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Brochure Quantity Form for Fee-for-Service Plans
Plan Name _______________________________
The total quantity of brochures chargeable to the Federal Employees Health Benefits
(FEHB) Program for your plan is shown below. This quantity was determined by using
the formulas shown. Any quantities ordered over this amount will not be chargeable to
administrative expenses under the FEHB Program. All brochures must reach their
destinations by October 15, 2001.
Agency quantities (determined by OPM) ____________________
Plan enrollment as of March 31, 2001 ____________________
Number of organization members not
enrolled in Plan ____________________
Subtotal ____________________
10% of subtotal for Plan's stock
(Rounded to 100) ____________________
Total FEHB quantity order for Plan
brochure (Rounded to 100) Total ____________________
Mail _______ brochures to your OPM Contract Specialist.
Send to: Office of Personnel Management
Office of Insurance Programs
Attn: {put the name of your contract specialist}
1900 E Street NW, Room 3424
Washington, DC 20415-0001
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Completed 6 November 2019

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