Fill - Free fillable Sf2810 (U.S. Office of Personnel Management) PDF form

8. Date this action becomes

effective

Your enrollment has been changed from family coverage to self

only. Your plan will send you a new identification card.

Your new enrollment code number is shown below.

(Note: This item is completed by Retirement Systems only.)

Copy 1 - To Enrollee

( )

Notice of Change in Health Benefits Enrollment

Part A - Identifying Information

Part B - Termination

Part C - Transfer In

Part E - Change in Name of Enrollee

Part G - Remarks

Part H - Date of Notice

Part D - Reinstatement

Part F - Change In Enrollment-Survivor Annuitant

Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.

Keep this form for your records.

Note: Instructions for Employing Offices are on the back of Copy 4 of this form.

1. Name

(Last, first, middle initial)

2. Date of birth

3. Social security number

4. Home address

(including ZIP Code)

5. Payroll office number

6. Enrollment code number

7. SF 2811 Report number

Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.

Important Notice:

You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have

the right to temporarily continue your group coverage.

See

Part B - Termination

on the back of this form for information

about 31-day extension of coverage, conversion, and temporary continuation of coverage.

If termination is due to death of enrollee enter date of death

Date of death (mo, dy, yr)

The new Payroll Office (or Retirement System) shown in Part H

below has accepted transfer of this enrollment and will continue

it.

Your enrollment has been reinstated effective on the date

in Part A, item 8, above.

Name Date of Birth

Address (including ZIP Code) if different from Part A, item 4, above.

New Enrollment Code Number

Federal Employees

Health Benefits Program

Name and address of agency

(including ZIP Code)

Personnel contact and telephone number

( )

Payroll contact and telephone number

Signature of authorized agency official Date

U.S. Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234

Previous edition is usable Standard Form 2810

2810-104 Revised June 1995

The name under which this enrollment is carried has been

changed to:

RESET

SAVE

Instructions for Employing Offices

Disposition Instructions To Payroll Offices - Pg 5

31-Day Extension of Coverage

Your enrollment terminates on the date shown in Part A, item 8, on the

front of this form. Coverage under your enrollment continues temporarily

for 31 days from the date shown. If you, or any covered member of

your family, are a patient in a hospital on the 31st day of this temporary

extension, benefits of the plan may continue for the rest of that

confinement, but not beyond 60 more days.

Conversion to Nongroup Contract

You may convert your enrollment to a nongroup contract, without

evidence of good health. The nongroup contract to which you may

convert is one regularly offered by your plan. It may differ from your

group plan in benefits, or cost, or both, and you will have to pay the

entire cost of the nongroup contract directly to the plan. The nongroup

contract is effective on the day after your 31-day extension of coverage

ends.

If you are interested in converting to a nongroup contract, write for

information to the nearest office of the plan in which you have been

enrolled (see the plan’s brochure or ask your employing office for the

address of the plan’s nearest office). The plan will promptly send you an

application form and details concerning benefits and rates of the

nongroup contract to which you may convert.

Time Limit on Conversion

Normally, to be eligible for conversion, you must send your written

request for information to your plan within 31 days after the date shown

in Part H. However, if the date shown in Part H is more than 60 days

after the date your enrollment terminates (Part A, item 8), you must

forward it to your plan within 91 days after the date shown in Part A,

item 8.

If you are prevented by causes beyond your control from submitting a

timely request for information about conversion to a nongroup contract,

you should write to your plan as soon as possible asking approval of a

belated conversion opportunity. Explain fully the circumstances that

Part B - Termination

If Part B on the other side of this form is checked, read the following instructions carefully.

prevented earlier action and attach proof of the loss of group coverage

(e.g., Standard Form 50 terminating Federal employment). A plan may

consider requests filed within 6 months after group eligibility ends. If

your plan needs assistance in processing your request, it should contact

OPM.

Temporary Continuation of Coverage

If you are an employee whose enrollment is terminating because you are

separating from service (including separation for retirement), you may be

eligible to temporarily continue your benefits coverage under the Federal

Employees Health Benefits Program after separation. Within 61 days

after the date shown in Part A, item 8, on the front of this form, your

employing office will formally notify you of your rights regarding

temporary continuation of coverage and tell you where you may obtain

additional information. You will have 60 days after the later of (1) your

date of separation from service, or (2) the date you receive the notice

from your employing office in which to elect temporary continuation of

coverage.

When your temporary continuation of coverage expires, you will be

entitled to the 31-day extension of coverage and the opportunity to

convert to a nongroup contract.

Entry on Active Military Duty

If you elected to terminate your enrollment because you are entering

military service, you may convert to a nongroup contract even though

your family members are entitled to care under the Uniformed Services

Health Benefits Program. If you return to civilian duty in the exercise of

reemployment rights, your enrollment will be reinstated effective on the

day you return to active duty. If you return to civilian duty not in the

exercise of reemployment rights, you must, if eligible for coverage,

your enrollment will be reinstated on the day you are separated from

military service. You must notify your retirement system of this event

by furnishing a copy of your separation papers.

Part C - Transfer of Enrollment

If Part C on the other side of this form is checked, read carefully whichever of the following instructions applies:

Keep This Form For Your Records

Transfer of Employment

Your enrollment has been transferred from your previous agency or

payroll office to the agency or payroll office shown in Part H. If you are

in a prepaid comprehensive medical plan and you left the area served by

the plan, you may be able to change to another plan. For details about

your right to change plans, check with your employing office.

Retirement

Your enrollment has been transferred from your employing agency to the

retirement system shown in Part H. Your enrollment continues

automatically during retirement if you retire on an immediate annuity and

you have been enrolled under the Federal Employees Health Benefits

Program for the lesser of (1) all your service since your first opportunity

to enroll, or (2) the 5 years of service immediately preceding retirement.

Your share of the cost of your enrollment will be withheld from your

annuity.

Death

The enrollment of the deceased employee named in Part A has been

transferred to the retirement system shown in Part H. If the deceased

employee or annuitant was enrolled for self and family at the time of

death, and if at least one member of the family is entitled to a survivor

annuity (or the widow(er) is entitled to the Basic Employee Death

Benefits under FERS), coverage for each family member who was

covered by the employee’s enrollment continues automatically.

If there is only one eligible survivor, the enrollment will be changed from

family coverage to self only. The survivor’s share of the cost of the

enrollment will be deducted from the annuity. Application for Death

Benefits (Standard Form 2800 or the equivalent) should be filed

promptly to avoid any question about health benefits coverage. When

the survivor annuity is approved, another form like this one will be

issued to show that the enrollment is being continued in the survivor’s

name.

Employees' Compensation

Your enrollment has been transferred to the Office of Workers'

Compensation Programs. Your enrollment continues automatically while

you receive monthly compensation from the Office of Workers'

Compensation Programs if the Secretary of Labor has held that you are

unable to return to duty and if you have been enrolled under the Federal

Employees Health Benefits Program for the lesser of (1) all your service

since your first opportunity to enroll, or (2) the 5 years of service

immediately preceding the start of your compensation. Enrollment of

covered family members of a deceased employee or compensationer

also continues automatically while they receive monthly compensation,

if (1) the deceased employee or compensationer was enrolled for self

and family at the time of death, and (2) at least one of the covered

family members is entitled to compensation as a surviving beneficiary

under the Federal Employees’ Compensation Act. The compensationer’s

or survivor’s share of the cost of the enrollment will be deducted from

the compensation checks.

Back, Copy 1

Standard Form 2810

Revised June 1995

Return to Form

Your enrollment has been changed from family coverage to self

only. Your plan will send you a new identification card.

Your new enrollment code number is shown below.

(Note: This item is completed by Retirement Systems only.)

New Enrollment Code Number

Copy 2 - To Insurance Carrier

U.S. Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234

( )

Notice of Change in Health Benefits Enrollment

Part A - Identifying Information

Part B - Termination

Part C - Transfer In

Part E - Change in Name of Enrollee

Part G - Remarks

Part H - Date of Notice

Part D - Reinstatement

Part F - Change In Enrollment-Survivor Annuitant

Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.

Keep this form for your records.

Note: Instructions for Employing Offices are on the back of Copy 4 of this form.

1. Name

(Last, first, middle initial)

2. Date of birth

3. Social security number

4. Home address

(including ZIP Code)

5. Payroll office number

6. Enrollment code number

7. SF 2811 Report number

8. Date this action becomes

Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.

Important Notice:

You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have

the right to temporarily continue your group coverage.

See

Part B - Termination

on the back of this form for information

about 31-day extension of coverage, conversion, and temporary continuation of coverage.

If termination is due to death of enrollee enter date of death

Date of death (mo, dy, yr)

effective

The new Payroll Office (or Retirement System) shown in Part H

below has accepted transfer of this enrollment and will continue

it.

Your enrollment has been reinstated effective on the date

in Part A, item 8, above.

Name Date of Birth

Address (including ZIP Code) if different from Part A, item 4, above.

Federal Employees

Health Benefits Program

Name and address of agency

(including ZIP Code)

Personnel contact and telephone number

( )

Payroll contact and telephone number

Signature of authorized agency official Date

The name under which this enrollment is carried has been

changed to:

Previous edition is usable Standard Form 2810

2810-104 Revised June 1995

Copy 3 - To Payroll Office

U.S. Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234

( )

Notice of Change in Health Benefits Enrollment

Part A - Identifying Information

Part B - Termination

Part C - Transfer In

Part E - Change in Name of Enrollee

Part G - Remarks

Part H - Date of Notice

Part D - Reinstatement

Part F - Change In Enrollment-Survivor Annuitant

Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.

Keep this form for your records.

Note: Instructions for Employing Offices are on the back of Copy 4 of this form.

1. Name

(Last, first, middle initial)

2. Date of birth

3. Social security number

4. Home address

(including ZIP Code)

5. Payroll office number

6. Enrollment code number

7. SF 2811 Report number

8. Date this action becomes

Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.

Important Notice:

You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have

the right to temporarily continue your group coverage.

See

Part B - Termination

on the back of this form for information

about 31-day extension of coverage, conversion, and temporary continuation of coverage.

If termination is due to death of enrollee enter date of death

Date of death (mo, dy, yr)

effective

The new Payroll Office (or Retirement System) shown in Part H

below has accepted transfer of this enrollment and will continue

it.

Your enrollment has been reinstated effective on the date

in Part A, item 8, above.

Name Date of Birth

Address (including ZIP Code) if different from Part A, item 4, above.

Your enrollment has been changed from family coverage to self

only. Your plan will send you a new identification card.

Your new enrollment code number is shown below.

(Note: This item is completed by Retirement Systems only.)

New Enrollment Code Number

Federal Employees

Health Benefits Program

Name and address of agency

(including ZIP Code)

Personnel contact and telephone number

( )

Payroll contact and telephone number

Signature of authorized agency official Date

The name under which this enrollment is carried has been

changed to:

Previous edition is usable Standard Form 2810

2810-104 Revised June 1995

Disposition Instructions To Payroll Offices

Copy 2

Copy 3

Copy 4

Back, Copy 3

Standard Form 2810

Revised June 1995

Send to insurance carrier, attached to Transmittal Report to Carrier (SF 2811),

at the earliest possible date.

Under no

circumstances should SF 2810s be accumulated for longer than a week, nor should they be delayed to coincide with

applicable payroll deductions.

Use as payroll action document, if necessary.

In cases of death or retirement under the Civil Service Retirement System or the Federal Employees Retirement System,

send to the Office of Personnel Management together with the Official Personnel Folder copy of each Health Benefits

Registration Form (SF 2809) accepted from the employee including any Medical Certificates attached thereto, Individual

Retirement Record (SF 2806 [CSRS] or SF 3100 [FERS]) and any other applicable documents. For other retirement

systems (including Office of Workers' Compensation Programs, Department of Labor), send these documents (or the

equivalent) to the office administering the system.

Return to Form

Copy 4 - For Official Personnel Folder

U.S. Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234

( )

Notice of Change in Health Benefits Enrollment

Part A - Identifying Information

Part B - Termination

Part C - Transfer In

Part E - Change in Name of Enrollee

Part G - Remarks

Part H - Date of Notice

Part D - Reinstatement

Part F - Change In Enrollment-Survivor Annuitant

Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.

Keep this form for your records.

Note: Instructions for Employing Offices are on the back of Copy 4 of this form.

1. Name

(Last, first, middle initial)

2. Date of birth

3. Social security number

4. Home address

(including ZIP Code)

5. Payroll office number

6. Enrollment code number

7. SF 2811 Report number

8. Date this action becomes

Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.

Important Notice:

You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have

the right to temporarily continue your group coverage.

See

Part B - Termination

on the back of this form for information

about 31-day extension of coverage, conversion, and temporary continuation of coverage.

If termination is due to death of enrollee enter date of death

Date of death (mo, dy, yr)

effective

The new Payroll Office (or Retirement System) shown in Part H

below has accepted transfer of this enrollment and will continue

it.

Your enrollment has been reinstated effective on the date

in Part A, item 8, above.

Name Date of Birth

Address (including ZIP Code) if different from Part A, item 4, above.

Your enrollment has been changed from family coverage to self

only. Your plan will send you a new identification card.

Your new enrollment code number is shown below.

(Note: This item is completed by Retirement Systems only.)

New Enrollment Code Number

Federal Employees

Health Benefits Program

Name and address of agency

(including ZIP Code)

Personnel contact and telephone number

( )

Payroll contact and telephone number

Signature of authorized agency official Date

The name under which this enrollment is carried has been

changed to:

Previous edition is usable Standard Form 2810

2810-104 Revised June 1995

Instructions for Employing Offices

Purpose of Form

This form covers health benefits actions

except

enrollments, changes from one plan to another, changes of coverage within a plan and

cancellations, which are processed on the Health Benefits Registration Form (Standard Form 2809). When an action requires a change

in health benefits enrollment, prepare SF 2810

As Soon As the Effective Date Is Known

and give the appropriate copies to the enrollee

and payroll office

Immediately.

Preparation and distribution of copies should not be delayed pending SF 50 action in the case of

transfers to another payroll office.

Prompt Action Required for Conversion

Give this form to the enrollee within 60 days after the date shown in Part A, item 8. To be eligible to convert to a nongroup contract,

the enrollee must send a written request for information about conversion to a nongroup contract to his or her plan within 31 days

after the date shown in Part H, but not later than 91 days after the date shown in Part A, item 8.

Completion of Form

Disposition

Back, Copy 4

Standard Form 2810

Revised June 1995

Part A - Identifying Information

1. For items 1, 2, and 6, transcribe from the last SF 2809 or

SF 2810, whichever is the most recent.

. Item 4, use most recent known address.

3. Item 5, use payroll office number of office authorized to

process withholdings.

4. Item 8, date as follows for action reported in:

Termination

- Last day of pay period in which separa-

tion (or other action terminating enrollment) occurs

except, when coverage terminates because of com-

pletion of 365 days in nonpay status, use the last

day of the pay period which includes the 365th day

of continuous nonpay status; and when coverage

terminates because of military duty not limited to 30

days or less, use date employee is

separated, was

furloughed or placed on leave of absence for military

duty.

Transfer In

- Actual date (first day on gaining

employing office or retirement system rolls.)

Reinstatement

- Actual date.

Change In Name Of Enrollee

- Actual date.

Change In Enrollment-Survivor Annuitant

- Effective

day of sole survivor's annuity.

Part B - Termination

These most frequently occuring actions terminate enrollment:

Separated.

Retired - not eligible to continue enrollment.

Died - no survivor eligible to continue enrollment.

Termination of title to annuity or compensation.

Changed to excluded position or category.

365 days nonpay status completed.

Temporary continuation of coverage expired.

Part C - Transfer In

Gaining office uses this box to report transfer actions such as:

Acceptance of transfer from another agency to payroll office

number.

Retired - Acceptance of transfer by retirement system because

employee is eligible to continue enrollment as an annuitant.

Death - Acceptance of transfer by retirement system because

survivor is eligible to continue enrollment as a survivor

annuitant.

Transfer accepted by Office of Workers' Compensation

Programs.

Note:

Retirement systems (including OWCP) accepting

transfer in, show also in "Remarks" whether enrollment is for

"Employee Annuitant"

or "Survivor Annuitant."

Part D - Reinstatement

State in "Remarks"reason for any action not applicable to active

military duty, such as "Reinstatement of erroneous separation."

Part E - Change in Name of Enrollee

Use this box only for reporting changes in name where change of

coverage within a plan by SF 2809 is not involved. Show date of

birth only where enrollment is changed from employee’s or

annuitant’s name to name of survivor annuitant.

Part F - Change in Enrollment - Survivor Annuitant

Only agencies administering retirement systems will make this

determination on the basis of documentary evidence that there is

only one survivor annuitant.

Part G - Remarks

Use this box to bring to the attention of the employee, annuitant,

or insurance carrier any pertinent information to clarify or support

the action being taken.

Part H - Date of Notice

Facsimile signature is acceptable. Date as of day of issuance.

Copy 1

Copies 2 and 3

Copy 4

Deliver (or mail) to employee, annuitant or survivor

at the earliest possible date,

but before 60 days from the date

shown in Part A, item 8.

Send to appropriate insurance carrier and payroll office.

File in Official Personnel Folder (or its equivalent).

Return to Form

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