Fill - Free fillable Sf2809 Health Benefits Election Form PDF form

Health Benefits Election Form

Form Approved:

OMB No. 3206-0160

Standard Form 2809

Revised November 2015

Previous edition is not usable

Uses for Standard Form (SF) 2809

Use this form to:

•

Switch designated eligible family member; or

•

Enroll or reenroll in the FEHB Program; or

•

Elect not to enroll in the FEHB Program (employees only);or

•

Change your FEHB enrollment; or

•

Cancel your FEHB enrollment; or

•

Suspend your FEHB enrollment (annuitants or former spouses

only).

Who May Use SF 2809

1. Employees eligible to enroll in or currently enrolled in the FEHB

Program. Employees automatically participate in premium

conversion unless they waive it, see page 7.

2. Annuitants in retirement systems other than the Civil Service

Retirement System (CSRS) or Federal Employees Retirement

System (FERS), including individuals receiving monthly

compensation from the Office of Workers’ Compensation Programs

(OWCP).

Note: Civil Service Retirement System (CSRS) and Federal

Employees Retirement System (FERS) annuitants and former

spouses and children of CSRS/FERS annuitants -- Do not use

this form.

Instead, use form OPM 2809, which is available at

www.opm.gov/forms/OPM-forms, or call the Retirement Information

Office toll-free at 1-888-767-6738.

3. Former spouses eligible to enroll in or currently enrolled in the

FEHB Program under the Spouse Equity law or similar statutes.

4. Individuals eligible for Temporary Continuation of Coverage (TCC)

under the FEHB Program, including:

•

Former employees (who separated from service);

•

Children who lose FEHB coverage; and

•

Former spouses who are not eligible for FEHB under item 3

above.

Instructions for Completing SF 2809

Type or Print. We have not provided instructions for

those items that have an explanation on the form.

Part A — Enrollee and Family Member Information

You must complete this part.

Item 2. See the Privacy Act and Public Burden Statements on page 5.

Item 5. If you are separated but not divorced, you are still married.

Item 7. If you have Medicare, check which Parts you have, including

prescription drug coverage under Medicare Part D.

Item 8. If you have Medicare, enter your Medicare Claim Number.

This number is on your Medicare Card.

Item 9. If you are covered by other health insurance, either in your

name or under a family member’s policy, check yes and

complete item 10.

Item 10. Provide the information requested on any other health

insurance that covers you. An FEHB Self Plus One

enrollment covers the enrollee and one eligible family

member designated by the enrollee. An FEHB Self and

Family enrollment covers the enrollee and all eligible family

members. If you or a family member is covered under

another FEHB enrollment, check the FEHB box and

Contact your Human Resources office or retirement system

immediately as this is a dual coverage situation. Some

examples of how this could occur are:

•

You are enrolling in an FEHB Self Only plan while

your spouse has either an FEHB Self Plus One or Self

and Family plan, in which you are already covered.

•

You are enrolling in an FEHB Self Plus One plan while

you are also covered under your spouse’s FEHB Self

Plus One plan or FEHB Self and Family plan.

•

You are enrolling in an FEHB Self and Family plan

while your spouse is already enrolled in either a FEHB

Self Only plan, an FEHB Self Plus One plan that covers

you, or an FEHB Self and Family plan that covers you.

•

You are an employee under age 26 and have no eligible

family members. You are enrolling in your own FEHB

plan while you are covered under your parent’s FEHB

Self Plus One plan or Self and Family plan.

•

You are an annuitant who is reemployed in the Federal

government. You are enrolling in an FEHB plan as an

employee while you are covered under your own or a

family member’s FEHB plan.

No person may be covered under more than one FEHB

enrollment.

However, in certain unusual circumstances, your

agency may allow you to enroll in order to:

•

Enable an employee under age 26 who is covered under

a parent’s Self Plus One or Self and Family FEHB

enrollment to enroll in FEHB to cover his or her own

spouse and/or child;

•

Enable an employee under age 26 who is covered under

a parent’s Self Plus One or Self and Family FEHB

enrollment, but lives outside his or her parent’s HMO

service area, to have FEHB coverage;

•

Enable an employee who separates or divorces to enroll

in FEHB to cover family members who move outside

the HMO service area of the covering FEHB Self Plus

One or Self and Family enrollment.

In these unusual situations, each enrollee must notify his or

her plan as to which family members are covered under

which enrollment. See Dual Enrollment information on

page 5.

If your enrollment is for Self Plus One or Self and Family, complete the

family member information as appropriate. (If you need extra space for

additional family members, list them on a separate sheet and attach.)

Important: In order for your Self Plus One FEHB enrollment election to

be processed, you must complete the family member information for

your designated family member.

The instructions for completing items 13 through 24 for your initial

family member also apply to the information you provide for additional

family members.

Item 14. Provide the Social Security Number for this family member if

he/she has one. If your family member does not have a Social

Security Number, leave blank; benefits will not be withheld.

(See Privacy Act Statement on page 5.)

Item 17. Provide the code which indicates the relationship of each

eligible family member to you.

Code Family Relationship

01 Spouse

19 Child under age 26

09 Adopted Child under age 26

17 Stepchild under age 26

10 Foster Child under age 26

99 Disabled child age 26 or older who is incapable

of self support because of a physical or mental

disability that began before his/her 26

birthday.

Item 18. If your family member does not live with you, enter his/her

home address.

Item 19. If your family member has Medicare, check which Parts

(Part A [Hospital Insurance] and/or Part B [Medical

Insurance]) he/she has, including prescription drug

coverage under Medicare Part D.

Item 20. If your family member has Medicare, enter his/her Medicare

Claim Number. This number is on his/her Medicare Card.

Item 21. If your family member is covered by other group insurance,

such as private, state, or Medicaid, check the box and

complete item 22.

Item 22. Provide the information requested on any other health

insurance that covers this family member. If your family

member is covered under another FEHB plan, see

instructions for item 10.

Item 23. Enter email address, if applicable, for this family member.

Item 24. Enter preferred telephone number, if applicable, for this

family member.

Family Members Eligible for Coverage

Unless you are a former spouse or survivor annuitant, family members

eligible for coverage under your Self Plus One enrollment include one

eligible family member (spouse or child under age 26) designated by

you. A Self and Family enrollment includes you and all of your eligible

family members.

Eligible children include your children born within marriage or adopted

children; stepchildren (may include children of your same-sex domestic

partner*); recognized natural children; or foster children who live with

you in a regular parent-child relationship.

*If you would marry but you live in a state that does not allow same-sex couples to marry.

Other relatives (for example, your parents)

are not eligible for coverage

even if they live with you and are dependent upon you.

If you are a former spouse or survivor annuitant, family members

eligible for coverage under your Self Plus One or Self and Family

enrollment are the natural or adopted children under age 26 of both you

and your former or deceased spouse.

In some cases, a disabled child age 26 or older is eligible for coverage

under your Self Plus One or Self and Family enrollment if you provide

adequate medical certification of a mental or physical disability that

existed before his/her 26

birthday and renders the child incapable of

self-support.

Note: Your employing office can give you additional details about

family member eligibility including any certification or documentation

that may be required for coverage. Contact your employing office for

more information about covering foster child(ren), or child(ren) of your

same-sex domestic partner who you would marry but for your state’s

marriage law. “Employing office” means the office of an agency or

retirement system that is responsible for health benefits actions for an

employee, annuitant, former spouse eligible for coverage under the

Spouse Equity provisions, or individual eligible for TCC.

Survivor Benefits

For your surviving family members to continue your FEHB enrollment

after your death, all of the following requirements must be met:

Self Plus One

•

You must have been enrolled for Self Plus One at the time of your

death; and

•

Your designated family member must be entitled to an annuity as

your survivor.

Note: The only survivor eligible to continue the health benefits enroll-

ment is the designated family member covered under FEHB on the date

of death as long as that individual is entitled to a survivor annuity. No

other family members are entitled to continue the enrollment even

though they may be entitled to a survivor annuity.

Self and Family

•

You must have been enrolled for Self and Family at the time of your

death; and

•

At least one family member must be entitled to an annuity as your

survivor.

Note: All of your survivors who meet the definition of “family member”

can continue their health benefits coverage under your enrollment as

long as any one of them is entitled to a survivor annuity. If the survivor

annuitant is the only eligible family member, the retirement system will

automatically change the enrollment to Self Only.

Standard Form 2809

Revised November 2015

Part B — FEHB Plan You Are Currently Enrolled In

You must complete this part if you are changing, cancelling, or

suspending your enrollment.

Item 1. Enter the name of the plan you are enrolled in from the front

cover of the plan brochure.

Item 2. Enter your current enrollment code from your plan ID card.

Part C — FEHB Plan You Are Enrolling In or

Changing To

Complete this part to enroll or change your enrollment in the FEHB

Program.

Item 1. Enter the name of the plan you are enrolling in or changing

to. The plan name is on the front cover of the brochure of the

plan you want to be enrolled in.

Item 2. Enter the enrollment code of the plan you are enrolling in or

changing to. The enrollment code is on the front cover of the

brochure of the plan you want to be enrolled in, and shows

the plan and option you are electing and whether you are

enrolling for Self Only, Self Plus One, or Self and Family.

To enroll in a Health Maintenance Organization (HMO), you must live

(or in some cases work) in a geographic area specified by the carrier.

To enroll in an employee organization plan, you must be or become a

member of the plan’s sponsoring organization, as specified by the

carrier.

Your signature in Part H authorizes deductions from your salary,

annuity, or compensation to cover your cost of the enrollment you elect

in this item, unless you are required to make direct payments to the

employing office.

Part D — Event That Permits You To Enroll, Change,

Or Cancel

Item 1. Enter the event code that permits you to enroll, change, or

cancel based on a Qualifying Life Event (QLE) from the

Table of Permissible Changes in Enrollment that applies to

you.

Explanation of Table of Permissible Changes in Enrollment

The tables on pages 7 through 14 illustrate when: an employee who

participates in premium conversion; annuitant; former spouse; person

eligible for TCC; or employee who waived participation in premium

conversion may enroll or change enrollment. The tables show those

permissible events that are found in the regulations at 5 CFR Parts 890

and 892.

The tables have been organized by enrollee category. Each category is

designated by a number, which identifies the enrollee group, as follows:

1. Employees who participate in premium conversion

2. Annuitants (other than CSRS/FERS annuitants), including

individuals receiving monthly compensation from the Office of

Workers’ Compensation Programs

3. Former spouses eligible for coverage under the Spouse Equity

provision of FEHB law

4. TCC enrollees

5. Employees who waived participation in premium conversion

Following each number is a letter, which identifies a specific Qualifying

Life Event (QLE); for example, the event code “1A” refers to the initial

opportunity to enroll for an employee who elected to participate in

premium conversion.

Item 2. Enter the date of the QLE using numbers to show month, day,

and complete year; e.g., 06/30/2011. If you are electing to

enroll, enter the date you became eligible to enroll (for

example, the date your appointment began). If you are

making an open season enrollment or change, enter the date

on which the open season begins.

Part E — Election NOT to Enroll

Place an “X” in the box only if you are an employee and you do NOT

wish to enroll in the FEHB Program. Be sure to read the information

titled Employees Who Elect Not to Enroll or Who Cancel Their

Enrollment.

Part F — Cancellation of FEHB

Place an “X” in the box only if you wish to cancel your FEHB

enrollment. Also enter your current plan name and enrollment code in

Part B. Be sure to read the information titled Employees Who Elect Not

to Enroll or Who Cancel Their Enrollment.

Note For Parts E and F. If you are Electing Not to Enroll or

Cancelling your enrollment because you are covered as a spouse or

child under another FEHB enrollment, your agency must enter the

enrollee’s name, Social Security number, and FEHB enrollment code

in REMARKS.

Cancellation of Enrollment

Employees participating in premium conversion may cancel their FEHB

enrollment only during the open season or when they experience a

Qualifying Life Event. Employees who waived participation in premium

conversion, annuitants, former spouses, and individuals enrolled under

TCC may cancel their enrollment at any time. However, if you cancel,

neither you nor any family member covered by your enrollment are

entitled to a 31-day temporary extension of coverage, or to convert to

an individual, nongroup policy. Moreover, family members who lose

coverage because of your cancellation are not eligible for TCC. Be sure

to read the additional information below about cancelling your FEHB

enrollment.

Employees Who Elect Not to Enroll (Part E) or Who Cancel

Their Enrollment (Part F)

To be eligible for an FEHB enrollment after you retire, you must retire:

•

Under a retirement system for Federal civilian employees, and

•

On an immediate annuity.

In addition, you must be currently enrolled in a plan under the FEHB

Program and must have been enrolled (or covered as a family member)

in a plan under the Program for:

•

The 5 years of service immediately before retirement (i.e.,

commencing date of annuity entitlement), or

•

If fewer than 5 years, all service since your first opportunity to

enroll. (Generally, your first opportunity to enroll is within 60 days

after your first appointment [in your Federal career] to a position

under which you are eligible to enroll under conditions that permit a

Government contribution toward the enrollment.)

If you do not enroll at your first opportunity or if you cancel your

enrollment, you may later enroll or reenroll only under the circumstances

Standard Form 2809

Revised November 2015

explained in the table beginning on page 7. Some employees delay their

enrollment or reenrollment until they are nearing 5 years before

retirement in order to qualify for FEHB coverage as a retiree; however,

there is always the risk that they will retire earlier than expected and not

be able to meet the 5-year requirement for continuing FEHB coverage

into retirement. When you elect not to enroll or cancel your enrollment

you are voluntarily accepting this risk. An alternative would be to

enroll in or change to a lower cost plan so that you meet the

requirements for continuation of your FEHB enrollment after retirement.

Note for temporary [under 5 U.S.C. 8906a] employees eligible for

FEHB without a Government contribution: Your decision not to enroll

or to cancel your enrollment will not affect your future eligibility to

continue FEHB enrollment after retirement.

Annuitants Who Cancel Their Enrollment

CSRS and FERS annuitants and their eligible family members should

not use this form but use form RI 79-9, Health Benefits

Cancellation/Suspension Confirmation, which is available at

www.opm.gov/forms/Retirement-and-Insurance-Forms, or call

1-888-767-6738.

Generally, you cannot reenroll as an annuitant unless you are

continuously covered as a family member under another person’s

enrollment in the FEHB Program during the period between your

cancellation and reenrollment. Your employing office or retirement

system can advise you on events that allow eligible annuitants to

reenroll. If you cancel your enrollment because you are covered under

another FEHB enrollment, you can reenroll from 31 days before through

60 days after you lose that coverage under the other enrollment.

If you cancel your enrollment for any other reason, you cannot later

reenroll, and you and any family members covered by your enrollment

are not entitled to a 31-day temporary extension of coverage or to

convert to an individual policy.

Former Spouses (Spouse Equity) Who Cancel Their Enrollment

Generally, if you cancel your enrollment in the FEHB Program, you

cannot reenroll as a former spouse. However, if you cancel the

enrollment because you become covered under FEHB as a new spouse

or employee, your eligibility for FEHB coverage under the Spouse

Equity provisions continues. You may reenroll as a former spouse from

31 days before through 60 days after you lose coverage under the other

FEHB enrollment.

If you cancel your enrollment for any other reason, you cannot later

reenroll, and you and any family members covered by your enrollment

are not entitled to a 31-day temporary extension of coverage or to

convert to an individual policy.

Temporary Continuation of Coverage (TCC) Enrollees Who

Cancel Their Enrollment

If you cancel your TCC enrollment, you cannot reenroll. Your family

members who lose coverage because of your cancellation cannot enroll

for TCC in their own right nor can they convert to a nongroup policy.

Family members who are Federal employees or annuitants may enroll in

the FEHB Program when you cancel your coverage if they are eligible

for FEHB coverage in their own right.

Note 1: If you become covered by a regular enrollment in the FEHB

Program, either in your own right or under the enrollment of someone

else, your TCC enrollment is suspended. You will need to send

documentation of the new enrollment to the employing office

maintaining your TCC enrollment so that they can stop the TCC

enrollment. If your new FEHB coverage stops before the TCC

enrollment would have expired, the TCC enrollment can be reinstated

for the remainder of the original eligibility period (18 months for

separated employees or 36 months for eligible family members who lose

coverage).

Note 2: Former spouses (Spouse Equity) and TCC enrollees who fail to

pay their premiums within specified timeframes are considered to have

voluntarily cancelled their enrollment.

Part G — Suspension of FEHB

CSRS and FERS annuitants and their eligible family members should

not use this form but use form RI 79-9, Health Benefits

Cancellation/Suspension Confirmation, which is available at

www.opm.gov/forms/Retirement-and-Insurance-Forms, or call

1-888-767-6738.

Place an “X” in the box only if you are an annuitant or former spouse

and wish to suspend your FEHB enrollment. Also enter your current plan

name and enrollment code in Part B.

You may suspend your FEHB enrollment because you are enrolling in

one of the following programs:

•

A Medicare Advantage plan or Medicare HMO,

•

Medicaid or similar State-sponsored program of medical assistance

for the needy,

• TRICARE (including Uniformed Services Family Health Plan or

TRICARE for Life),

•

CHAMPVA, or

•

Peace Corps.

You can reenroll in the FEHB Program if your other coverage ends.

If your coverage ends involuntarily, you can reenroll from 31 days

before your other coverage ends through 60 days after your other

coverage ends. If your coverage ends voluntarily because you disenroll,

you can reenroll during the next open season.

You must submit documentation of eligibility for coverage under the

non-FEHB Program to the office that maintains your enrollment. That

office must enter in REMARKS the reason for your suspension.

Part H — Signature

Your agency, retirement system, or office maintaining your enrollment

cannot process your request unless you complete this part.

If you are registering for someone else under a written authorization

from him or her to do so, sign your name in Part H and attach the written

authorization.

If you are registering for a former spouse eligible for coverage under the

Spouse Equity provisions or for an individual eligible for TCC as his

or her court-appointed guardian, sign your name in Part H and attach

evidence of your court-appointed guardianship.

Standard Form 2809

Revised November 2015

Part I - Agency or Retirement System Information

and Remarks

•

For the eligible former spouse of an enrollee, the enrollee or the

former spouse must notify the employing office within 60 days after

the former spouse’s change in status; e.g., the date of the divorce.

Leave this section blank as it is for agency or retirement system use only.

Electronic Enrollments

Many agencies use automated systems that allow their employees to

make changes using a touch-tone telephone, or a computer instead of

a form. This may be Employee Express or another automated system.

If you are not sure whether the electronic enrollment option is available

to you, contact your employing office.

Dual Enrollment

No person (enrollee or family member) is entitled to receive benefits

under more than one enrollment in the FEHB Program. Normally, you

are not eligible to enroll if you are covered as a family member under

someone else’s enrollment in the Program. However, such dual

enrollments may be permitted under certain circumstances in order to:

•

Protect the interests of children who otherwise would lose coverage

as family members, or

•

Enable an employee who is under age 26 and covered under a

parent’s enrollment and marries or becomes the parent of a child to

enroll for Self Plus One or Self and Family coverage.

Each enrollee must notify his or her plan of the names of the persons to

be covered under his or her enrollment who are not covered under the

other enrollment. See instructions for item 10 for more information.

Temporary Continuation of Coverage (TCC)

The employing office must notify a former employee of his or her

eligibility for TCC. The enrollee, child, former spouse, or their

representative must notify the employing office when a child or former

spouse becomes eligible.

•

For the eligible child of an enrollee, the enrollee must notify the

employing office within 60 days after the qualifying event occurs;

e.g., child reaches age 26.

An individual eligible for TCC who wants to continue FEHB coverage

may choose any plan, option, and type of enrollment for which he or she

is eligible. The time limit for a former employee, child, or former spouse

to enroll with the employing office is within 60 days after the Qualifying

Life Event, or receiving notice of eligibility, whichever is later.

Effective Dates

Except for open season, most enrollments and changes of enrollment are

effective on the first day of the pay period after the employing office

receives this form and that follows a pay period during any part of which

the employee is in pay status. Your employing office can give you the

specific date on which your enrollment or enrollment change will take

effect.

Note 1: If you are changing your FEHB enrollment from Self Plus One

or Self and Family to Self Only so that your spouse can enroll for Self

Only, you should coordinate the effective date of your spouse’s

enrollment with the effective date of your enrollment change to avoid a

gap in your spouse’s coverage.

Note 2: If you are cancelling your FEHB enrollment and intend to be

covered under someone else’s enrollment at the time you cancel, you

should coordinate the effective date of your cancellation with the

effective date of your new coverage to avoid a gap in your coverage.

Agency Distribution of SF 2809

Agencies must distribute one copy of the completed SF 2809 to each of

the following, as appropriate:

•

Official Personnel Folder

•

New Carrier

•

Old Carrier

•

Payroll Office

•

Enrollee

Privacy Act and Public Burden Statements

The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program under Chapter 89, title 5, U.S.

Code. The principal use of this information will be to share it with the health insurance carrier you select so that it may (1) identify your enrollment in the plan,

(2) verify your and/or your family’s eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment of claims with other carriers

with whom you might also make a claim for payment of benefits. Other routine uses include disclosures to other Federal agencies or Congressional offices which may

have a need to know it in connection with your application for a job, license, grant, or other benefit. It may also be shared and is subject to verification, via paper,

electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or Social Security administrative agencies to

determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the

extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local

law enforcement agency. While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your

enrollment.

We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB Program, and for other purposes. Executive

Order 13478 (November 18, 2009) allows Federal agencies to use Social Security Numbers as individual identifiers to distinguish between people of same or similar

names. In addition, a mandatory insurer reporting law (Section 111 of Public Law number 110-173) requires your health insurance carrier to report your Social Security

Number or your Medicare Claim Number in order to properly coordinate benefits between your health plan and Medicare. Also, Section 6055 of the Internal Revenue

Code requires your health insurance plan to report, to the Internal Revenue Service (IRS), information necessary to confirm that you and your covered family members

have minimum essential coverage from your health plan. The information required from your health insurance plan includes a Social Security Number for yourself and

each of your covered family members. Failure to furnish your Social Security Number and/or Medicare Claim Number may result in the US. Office of Personnel

Management’s (OPM) inability to ensure the prompt payment of your and/or family’s claims for health benefits services or supplies, proper coordination with Medicare

and proper health insurance status reporting to the IRS.

We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed

form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel

Management, Retirement Services Publications Team, (3206-0160), Washington, D.C. 20415-3430. The OMB number, 3206-0160 is currently valid. OPM may not

collect this information, and you are not required to respond, unless this number is displayed.

Standard Form 2809

Revised November 2015

Federal Employees Receiving Premium Conversion Tax Benefits

Table of Permissible Changes in FEHB Enrollment and Premium Conversion Election

Premium Conversion allows employees who are eligible for FEHB the opportunity to pay for their share of FEHB premiums with pre-tax dollars. Premium conversion plans are governed by Section 125 of the

Internal Revenue Code, and IRS rules govern when a participant may change his or her election outside of the annual open season. All employees who enroll in the FEHB Program automatically receive

premium conversion tax benefits, unless they waive participation. When an employee experiences a Qualifying Life Event (QLE) as described below, certain changes to the employee’s FEHB coverage

(including change to Self Only and cancellation) and premium conversion election may be permitted, so long as they are because of and consistent with the QLE’s. If you are covering child(ren) of your

same-sex domestic partner who you would marry but for your state’s marriage law, contact your employing office for more information on premium conversion availability and other tax considerations. For more

information about premium conversion, please visit www.opm.gov/healthcare-insurance/healthcare.

Qualifying Life Events (QLE’s) that May

Permit Change in FEHB Enrollment,

Designated Family Member or

Premium Conversion Election

Change that May

Be Permitted

Premium Conversion

Change that May Be

Permitted

Time Limits in which

Change

May Be Permitted

Event

Code

Event From Not

Enrolled

From Self

Only to Self

Plus One or

Self and

Family

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or

Self Only

Switch

Designated

Family

Member

Participate Waive When You Must File

Health Benefits Election

Form With Your

Employing Office

1 Employee electing to receive or receiving premium conversion tax benefits

1A Initial opportunity to enroll, for example:

• New employee

• Change from excluded position

• Temporary employee who completes 1 year of service and is

eligible to enroll under 5 USC 8906a

Yes N/A N/A N/A N/A Automatic

Unless Waived

Yes Within 60 days after

becoming eligible

1B Open Season Yes Yes Yes Yes Yes Yes Yes As announced by OPM

1C Change in family status that results in increase or decrease in

number of eligible family members, for example:

• Marriage, divorce, annulment

• Birth, adoption, acquiring foster child or stepchild, issuance of

court order requiring employee to provide coverage for child

• Last child loses coverage, for example, child reaches age 26,

disabled child becomes capable of self-support, child acquires

other coverage by court order

• Death of spouse or eligible family member

Yes Yes Yes Yes

Yes Yes Yes Within 60 days after change

in family status

Employees may enroll or change

beginning 31 days before the event.

1D Any change in employee’s employment status that could result in

entitlement to coverage, for example:

• Reemployment after a break in service of more than 3 days

• Return to pay status from nonpay status, or return to receiving

pay sufficient to cover premium withholdings, if coverage

terminated (If coverage did not terminate, see 1G.)

Yes N/A N/A N/A No Automatic

Unless Waived

Yes Within 60 days after

employment status change

1E Any change in employee’s employment status that could affect cost

of insurance, including:

• Change from temporary appointment with eligibility for

coverage under 5 USC 8906a to appointment that permits

receipt of government contribution

• Change from full time to part-time career or the reverse

Yes Yes Yes Yes No Yes Yes Within 60 days after

employment status change

1F Employee restored to civilian position after serving in uniformed

services.

Yes Yes Yes Yes No Yes Yes Within 60 days after return

to civilian position

Qualifying Life Events (QLE’s) that May

Permit Change in FEHB Enrollment,

Designated Family Member or

Premium Conversion Election

Change that May

Be Permitted

Premium Conversion

Change that May Be

Permitted

Time Limits in which

Change

May Be Permitted

Event

Code

Event From Not

Enrolled

From Self

Only to Self

Plus One or

Self and

Family

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or

Self Only

Switch

Designated

Family

Member

Participate Waive When You Must File

Health Benefits Election

Form With Your

Employing Office

1G Employee, spouse or eligible family member:

• Begins nonpay status or insufficient pay

• Ends nonpay status or insufficient pay if coverage continued

• (If employee’s coverage terminated, see 1D.)

• (If spouse’s or eligible family member’s coverage terminated, see

1M.)

No No No Yes No Yes Yes Within 60 days after

employment status change

1H Salary of temporary employee insufficient to make withholdings for

plan in which enrolled.

N/A No Yes Yes No Yes Yes Within 60 days after receiv-

ing notice from employing

office

1I Employee (or covered family member) enrolled in FEHB health

maintenance organization (HMO) moves or becomes employed out-

side the geographic area from which the FEHB carrier accepts

enrollments or, if already outside the area, moves further from this

area.

N/A Yes Yes N/A

(see 1M)

Yes No

(see 1M)

Upon notifying employing

office of move

1J Transfer from post of duty within a State of the United States or the

District of Columbia to post of duty outside a State of the United

States or District of Columbia, or reverse.

Yes Yes Yes Yes Yes Yes Yes Within 60 days after arriv-

ing at new post

Employees may enroll or change

beginning 31 days before leaving the old

post of duty.

1K Separation from Federal employment when the employee or

employee’s spouse is pregnant.

Yes Yes Yes N/A No N/A N/A During employee’s final

pay period

1L Employee becomes entitled to Medicare and wants to change to

another plan or option.

No No Yes

(Changes

may be

made only

once.)

N/A

(see 1P)

No N/A

(see 1P)

N/A

(see 1P)

Any time beginning on the

30th day before becoming

eligible for Medicare

1M Employee or eligible family member loses coverage under FEHB or

another group insurance plan including the following:

• Loss of coverage under another FEHB enrollment due to termina-

tion, cancellation, or change to Self Plus One or Self Only of the

covering enrollment

• Loss of coverage due to termination of membership in employee

organization sponsoring the FEHB plan

• Loss of coverage under another federally-sponsored health

benefits program, including: TRICARE, Medicare, Indian Health

Service

• Loss of coverage under Medicaid or similar State-sponsored

program of medical assistance for the needy

• Loss of coverage under a non-Federal health plan, including

foreign, state or local government, private sector

• Loss of coverage due to change in worksite or residence

(Employees in an FEHB HMO, also see 1I.)

Yes Yes Yes Yes Yes Yes Yes Within 60 days after loss of

coverage

Employees may enroll or change

beginning 31 days before the event

Qualifying Life Events (QLE’s) that May

Permit Change in FEHB Enrollment,

Designated Family Member or

Premium Conversion Election

Change that May

Be Permitted

Premium Conversion

Election Change that

May Be

Permitted

Time Limits in which

Change

May Be Permitted

Event

Code

Event From Not

Enrolled

From Self

Only to Self

Plus One or

Self and

Family

From One

Plan or

Option to

Another

Cancel or

Change to

Self Plus

One or

Self Only

Switch

Designated

Family

Member

Participate Waive When You Must File

Health Benefits Election

Form With Your

Employing Office

1N Loss of coverage under a non-Federal group health plan because an

employee moves out of the commuting area to accept another posi-

tion and the employee’s non-Federally employed spouse terminates

employment to accompany the employee.

Yes Yes Yes Yes Yes Yes Yes From 31 days before the

employee leaves the com-

muting area to 180 days

after arriving in the new

commuting area

1O Employee or eligible family member loses coverage due to discon

tinuance in whole or part of FEHB plan.

Yes Yes Yes Yes Yes Yes Yes During open season, unless

OPM sets a different time

1P Enrolled employee or eligible family member gains coverage under No No No Yes

Yes Yes Yes Within 60 days after QLE

FEHB or another group insurance plan, including the following:

• Medicare (Employees who become eligible for Medicare and

want to change plans or options, see 1L

• TRICARE for Life, due to enrollment in Medicare.

• TRICARE due to change in employment status, including: (1)

entry into active military service, (2) retirement from reserve mil-

itary service under Chapter 67, title 10.

• Health insurance acquired due to change of worksite or residence

that affects eligibility for coverage

• Health insurance acquired due to spouse’s or eligible family

member’s change in employment status (includes state, local, or

foreign government or private sector employment).

1Q Change in spouse’s or eligible family member’s coverage options No No No Yes

Yes Yes Yes Within 60 days after QLE

under a health plan, for example:

• Employer starts or stops offering a different type of coverage

(If no other coverage is available, also see 1M.)

• Change in cost of coverage

• HMO adds a geographic service area that now makes spouse

eligible to enroll in that HMO

• HMO removes a geographic area that makes spouse ineligible

for coverage under that HMO, but other plans or options are

available (If no other coverage is available, see 1M)

1R Employee or eligible family member becomes eligible for assistance

under Medicaid or a State Children’s Health Insurance Program

(CHIP).

Yes Yes Yes Yes

Yes Yes Yes Within 60 days after the

date the employee or family

member becomes eligible

for assistance.

(If you are a United States Postal Service employee, these rules may be different. Consult your employing office or information provided by your agency.)

1. Employees may change to Self Only outside of open season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment. Employees may change to Self Plus One outside of

Open Season only if the QLE causes only one family member to be eligible under the FEHB enrollment. Employees may cancel enrollment outside of open season only if the QLE caused the enrollee and all eligible

family members to acquire other health insurance coverage.

2. Employees who enter active military service are given the opportunity to terminate coverage. Termination for this reason does not count against the employee for purposes of meeting the requirements for continuing

coverage after retirement. Additional information on the FEHB coverage of employees who return from active military service is available in the Frequently Asked Questions section of the FEHB website at

www.opm.gov/healthcare-insurance/healthcare.

(Listing continued on the reverse)

3. Employees who begin nonpay status or insufficient pay must be given an opportunity to elect to continue or terminate coverage. A termination differs from a cancellation as it allows conversion to nongroup coverage

and does not count against the employee for purposes of meeting the requirements for continuing coverage after retirement.

4. This code reflects the FEHB regulation that gives employees enrolled in an FEHB HMO who change from Self Only or Self Plus One to Self and Family or from one plan or option to another a different timeframe

than that allowed under 1M. For change to Self-Only or Self Plus One, cancellation, or change in premium conversion status, see 1M.

5. This code reflects the FEHB regulation that gives employees enrolled in FEHB a one-time opportunity to change plans or options under a different timeframe than that allowed by 1P. For change to Self Only or

Self Plus One, cancellation, or change in premium conversion status, see 1P.

6. If employee’s membership terminates (e.g., for failure to pay membership dues), the employee organization will notify the agency to terminate the enrollment.

7. Employee’s failure to select another FEHB plan is deemed a cancellation for purposes of meeting the requirements for continuing coverage after retirement.

8. Under IRS rules, this includes start/stop of employment or nonpay status, strike or lockout, and change in worksite.

9. Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage. Employees may change to Self Plus One outside of Open

Season only if the QLE caused all but one eligible family member to acquire other health insurance coverage. Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all

eligible family members to acquire other health insurance coverage.

Tables of Permissible Changes in FEHB Enrollment for Individuals Who Are Not Participating

in Premium Conversion

Enrollment May Be Cancelled or Changed from Self and Family to Self Plus One or Self Only or from Self Plus

One to Self Only at Any Time

QLE’s That Permit

Enrollment or Change

Change that May Be Permitted Time Limits

Event

Code

Event

From Not

Enrolled to

Enrolled

From Self

Only to Self

Plus One or

Self

and Family

From

One

Plan or

Option

Another

Switch

Designated

Family

Member

When You Must File Health

Benefits Election Form With

Your Employing Office

2 Annuitant (Includes Compensationers)

Note for enrolled survivor annuitants: A change in family status based on additional family members can only occur if the additional

eligible family members are family members of the deceased employee or annuitant.

2A Open Season No Yes Yes Yes As announced by OPM.

2B Change in family status; for example: marriage, birth or

death of family member, adoption, or divorce.

No Yes Yes Yes From 31 days before through 60

days after the event.

2C Reenrollment of annuitant who suspended FEHB

enrollment to enroll in a Medicare Advantage plan,

Medicaid or similar State-sponsored program, or to use

TRICARE (including Uniformed Services Family Health

Plan and TRICARE for Life), Peace Corps, or

CHAMPVA, and who later involuntarily loses this

coverage under one of these programs.

May Reenroll N/A N/A No From 31 days before through 60

days after involuntary loss of

coverage.

2D Reenrollment of annuitant who suspended FEHB enroll-

ment to enroll in a Medicare Advantage plan, Medicaid,

or similar State-sponsored program, or to use TRICARE

(including Uniformed Services Family Health Plan or

TRICARE for Life), Peace Corps, or CHAMPVA, and

who wants to reenroll in the FEHB Program for any

reason other than an involuntary loss of coverage.

May Reenroll N/A N/A No During open season.

2E Restoration of annuity or compensation (OWCP)

payments, for example:

• Disability annuitant who was enrolled in FEHB, and

whose annuity terminated due to restoration of earning

capacity or recovery from disability, and whose

annuity is restored;

• Compensationer whose compensation terminated

because of recovery from injury or disease and whose

compensation is restored due to a recurrence of

medical condition;

• Surviving spouse who was covered by FEHB

immediately before survivor annuity terminated

because of remarriage and whose annuity is restored;

• Surviving child who was covered by FEHB

immediately before survivor annuity terminated

because student status ended and whose survivor

annuity is restored;

• Surviving child who was covered by FEHB immedi

ately before survivor annuity terminated because of

marriage and whose survivor annuity is restored.

Yes N/A N/A No Within 60 days after the retire-

ment system or OWCP mails a

notice of insurance eligibility.

2F Annuitant or eligible family member loses FEHB

coverage due to termination, cancellation, or change to

Self Plus One or Self Only of the covering enrollment.

Yes Yes Yes Yes From 31 days before through 60

days after date of loss of cover

age.

QLE’s That Permit

Enrollment or Change

Change that May Be Permitted Time Limits

Event

Code

Event

From Not

Enrolled to

Enrolled

From Self

Only to Self

Plus One or

Self

and Family

From

One

Plan or

Option

Another

Switch

Designated

Family

Member

When You Must File Health

Benefits Election Form With

Your Employing Office

2G Annuitant or eligible family member loses coverage

under another group insurance plan, for example:

•

Loss of coverage under another federally-sponsored

health benefits program;

• Loss of coverage due to termination of membership in

the employee organization sponsoring the FEHB plan;

• Loss of coverage under Medicaid or similar

State-sponsored program (but see events 2C and 2D);

•

Loss of coverage under a non-Federal health plan.

No Yes Yes Yes From 31 days before through 60

days after loss of coverage.

2H Annuitant or eligible family member loses coverage due

to the discontinuance, in whole or part, of an FEHB plan.

N/A Yes Yes Yes During open season, unless

OPM sets a different time.

2I Annuitant or covered family member in a Health

Maintenance Organization (HMO) moves or becomes

employed outside the geographic area from which the

carrier accepts enrollments, or if already outside this area,

moves or becomes employed further from this area.

N/A Yes Yes Yes Upon notifying the employing

office of the move or change of

place of employment.

2J Employee in an overseas post of duty retires or dies. No Yes Yes Yes Within 60 days after retirement

or death.

2K An enrolled annuitant separates from duty after serving

31 days or more in a uniformed service.

N/A Yes Yes No Within 60 days after separation

from the uniformed service.

2L On becoming eligible for Medicare.

(This change may be made only once in a lifetime.)

N/A No Yes No At any time beginning on the

30th day before becoming eligi-

ble for Medicare.

2M Annuitant’s annuity is insufficient to make withholdings

for plan in which enrolled.

N/A No Yes No Employing office will advise

annuitant of the options.

3 Former Spouse Under The Spouse Equity Provisions

Note: Former spouse may change to Self Plus One or Self and Family only if family members are also eligible family members of the

employee or annuitant.

3A Initial opportunity to enroll. Former spouse must be

eligible to enroll under the authority of the Civil Service

Retirement Spouse Equity Act of 1984 (P.L. 98-615), as

amended, the Intelligence Authorization Act of 1986

(P.L. 99-569), or the Foreign Relations Authorization

Act, Fiscal Years 1988 and 1989 (P.L. 100-204).

Yes N/A N/A N/A Generally, must apply within

60 days after dissolution of

marriage. However, if a retiring

employee elects to provide a

former spouse annuity or

insurable interest annuity for

the former spouse, the former

spouse must apply within 60

days after OPM’s notice of

eligibility for FEHB. May enroll

any time after employing office

establishes eligibility.

3B Open Season. No Yes Yes Yes As announced by OPM.

3C Change in family status based on addition of family

members who are also eligible family members of the

employee or annuitant.

No Yes Yes Yes From 31 days before through 60

days after change in family

status.

3D Reenrollment of former spouse who suspended FEHB

enrollment to enroll in a Medicare Advantage plan,

Medicaid, or similar State-sponsored program, or to

use TRICARE (including Uniformed Services Family

Health Plan or TRICARE for Life), Peace Corps, or

CHAMPVA, and who later involuntarily loses this

coverage under one of these programs.

May reenroll N/A N/A No From 31 days before through 60

days after involuntary loss of

coverage.

QLE’s That Permit

Enrollment or Change

Change that May Be Permitted Time Limits

Event

Code

Event

From Not

Enrolled to

Enrolled

From Self

Only to Self

Plus One or

Self

and Family

From

One

Plan or

Option to

Another

Switch

Designated

Family

Member

When You Must File Health

Benefits Election Form With

Your Employing Office

3E Reenrollment of former spouse who suspended FEHB

enrollment to enroll in a Medicare Advantage plan,

Medicaid, or similar State-sponsored program, or to use

TRICARE (including Uniformed Services Family Health

Plan or TRICARE for Life), Peace Corps, or

CHAMPVA, and who wants to reenroll in the FEHB

Program for any reason other than an involuntary loss of

coverage.

May reenroll N/A N/A No During open season.

3F Former spouse or eligible child loses FEHB coverage

due to termination, cancellation, or change to Self Only

of the covering enrollment.

Yes Yes Yes Yes From 31 days before through 60

days after date of loss of cover-

age.

3G Enrolled former spouse or eligible child loses coverage

under another group insurance plan, for example:

•

Loss of coverage under another federally-sponsored

health benefits program;

• Loss of coverage due to termination of membership in

the employee organization sponsoring the FEHB plan;

•

Loss of coverage under Medicaid or similar

State-sponsored program (but see 3D and 3E);

• Loss of coverage under a non-Federal health plan.

N/A Yes Yes Yes From 31 days before through 60

days after loss of coverage.

3H Former spouse or eligible family member loses coverage

due to the discontinuance, in whole or part, of an FEHB

plan.

N/A Yes Yes Yes During open season, unless

OPM sets a different time.

3I Former spouse or covered family member in a Health

Maintenance Organization (HMO) moves or becomes

employed outside the geographic area from which the

carrier accepts enrollments, or if already outside this

area, moves or becomes employed further from this area.

N/A Yes Yes Yes Upon notifying the employing

office of the move or change of

place of employment.

3J On becoming eligible for Medicare

(This change may be made only once in a lifetime.)

N/A No Yes No At any time beginning the 30th

day before becoming eligible for

Medicare.

3K Former spouse’s annuity is insufficient to make FEHB

withholdings for plan in which enrolled.

No No Yes No Retirement system will advise

former spouse of options.

4 Temporary Continuation of Coverage (TCC) For Eligible Former Employees, Former Spouses, and Children.

Note: Former spouse may change to Self Plus One or Self and Family only if family members are also eligible family members of the

employee or annuitant.

4A Opportunity to enroll for continued coverage under TCC

provisions:

•

Former employee

• Former spouse

• Child who ceases to qualify as a family

member

Yes

N/A

Yes

N/A

Within 60 days after the qualify-

ing event, or receiving notice of

eligibility, whichever is later.

4B Open Season:

•

Former employee

•

Former spouse

•

Child who ceases to qualify as a family

member

Yes

As announced by OPM.

4C Change in family status (except former spouse); for

example, marriage, birth or death of family member,

adoption, or divorce.

No Yes Yes Yes From 31 days before through 60

days after event.

QLE’s That Permit

Enrollment or Change

Change that May Be Permitted Time Limits

Event

Code

Event

From Not

Enrolled to

Enrolled

From Self

Only to Self

Plus One or

Self and

Family

From

One

Plan or

Option

Another

Switch

Designated

Family

Member

When You Must File Health

Benefits Election Form With

Your Employing Office

4D Change in family status of former spouse, based on

addition of family members who are eligible family

members of the employee or annuitant.

No Yes Yes Yes From 31 days before through 60

days after event.

4E Reenrollment of a former employee, former spouse, or

child whose TCC enrollment was terminated because of

other FEHB coverage and who loses the other FEHB

coverage before the TCC period of eligibility (18 or 36

months) expires.

May reenroll N/A N/A No From 31 days before through 60

days after the event. Enrollment

is retroactive to the date of the

loss of the other FEHB cover-

age.

4F Enrollee or eligible family member loses coverage

under FEHB or another group insurance plan, for

example:

•

Loss of coverage under another FEHB enrollment

due to termination, cancellation, or change to Self

Plus One or Self Only of the covering enrollment

(but see event 4E);

• Loss of coverage under another federally-sponsored

health benefits program;

• Loss of coverage due to termination of membership

in the employee organization sponsoring the FEHB

plan;

• Loss of coverage under Medicaid or similar

State-sponsored program;

• Loss of coverage under a non-Federal health plan.

No Yes Yes Yes From 31 days before through 60

days after loss of coverage.

4G Enrollee or eligible family member loses coverage due

to the discontinuance, in whole or part, of an FEHB

plan.

N/A Yes Yes Yes During open season, unless

OPM sets a different time.

4H Enrollee or covered family member in a Health

Maintenance Organization (HMO) moves or becomes

employed outside the geographic area from which the

carrier accepts enrollments, or if already outside this

area, moves or becomes employed further from this

area.

N/A Yes Yes No Upon notifying the employing

office of the move or change of

place of employment.

4I On becoming eligible for Medicare.

(This change may be made only once in a lifetime.)

N/A No Yes No At any time beginning on the

30th day before becoming eligi-

ble for Medicare.

5 Employees Who Are Not Participating In Premium Conversion

5A Initial opportunity to enroll. Yes N/A N/A N/A Within 60 days after becoming

eligible.

5B Open Season. Yes Yes Yes Yes As announced by OPM.

5C Change in family status; for example: marriage, birth or

death of family member, adoption, or divorce

Yes Yes Yes Yes From 31 days before through 60

days after event.

QLE’s That Permit

Enrollment or Change

Change that May Be Permitted Time Limits

Event

Code

Event

From Not

Enrolled to

Enrolled

From Self

Only to Self

Plus One or

Self and

Family

From

One

Plan or

Option

Another

Switch

Designated

Family

Member

When You Must File Health

Benefits Election Form With

Your Employing Office

5D Change in employment status, for example:

•

Reemployment after a break in service of more than 3

days;

•

Return to pay status following loss of coverage due to

expiration of 365 days of LWOP status or termination

of coverage during LWOP;

• Return to pay sufficient to make withholdings

after termination of coverage during a period of

insufficient pay;

• Restoration to civilian position after serving in

uniformed services;

• Change from temporary appointment to appointment

that entitles employee receipt of Government

contribution;

•

Change to or from part-time career employment.

Yes Yes Yes No Within 60 days of employment

status change.

5E Separation from Federal employment when the

employee is employee’s spouse is pregnant.

Yes Yes Yes No Enrollment or change must

occur during final pay period of

employment.

5F Transfer from a post of duty within the United States to

a post of duty outside the United States, or reverse.

Yes Yes Yes Yes From 31 days before leaving old

post through 60 days after arriv-

ing at new post.

5G Employee or eligible family member loses coverage

under FEHB or another group insurance plan, for

example:

•

Loss of coverage under another FEHB enrollment

due to termination, cancellation, or change to Self

Plus One or Self Only of the covering enrollment;

• Loss of coverage under another federally-sponsored

health benefits program;

• Loss of coverage due to termination of membership

in the employee organization sponsoring the FEHB

plan;

• Loss of coverage under Medicaid or similar

State-sponsored program;

•

Loss of coverage under a non-Federal health plan.

Yes Yes Yes Yes From 31 days before through 60

days after loss of coverage.

5H Enrollee or eligible family member loses coverage due

to the discontinuance, in whole or part, of an FEHB

plan.

N/A Yes Yes Yes During open season, unless

OPM sets a different time.

5I Loss of coverage under a non-Federal group health plan

because an employee moves out of the commuting area

to accept another position and the employee’s

non-federally employed spouse terminates employment

to accompany the employee.

Yes Yes Yes Yes From 31 days before the

employee leaves the commuting

area through 180 days after

arriving in the new commuting

area.

5J Employee or covered family member in a Health

Maintenance Organization (HMO) moves or becomes

employed outside the geographic area from which the

carrier accepts enrollments, or if already outside the

area, moves or becomes employed further from this

area.

N/A Yes Yes Yes Upon notifying the employing

office of the move or change of

place of employment.

QLE’s That Permit

Enrollment or Change

Change that May Be Permitted Time Limits

Event

Code

Event

From Not

Enrolled to

Enrolled

From Self

Only to Self

Plus One or

Self

and Family

From

One

Plan or

Option

Another

Switch

Designated

Family

Member

When You Must File Health

Benefits Election Form With

Your Employing Office

5K On becoming eligible for Medicare

(This change may be made only once in a lifetime.)

N/A No N/A No At any time beginning on the

30th day before becoming

eligible for Medicare.

5L Temporary employee completes one year of continuous

service in accordance with 5 U.S.C. Section 8906a.

Yes N/A N/A No Within 60 days after becoming

eligible.

5M Salary of temporary employee insufficient to make

withholdings for plan in which enrolled.

N/A No Yes No Within 60 days after receiving

notice from employing office.

5N Employee or eligible family member becomes eligible for

assistance under Medicaid or a State Children’s Health

Insurance Program (CHIP).

Yes Yes Yes Yes Within 60 days after the date the

employee or family member

becomes eligible for assistance.

Health Benefits Election Form

Form Approved:

OMB No. 3206-0160

Standard Form 2809

Revised November 2015

Previous edition is not usable.

U.S. Office of Personnel Management

Federal Employees

Health Benefits Program

For agency distribution of copies, see page 5 of the instructions.

Part A - Enrollee and Family Member Information (for additional family members use a separate sheet and attach)

1. Enrollee name (last, first, middle initial) 2. Social Security Number 3. Date of birth (mm/dd/yyyy) 4. Sex

M F

5. Are you married?

Yes No

6. Home mailing address (including ZIP Code)

7. If you are covered by Medicare,

check all that apply.

B D

8. Medicare Claim Number

9. Are you covered by insurance other than Medicare?

Yes, indicate in item 10 below. No

10. Indicate the type(s) of other insurance:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

TRICARE

Other

Name of other insurance: ______________________________________________ _____________________

FEHB

An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the

enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.

Policy Number:

11.

Email address 12. Preferred telephone number

13. Name of family member (last, first, middle initial) 14. Social Security Number 15. Date of birth (mm/dd/yyyy)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

16. Sex

M F

17. Relationship code

18. Address (if different from enrollee)

19. If this family member is covered

by Medicare, check all that apply.

A B D

20. Medicare Claim Number

21.

Is this family member covered by insurance other than Medicare?

Yes, indicate in item 22 below. No

22. Indicate the type(s) of other insurance:

TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________

FEHB

An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the

enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.

23. Email address (if applicable, enter email address of your spouse or adult child) 24. Preferred telephone number (if applicable, enter preferred phone number of

your spouse or adult child)

25. Name of family member (last, first, middle initial)

26. Social Security Number 27. Date of birth (mm/dd/yyyy) 28. Sex

M F

29. Relationship code

30. Address (if different from enrollee)

31. If this family member is covered

by Medicare, check all that apply.

33. Is this family member covered by insurance other than Medicare?

34. Indicate the type(s) of other insurance:

A B

32. Medicare Claim Number

Yes, indicate in item 34 below. No

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________

37. Name of family member (last, first, middle initial)

43. If this family member is covered

by Medicare, check all that apply.

45. Is this family member covered by insurance other than Medicare?

35. Email address (if applicable, enter email address of your spouse or adult child) 36. Preferred telephone number (if applicable, enter preferred phone number of

your spouse or adult child)

42. Address (if different from enrollee)

38. Social Security Number 39. Date of birth (mm/dd/yyyy) 40. Sex

M F

41. Relationship code

A B

44. Medicare Claim Number

Yes, indicate in item 46 below. No

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

46. Indicate the type(s) of other insurance

TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________

47. Email address (if applicable, enter email address of your spouse or adult child) 48. Preferred telephone number (if applicable, enter preferred phone number of

your spouse or adult child)

(Continued on the reverse)

FEHB

An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the

enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.

FEHB

An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the

enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.

Enrollee name: _________________________________________________________ Date of birth: ____________________________

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 2) Part E - Election NOT to Enroll (Employees Only)

Part F - Cancellation of FEHB

I do NOT want to enroll in the FEHB Program.

I CANCEL my enrollment.

Event code1.

Date of event2.

My signature in Part H certifies that I have read and understand the

information on page 3 regarding this election.

My signature in Part H certifies that I have read and understand the

information on page 3 regarding cancellation of enrollment.

Part G - Suspension of FEHB (Annuitants/Former Spouses Only)

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the

information on page 4 regarding suspension of enrollment.

Part H - Signature

Part B - FEHB Plan You Are Currently Enrolled In (if applicable)

Plan name 2. Enrollment code

Part C - FEHB Plan You Are Enrolling In or Changing To

1. Plan name1. 2. Enrollment code

WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than

$10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001.)

1. Your signature (do not print) 2. Date (mm/dd/yyyy)

REMARKS

Part I -To be completed by agency or retirement system

Date received (mm/dd/yyyy)

2. Effective date of action (mm/dd/yyyy) 3. Personnel telephone number

( )

4. Name and address of agency or retirement system

Authorizing official (please print)

6. Signature of authorized agency official

Payroll office number

8. Payroll office contact (please print) 9. Payroll telephone number

( )

Standard Form 2809

Reverse of revised November 2015

Previous edition is not usable

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Sf2809 Health Benefits Election Form

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