Fill and Sign the Form 8821 Rev January 2021 Tax Information Authorization

Department of Employee Trust Funds P.O. Box 7931 Madison, WI 53707-7931 EMPLOYEE REIMBURSEMENT ACCOUNTS PROGRAM AUTOMATIC PREMIUM CONVERSION WAIVER/REVOCATION OF WAIVER     To waive your participation in Automatic Premium Conversion, complete Sections A and B. To revoke a waiver of premium conversion that you filed previously, complete Sections A and C. Sign and date this form and return to your payroll/staff benefits office. A premium conversion waiver will be effective with the next scheduled premium payment if filed:  Within 30 days of initial enrollment in the group insurance plan(s) checked below; or  Within 30 days of initial eligibility for the ERA program if you are already enrolled in the insurance plan(s), or  Within 30 days of an approved change in status event; or  January 1 of the next plan year if this form is filed at any time other than listed above.  A revocation of waiver will be effective with the next scheduled premium payment if filed:  Within 30 days of an approved change in status event; or  January 1 of the next plan year if this form is filed at any time other than listed above. SECTION A. EMPLOYEE DATA Name Last Home Address First Street Daytime Telephone MI City Social Security Number State Zip Code Employer (State Agency or UW Campus) SECTION B. AUTOMATIC PREMIUM CONVERSION WAIVER I hereby waive participation in Automatic Premium Conversion for the insurance plan(s) indicated below. (Check all that apply.) State Group Health Insurance EPIC Insurance DentalBlue Dental Insurance State Group Life Insurance Vision Service Plan (VSP) By waiving my participation, I understand that my share of state group insurance premiums will be taken from my paycheck after federal, state, and Social Security taxes have been taken. SECTION C. REVOCATION OF WAIVER I hereby revoke any previously filed waiver of participation in Automatic Premium Conversion for the insurance plan(s) indicated below. (Check all that apply.) State Group Health Insurance EPIC Insurance DentalBlue Dental Insurance State Group Life Insurance Vision Service Plan (VSP) By revoking the waiver I filed previously, I understand that my share of state group insurance premiums will be taken from my gross pay prior to calculation of federal, state, and Social Security taxes. I understand that this waiver or revocation will remain in effect as long as I remain employed, unless I file another form to change my election. Such changes will be effective for future plan years only.  I understand that this is not an application for insurance. To enroll in the insurance plans, I must complete insurance enrollment forms.  I have read and understand the information regarding automatic premium conversion found on this form and in the current Wisconsin Employee Reimbursement Account Program enrollment booklet. Date Signed Employee Signature Payroll Effective Date Date Received RETURN THIS FORM TO YOUR PAYROLL/STAFF BENEFITS OFFICE ET-2340 (REV 09/2009)