Pre Tax Conversion Form

Pre-Tax Premium Conversion

Pre-Tax Premium Conversion of Section 125 of the United States Tax Code.
    I would like to change how my premium for Medical, Dental, and/or Vision Premiums are taxed beginning January of next year.
  • Enter your SAP# or Last Four Digits of Your Social Security Number
  • Pre-Tax means I elect to have the premium deducted from my check on a pre-tax basis. This will reduce the taxable income that is reported on my W-2. I cannot drop medical, dentall or vision mid-year unless there is a qualifying family status change. Post Tax means I elect to have the premium deducted from my check on a post-tax basis. This means I will pay Social Security, Federal and State taxes on the premium amount.
    I understand that elections for Premium Conversion can commence, change or terminate during the plan year only if one of the following Change in Family Status circumstances occur: marriage, divorce, death of spouse or dependent, birth or adoption, commencement or termination of employment of spouse, change from full-time to part-time employment or part-time to full-time employment of employee or spouse, commence of or return from unpaid leave of absence by employee or spouse, loss of a dependent’s eligibility status, and substantial change in insurance coverage of the employee or spouse attributable to the spouse’s employment. I further understand that I must complete and submit the required forms to the UAMS Office of Human Resources within 31 days of the qualified event, or during the annual Section 125 open enrollment period. I attest that by clicking the signature box I am electronically signing this form.
  • Date Format: MM slash DD slash YYYY