Did not provide law enforcement, firefighting, emergency medical, or chaplain services. 

At the time of my separation from service immediately prior to retirement, I        (check appropriate box)

Public Safety Officer Certification 

SC Public Employee Benefit Authority

South Carolina Retirement Systems 

Retired Public Safety Officers' Insurance Payment Program Deduction Form 

Not Applicable for SC Employee Insurance Program (EIP)


Payment Address

Insurance Type

Monthly Premium Amount


Zip Code

Withholding Authorization: 

Social Security Number

Telephone Number

Daytime Telephone Number

Insurance Provider Information

Member Information

control or reduction, or enforcement of the criminal laws, including, but not limited to, police, corrections, probation, parole, and judicial officers. 

or designated member of a legally organized volunteer fire department. 

a rescue squad or ambulance crew. 

departments or police departments. 

Insurance Company Name

Group/Policy Number





- Attach a copy of your invoice

Form 7701
Revised 2/3/2017
Page 1

I hereby authorize the Retirement Systems to reduce my gross annuity benefit, after taxes are calculated, by the total amount of qualified insurance premiums up to $3,000 per year and submit them directly to the insurance provider I have identified on this form. I understand that the Retirement Systems must have an approved agreement with my insurance provider and this will result in a change of my net monthly pension annuity.  I will be notified when the deduction is scheduled to begin.

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 my insurance provider and me.

I must contact the Retirement Systems to change or stop premium remittance amounts. 

To stop premium remittance with the Retirement Systems, complete an additional Form 7701 and check "Stop previously designated payments" in the insurance provider information block. I understand that I must contact my insurance provider directly to cancel my insurance policy.

To change premium remittance amounts with the Retirement Systems, complete an additional Form 7701 and check "change to previously designated policy" in the insurance provider information block.  The Retirement Systems must have at least 30 days notice to process premium remittance amount changes. 

This election will stay in effect until the Retirement Systems is notified to cancel or change the premium remittance.

If after my initial election in the program, I would like to add an additional premium payment, I may do so by completing an additional Form 7701 and checking "new designation" in the insurance provider information block.

I authorize the Retirement Systems to process changes in premium amounts from the insurance providers designated on this form. As a result, the Retirement Systems will process changes to premium amounts upon notification from me, the retiree, or upon notification from my insurance provider.

Insurance Provider Number - Assigned by the Retirement Systems

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