITS STAFF AND ADVISORS, AND THE EMPLOYER FROM ANY LIABILITY ARISING FROM THE ADMINISTRATION OF PAYMENTS TO ANY INSURER.
Insurance Provider Information
I have read the statements on this form and agree to the terms and conditions. I attest that the information provided on this form is true and accurate.
THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT AND TO REVISE THIS PROGRAM AS IT DEEMS APPROPRIATE.
departments or police departments.
Did provide law enforcement, firefighting, emergency medical, or chaplain services.
directly to the South Carolina Employee Insurance Program (EIP). By signing this form, I authorize the Retirement Systems to continue remitting these premiums to EIP and acknowledge that the eligible premiums should be reported on my individual tax return in order to claim the exclusion from taxable income.