Elective Coverage Premium Reconsideration Request

Step 1: Confirm this is the right form

This form is for Elective Coverage wage review or correction requests. Wage changes may affect premiums, fees, or penalties.

Elective Coverage includes:
• Self-employed individuals
• Employees of opted-out local governments

Is your request about a claim decision (benefit payments, claim approval/denial)?

Yes → Please submit your request through My FAMLI+
No → Continue with this form

Step 2: Tell us about your account

Select one:

I am self-employedI am an employee of an opted-out local government

Step 3: Your Information

Full name

Phone Number

Email Address

FAMLI ID (if available)

Step 4: Reason for Reconsideration

Please tell us why you are requesting a reconsideration.

Note: Wage validation is based on gross income subject to premiums, not net income after expenses. Wages reported prior to the elective coverage start date may be adjusted, and any missing or inaccurate reporting may impact determinations.

Example: Wages were reported incorrectly for [quarter/year]. The correct amount should be $[amount], based on [brief explanation of the discrepancy].

To request a reasonable accommodation, or this form in an alternate accessible format, please refer to our department's Accessibility website and complete the Accessibility Feedback Form .

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