The SF 2809 is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for benefits under the Spouse Equity Act of 1984 (P.L. 98-615), and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage (TCC) provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Services Program. The Privacy Act Statement has been revised due to a general systematic review by our Chief Privacy Officer.
The latest form for Health Benefits Election Form expires 2022-04-30 and can be found here.
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Form and Instruction |
Supporting Statement A |
Supplementary Document |
Justification for No Material/Nonsubstantive Change |
Supplementary Document |
Supplementary Document |
Supplementary Document |