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Federal Health Benefits Election Form

This document is a health benefits election form that allows an enrollee to provide information about their health insurance enrollment and family members. It collects personal information such as name, address, social security number, and medicare status. The enrollee can elect to enroll in, cancel, or suspend their enrollment in the Federal Employees Health Benefits Program. The form requires signatures to authorize and certify the elections made.

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161 views1 page

Federal Health Benefits Election Form

This document is a health benefits election form that allows an enrollee to provide information about their health insurance enrollment and family members. It collects personal information such as name, address, social security number, and medicare status. The enrollee can elect to enroll in, cancel, or suspend their enrollment in the Federal Employees Health Benefits Program. The form requires signatures to authorize and certify the elections made.

Uploaded by

xofferson
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Form Approved:

OMB No. 3206-01 60

Health Benefits Election Form


1. Enrollee name (lasl,first, middle initial) 2, Social Securitvnumber 5. Are you married?
Yes No
6. Home mailing address (including ZIP Code) 7. Medicare (See note - page 2) 9. C)ther insurance

l0.Name of insurance I l.Insurance policy no.

I2. Name of family member (/ast first. niddle inilial) 13. Social Security number 14.Date of hirth [6.Relationship code

17. Address (if different from enrollee) lS.Medicare (See note - paCe 2) 20.Olher insurance

21.Name of insurance 22. Insarance pol icy no.

member (ast,first, middle initiary Relationship code

Address (if diffirentfron enrollee) Other insurance

Insurance policy no.

Name of frmily member

Address (f dfferentfron enrollee) Other insurance

Insurance policy no.

Name of family member (ast,first, middle initial)

Address (if difer ent fr om e nr o I I e e) Other insurance

Insurance policy no

1. Plan name Enrollment code

1. Eventcode I do NOT want to enroll in the FEHB Program.


My signature in Part H certilies that I huve read and underct&nd the
information on page 3 regarding this election,

I CANCEL my enrollment. I SUSPENDmyemollment.


My signature in Part H certijies thul I have rcad aftd understand the My signalare in Part H certiJies thd I huve redd and understand the
information on page 3 legarding cancellation ofenrollment. information on page 4 regalding suspension ofenrollmenl.

WARNING: Any iatentiondly lalse starement in this applicuion or willful m*repr*entalian rclalive thereto is a violntion of the low punishable by afine of not morc than
$10,000 or imprisonment ofnot more than 5 years, or both. (18 U.S.C. 1001.)
L Your sipature (do not print) 3. Daytime telephone number

REMARKS

1. Datereceived 2, Effective date ofaction 3. Personnel teleohone number 4. Name and address ofagency or retirement system

5. Authorizing offrcial (please print) 6. Signature of authorized agency official

7. Payroll offrce number 8. Payroll offrce contact (please print) Payroll telephone number

NSN 7s4G01-231-6227 Standard Form 2809


This edition supersedes all previous editions of SF 2809 and SF 2809-1 Revised October 2004
Copy 1 . Official Personnel Folder Previous editions are not usable.
U.S. Office of Personnel Management

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