Form SF-2809 Health Benefits Election Form

Health Benefits Election Form

SF2809_10_2004

Health Benefits Election Form

OMB: 3206-0160

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0160 can be found here:

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Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Uses for Standard Form (SF) 2809
Use this form to:

•

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).

Instructions for Completing SF 2809
Type or Print Firmly. 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.

Who May Use SF 2809
1. Employees eligible to enroll in or currently enrolled in the FEHB
Program, including temporary employees eligible under 5 U.S.C.
8906a. Employees automatically participate in premium
conversion unless they waive it, see page 7.
2. Annuitants (other than Civil Service Retirement System [CSRS] and
Federal Employees Retirement System [FERS] annuitants) eligible
to enroll in or currently enrolled in the FEHB Program, 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, call the Retirement Information Office toll-free at
1-888-767-6738. Customers within the local calling distance to
Washington, DC, should call 202-606-0500.

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, show which Parts you have. If you
complete this form after November 15, 2005, also indicate
whether you have prescription drug coverage under the
Medicare Part D program.

Item 8.

TRICARE is a health care program for active duty and retired
members of the uniformed services, their families, and
survivors. This includes TRICARE for Life for members 65
and over.

Item 9.

If you have other group insurance (private, state, Medicaid,
CHAMPVA), check the box.

Item 10.

Write the name of any other insurance you have.

Complete information for family members only if your enrollment is for
Self and Family. (If you need extra space for additional family members,
list them on a separate sheet and attach.)

3. Former spouses eligible to enroll in or currently enrolled in the
FEHB Program under the Spouse Equity law or similar statutes.

Item 13. Please provide Social Security Numbers for your dependents
if available. If not available, leave blank; benefits will not be
withheld. (See Privacy Act Statement on page 5.)

4. Individuals eligible for Temporary Continuation of Coverage (TCC)
under the FEHB Program, including:

Item 16. Provide the code which indicates the relationship of each
eligible family member to you.

•

Former employees (who separated from service);

•

Children who lose FEHB coverage; and

•

Former spouses who are not eligible for FEHB under item 3
above.

This form supersedes all previous editions of SF 2809 and SF 2809-1.

Code

Family Relationship

Spouse

Unmarried dependent child under age 22

Adopted Child

Stepchild

Foster Child

Unmarried disabled child over age 22 incapable
of self support because of a physical or mental
disability that began before age 22.

Standard Form 2809
Revised October 2004

Item 18. If a family member has Medicare, show which Parts he/she
has on the line with his/her name. If you complete this form
after November 15, 2005, also indicate whether you have prescription drug coverage under the Medicare Part D program.

Part C — New Plan.
Complete this part to enroll or change your enrollment in the FEHB
Program.
Items 1
and 2.

Item 19. If a family member has TRICARE, see item 8. Check the

box.

Item 20. If a family member has other group insurance (private, state,
Medicaid), check the box.
Item 21. Give the name of any other insurance this family member

has.

To enroll in a Health Maintenance Organization (HMO), you must live
(or in some cases work) in a geographic area specified by the carrier.

Family Members Eligible for Coverage

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.

Unless you are a former spouse or survivor annuitant, family members
eligible for coverage under your Self and Family enrollment include
your spouse and your unmarried dependent children under age 22.
Eligible children include your legitimate or adopted children; and
recognized children born out of wedlock, stepchildren or foster children,
if they live with you in a regular parent-child relationship. A recognized
child born out of wedlock also may be included if a judicial determination of support has been obtained or you show that you provide regular
and substantial support for the child.

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 Code.
Item 1.

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 and Family enrollment are the
unmarried dependent natural or adopted children under age 22 of
both you and your former or deceased spouse.

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.

In some cases, an unmarried, disabled child who is 22 years old or older
is eligible for coverage under your Self and Family enrollment if you
provide adequate medical certification of a mental or physical handicap
that existed before his or her 22nd birthday and renders the child
incapable of self-support.

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

Note: Your employing office can give you additional details about
family member eligibility including any certification or documentation
that may be required for coverage. “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.

3. Former spouses eligible for coverage under the Spouse Equity
provision of FEHB law
4. TCC enrollees

Part B — Present Plan.

5. Employees who waived participation in premium conversion

You must complete this part if you are changing, cancelling, or
suspending your enrollment.
Enter the name of the plan you are enrolled in from the front
cover of the plan brochure.

Item 2.

Enter your present enrollment code.

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

Children whose marriage ends before they reach age 22 become
eligible for coverage under your Self and Family enrollment from
the date the marriage ends until they reach age 22.

Item 1.

Enter the plan name and enrollment code from the front cover
of the brochure of the plan you want to be enrolled in. The
enrollment code shows the plan and option you are electing
and whether you are enrolling for Self Only or Self and
Family.

Following each number is a letter, which identifies a specific permissible
event; 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 permissible event using numbers to
show month, day, and complete year; e.g., 06/30/2004. 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.

Standard Form 2809
Revised October 2004

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.

Part E — Election NOT to Enroll.
Place an “X” in the box provided only if you are an employee and you
do NOT wish to enroll in the FEHB Program. Be sure to read the
information below in the paragraph titled Employees Who Elect Not to
Enroll or Who Cancel Their Enrollment.

Annuitants Who Cancel Their Enrollment
CSRS and FERS annuitants and their dependents should not use this
form but call 1-888-767-6738, or 202-606-0500 within the Washington,
D.C. area.

Part F — Cancellation.
Place an “X” in the box provided only if you wish to cancel your FEHB
enrollment. Also enter your present enrollment code in Part B. Be sure
to read the information below in the paragraph titled Employees Who
Elect Not to Enroll or Who Cancel Their Enrollment.

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.

Note For Parts E and F. If you are not enrolling or cancelling your
enrollment because you are covered as a spouse or child under
another FEHB plan, please write 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 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 stop the enrollment
because you acquire other FEHB coverage as a new spouse or employee,
your right to 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.

Employees Who Elect Not to Enroll or Who Cancel Their

Enrollment

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.

Temporary Continuation of Coverage Enrollees Who Cancel
Their Enrollment

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 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.
However, 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 dependents who lose coverage).

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
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. Please understand that 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 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.

Standard Form 2809
Revised October 2004

The FEHB Guide, plan brochures, and other information, including links
to plan websites, are available on the FEHB website at
http://www.opm.gov/insure/health.

Part G — Suspension.
CSRS and FERS annuitants and their dependents should not use this
form but call 1-888-767-6738, or 202-606-0500 within the Washington,
D.C. area.

Electronic Enrollments
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 present
enrollment code in Part B.

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 some other automated system.
If you are not sure whether the electronic enrollment option is available
to you, contact your employing office.

You may suspend your FEHB enrollment because you are enrolling in
one of the following programs:

•

A Medicare HMO or Medicare Advantage plan,

•

Medicaid or similar State-sponsored program of medical assistance
for the needy,

•

TRICARE (including Uniformed Services Family Health Plan or
TRICARE for Life), or

Normally, you are not eligible to enroll if you are covered as a family
member under someone else’s enrollment in the FEHB Program.
However, such dual enrollments may be permitted under certain
circumstances in order to:

•

CHAMPVA

•

Protect the interests of children who otherwise would lose coverage
as family members, or

•

Enable an employee who is under age 22 and covered under a
parent’s enrollment and becomes the parent of a child to enroll for
Self and Family coverage.

Dual Enrollment

You can reenroll in the FEHB Program if your other coverage ends.
If your coverage ends involuntarily, you can reenroll 31 days before
through 60 days after loss of coverage. If your coverage ends voluntarily
because you disenroll, you can reenroll during the next open season.

No person (enrollee or family member) is entitled to receive benefits
under more than one enrollment in the Program. 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.

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.

Temporary Continuation of Coverage (TCC)

Your agency, retirement system, or office maintaining your enrollment
cannot process your request unless you complete this part.

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.

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.

Part I - Agency or Retirement System Information

and Remarks.

•

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 22.

•

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.

An individual eligible for TCC who wants to continue FEHB coverage
may choose any plan for which he or she is eligible, option, and type of
enrollment. 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.

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

Guides to Federal Employees Health Benefits
Plans (FEHB Guides) and Plan Brochures

Note:

FEHB Guides contain plan and rate information. Be sure you have the
correct guide for your enrollment category since more than one guide is
used.

•

If someone other than the enrollee notifies the employing office of
the child’s eligibility for TCC within the specified time period, the
child’s opportunity to enroll ends 60 days after the qualifying event.

FEHB Plan brochures contain detailed information about plan benefits
and the contractual description of coverage.

•

If someone other than the enrollee or the former spouse notifies the
employing office of the former spouse’s eligibility for continued
coverage within the specified time period, the former spouse’s
opportunity to enroll ends 60 days after the change in status.

Where to Obtain FEHB Guides and Brochures
FEHB Guides and plan brochures may be available from your employing
office or the office that maintains your enrollment.
Your plan will send you its brochure before the beginning of each
contract year. You may also get copies of plan brochures by contacting
the plans directly at the telephone numbers shown in the FEHB Guide.
The FEHB Guide also shows which plans have their own website.

Standard Form 2809
Revised October 2004

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.

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 2: If you are cancelling your 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.

Note 1: If you are changing your enrollment from Self and Family to
Self Only so that your spouse can enroll for Self Only, you should

Privacy Act Statement
The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program (FEHB) under Chapter 89, title 5,
U.S. Code. This information will be shared 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. This information may be disclosed 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. Executive Order 9397 (November
22, 1943) allows Federal agencies to use the Social Security Number as an individual identifier to distinguish between people with the same or similar names. Failure to
furnish the requested information may result in the U.S. Office of Personnel Management’s (OPM) inability to ensure the prompt payment of your and/or your family’s
claims for health benefits services or supplies.
Agencies other than the OPM may have further routine uses for disclosure of information from the records system in which they file copies of this form. If this is the
case, they should provide you with any such uses which are applicable at the time they ask you to complete this form.

Public Burden Statement
We think 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, OPM Forms Officer, (3206-0160), Washington, D.C. 20415-7900. 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 October 2004

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, 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 QLEs. For more information about premium conversion,
please visit www.opm.gov/insure/health.

Qualifying Life Events (QLEs) that May
Permit Change in FEHB Enrollment or
Premium Conversion Election
Code

Event

FEHB Enrollment Change that May
Be Permitted

From Not
Enrolled
to
Enrolled

Time Limits in which
Change
May Be Permitted

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

Cancel or
Change to
Self Only1

Participate

Waive

When You Must File Health
Benefits Election Form With
Your Employing Office

Yes

N/A

Automatic Unless
Waived

Yes

Within 60 days after becoming
eligible

Employee electing to receive or receiving premium conversion tax benefits

Initial opportunity to enroll, for example:
•
•
•

Premimum Conversion
Election Change that May
Be
Permitted

New employee
Change from excluded position
Temporary employee who completes 1 year of service and is eligible to
enroll under 5 USC 8906a

Open Season

Yes

As announced by OPM

Change in family status that results in increase or decrease in number of
eligible family members, for example:

Yes

Within 60 days after change in
family status

•
•
•

•
1D

Any change in employee’s employment status that could result in
entitlement to coverage, for example:
•
•

•

Employees may enroll or change
beginning 31 days before the event.

Yes

N/A

Automatic Unless
Waived

Yes

Within 60 days after employment status change

Yes

Within 60 days after employment status change

Yes

Within 60 days after return to
civilian position

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.)

Any change in employee’s employment status that could affect cost of
insurance, including:
•

Marriage, divorce, annulment, legal separation
Birth, adoption, acquiring foster child or stepchild, issuance of court
order requiring employee to provide coverage for child
Last dependent child loses coverage, for example, child reaches age 22 or
marries, stepchild moves out of employee’s home, disabled child
becomes capable of self-support, child acquires other coverage by court
order
Death of spouse or dependent

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

Employee restored to civilian position after serving in uniformed services.2

7
7

Qualifying Life Events (QLEs) that May
Permit Change in FEHB Enrollment or
Premium Conversion Election
Code

Event

Employee, spouse or dependent:
•
•
•
•

FEHB Enrollment Change that May
Be Permitted

Premimum Conversion
Election Change that May
Be
Permitted

Time Limits in which
Change
May Be Permitted

From Not
Enrolled
to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

Cancel or
Change to
Self Only

Participate

Waive

Yes

Within 60 days after employment status change

Begins nonpay status or insufficient pay3 or
Ends nonpay status or insufficient pay if coverage continued
(If employee’s coverage terminated, see 1D.)
(If spouse’s or dependent’s coverage terminated, see 1M.)

When You Must File Health
Benefits Election Form With
Your Employing Office

Salary of temporary employee insufficient to make withholdings for plan in
which enrolled.

N/A

Yes

Within 60 days after receiving
notice from employing office

Employee (or covered family member) enrolled in FEHB health
maintenance organization (HMO) moves or becomes employed outside
the geographic area from which the FEHB carrier accepts enrollments or,
if already outside the area, moves further from this area.4

N/A

Yes

N/A

Upon notifying employing
office of move

(see 1M)

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

Within 60 days after arriving at
new post

Yes

Employees may enroll or change
beginning 31 days before leaving the old
post of duty.

Separation from Federal employment when the employee or employee’s
spouse is pregnant.

Yes

N/A

During employee’s final pay
period

Employee becomes entitled to Medicare and wants to change to another
plan or option. 5

Yes
(Changes
may be
made only
once.)

N/A

(see 1M)

Any time beginning on the 30th
day before becoming eligible
for Medicare

Yes

Within 60 days after loss of
coverage

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 termination,
cancellation, or change to Self Only of the covering enrollment
Loss of coverage due to termination of membership in employee organization sponsoring the FEHB plan6
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

Employees may enroll or change
beginning 31 days before the event.

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

From 31 days before the
employee leaves the commuting
area to 180 days after arriving
in the new commuting area

Employee or eligible family member loses coverage due to discontinuance
in whole or part of FEHB plan.7

Yes

During open season, unless
OPM sets a different time

Qualifying Life Events (QLEs) that May
Permit Change in FEHB Enrollment or
Premium Conversion Election
Code

Event

Enrolled employee or eligible family member gains coverage under FEHB
or another group insurance plan, including the following:
•
•
•
•
•
•

•
•
•

Premimum Conversion
Election Change that May
Be
Permitted

Time Limits in which
Change
May Be Permitted

From Not
Enrolled
to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

Cancel or
Change to
Self Only

Participate

Waive

Yes

Within 60 days after QLE

Yes

Within 60 days after QLE

When You Must File Health
Benefits Election Form With
Your Employing Office

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 military service under
Chapter 67, title 10.
Medicaid or similar State-sponsored program of Medical assistance for
the needy
Health insurance acquired due to change of worksite or residence that
affects eligibility for coverage
Health insurance acquired due to spouse’s or dependent’s change in
employment status (includes state, local, or foreign government or private
sector employment).8

Change in spouse’s or dependent’s coverage options under a non-Federal
health plan, for example:
•

FEHB Enrollment Change that May
Be Permitted

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)

(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 cancel enrollment outside of open
season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage.

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 will be forthcoming.

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.

This code reflects the FEHB regulation that gives employees enrolled in an FEHB HMO who change from self only 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, cancellation, or change in premium conversion status, see 1M.

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

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

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

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

Tables of Permissible Changes in FEHB Enrollment for Individuals Who Are Not Participating
in Premium Conversion
Enrollment May Be Cancelled or Changed From Family to Self Only at Any Time
QLE’s That Permit
Enrollment or Change

Code

Event

Change Permitted

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

Time Limits

From One
Plan or
Option to
Another

When You Must File Health
Benefits Election Form With
Your Employing Office

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.

Open Season

Yes

As announced by OPM.

Change in family status; for example: marriage, birth or death
of family member, adoption, legal separation, or divorce.

Yes

From 31 days before through 60
days after the event.

Reenrollment of annuitant who cancelled FEHB enrollment
to enroll in a Medicare-sponsored plan, Medicaid, or similar
State-sponsored program and who later was involuntarily
disenrolled from the Medicare-sponsored plan, Medicaid, or
similar State-sponsored program.

May Reenroll

N/A

From 31 days before through 60
days after disenrollment.

Reenrollment of annuitant who cancelled FEHB enrollment to
enroll in a Medicare-sponsored plan, Medicaid, or similar
State-sponsored program and who later voluntarily disenrolls
from the Medicare-sponsored plan, Medicaid, or similar
State-sponsored program.

May Reenroll

N/A

During open season.

Restoration of annuity or compensation (OWCP) payments;
for example:

Yes

N/A

Within 60 days after the retirement
system or OWCP mails a notice of
insurance eligibility.

Yes

From 31 days before through 60
days after date of loss of coverage.

•
•
•
•
•

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 immediately
before survivor annuity terminated because of marriage and
whose survivor annuity is restored.

Annuitant or eligible family member loses FEHB coverage
due to termination, cancellation, or change to Self Only of the
covering enrollment.

QLE’s That Permit
Enrollment or Change

Code

Event

Annuitant or eligible family member loses coverage under
FEHB or another group insurance plan; for example:
•
•
•
•

Change Permitted

Time Limits

When You Must File Health
Benefits Election Form With
Your Employing Office

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

Yes

From 31 days before through 60
days after loss of coverage.

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 Statesponsored program (but see events 2C and 2D);
Loss of coverage under a non-Federal health plan.

Annuitant or eligible family member loses coverage due to the
discontinuance, in whole or part, of an FEHB plan.

N/A

Yes

During open season, unless OPM
sets a different time.

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

Upon notifying the employing
office of the move or change of
place of employment.

Employee in an overseas post of duty retires or dies.

Yes

Within 60 days after retirement or
death.

An enrolled annuitant separates from duty after serving 31
days or more in a uniformed service.

N/A

Yes

Within 60 days after separation
from the uniformed service.

On becoming eligible for Medicare.

N/A

Yes

At any time beginning on the 30th
day before becoming eligible for
Medicare.

N/A

Yes

Employing office will advise
annuitant of the options.

(This change may be made only once in a lifetime.)
2M

Annuitant’s annuity is insufficient to make withholdings for
plan in which enrolled.

Former Spouse Under The Spouse Equity Provisions
Note: Former spouse may change to Self and Family only if family members are also eligible family members of the employee or
annuitant.

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

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.

Open Season.

Yes

As announced by OPM.

Change in family status based on addition of family members
who are also eligible family members of the employee or
annuitant.

Yes

From 31 days before through 60
days after change in family status.

Reenrollment of former spouse who cancelled FEHB enrollment to enroll in a Medicare-sponsored plan, Medicaid, or
similar State-sponsored program and who later was involuntarily disenrolled from the Medicare-sponsored plan,
Medicaid, or similar State-sponsored program.

May reenroll

N/A

From 31 days before through 60
days after disenrollment.

Reenrollment of former spouse who cancelled FEHB enrollment to enroll in a Medicare-sponsored plan, Medicaid, or
similar State-sponsored program and who later voluntarily
disenrolls from the Medicare-sponsored plan, Medicaid, or
similar State-sponsored program.

May reenroll

N/A

During open season.

QLE’s That Permit
Enrollment or Change

Code

Event

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to Self
and Family

From One
Plan or
Option to
Another

When You Must File Health
Benefits Election Form With
Your Employing Office

Former spouse or eligible child loses FEHB coverage due
to termination, cancellation, or change to Self Only of the
covering enrollment.

Yes

From 31 days before through 60
days after date of loss of coverage.

Enrolled former spouse or eligible child loses coverage under
another group insurance plan; for example:

N/A

Yes

From 31 days before through 60
days after loss of coverage.

•
•
•
•

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 Statesponsored program (but see 3D and 3E);
Loss of coverage under a non-Federal health plan.

Former spouse or eligible family member loses coverage due
to the discontinuance, in whole or part, of an FEHB plan.

N/A

Yes

During open season, unless OPM
sets a different time.

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

Upon notifying the employing
office of the move or change of
place of employment.

On becoming eligible for Medicare

N/A

Yes

At any time beginning the 30th
day before becoming eligible for
Medicare.

Yes

Retirement system will advise
former spouse of options.

(This change may be made only once in a lifetime.)
3K

Former spouse’s annuity is insufficient to make FEHB withholdings for plan in which enrolled.

Temporary Continuation of Coverage (TCC) For Eligible Former Employees, Former Spouses, and Children.
Note: Former spouse may change to Self and Family only if family members are also eligible family members of the employee or
annuitant.

Opportunity to enroll for continued coverage under TCC
provisions:
•
•
•

Former employee
Former spouse
Child who ceases to qualify as a family
member

Yes
Yes
Yes

Yes
N/A
N/A

No
No
No

Yes
Yes
Yes

Open Season:
•
•
•

Former employee
Former spouse
Child who ceases to qualify as a family
member

Within 60 days after the qualifying
event, or receiving notice of
eligibility, whichever is later.

As announced by OPM.

Change in family status (except former spouse); for example,
marriage, birth or death of family member, adoption, legal
separation, or divorce.

Yes

From 31 days before through 60
days after event.

Change in family status of former spouse, based on addition
of family members who are eligible family members of the
employee or annuitant.

Yes

From 31 days before through 60
days after event.

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

From 31 days before through 60
days after the event. Enrollment is
retroactive to the date of the loss of
the other FEHB coverage.

QLE’s That Permit
Enrollment or Change

Code

Event

Enrollee or eligible family member loses coverage under
FEHB or another group insurance plan; for example:
•
•
•
•
•

Change Permitted

Time Limits

When You Must File Health
Benefits Election Form With
Your Employing Office

From Not
Enrolled to
Enrolled

From Self
Only to
Family

From One
Plan or
Option to
Another

Yes

From 31 days before through 60
days after loss of coverage.

Loss of coverage under another FEHB enrollment due to
termination, cancellation, or change to 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 Statesponsored program;
Loss of coverage under a non-Federal health plan.

Enrollee or eligible family member loses coverage due to the
discontinuance, in whole or part, of an FEHB plan.

N/A

Yes

During open season, unless OPM
sets a different time.

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

Upon notifying the employing
office of the move or change of
place of employment.

On becoming eligible for Medicare.

N/A

Yes

At any time beginning on the 30th
day before becoming eligible for
Medicare.

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

Employees Who Are Not Participating In Premium Conversion

Initial opportunity to enroll.

Yes

N/A

Within 60 days after becoming
eligible.

Open Season.

Yes

As announced by OPM.

Change in family status; for example: marriage, birth or death
of family member, adoption, legal separation, or divorce

Yes

From 31 days before through 60
days after event.

Change in employment status; for example:

Yes

Within 60 days of employment
status change.

•
•
•
•
•
•

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.

QLE’s That Permit
Enrollment or Change

Code

Event

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to
Family

From One
Plan or
Option to
Another

When You Must File Health
Benefits Election Form With
Your Employing Office

Separation from Federal employment when the employee is
or employee’s spouse is pregnant.

Yes

Enrollment or change must occur
during final pay period of employment.

Transfer from a post of duty within the United States to a
post of duty outside the United States, or reverse.

Yes

From 31 days before leaving old
post through 60 days after arriving
at new post.

Employee or eligible family member loses coverage under
FEHB or another group insurance plan; for example:

Yes

From 31 days before through 60
days after loss of coverage.

•
•
•
•
•

Loss of coverage under another FEHB enrollment due to
termination, cancellation, or change to 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 Statesponsored program;
Loss of coverage under a non-Federal health plan.

Enrollee or eligible family member loses coverage due to the
discontinuance, in whole or part, of an FEHB plan.

N/A

Yes

During open season, unless OPM
sets a different time.

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

From 31 days before the employee
leaves the commuting area through
180 days after arriving in the new
commuting area.

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

Upon notifying the employing
office of the move or change of
place of employment.

On becoming eligible for Medicare

N/A

Yes

At any time beginning on the 30th
day before becoming eligible for
Medicare.

(This change may be made only once in a lifetime.)
5L

Temporary employee completes one year of continuous
service in accordance with 5 U.S.C. Section 8906a.

Yes

N/A

Within 60 days after becoming
eligible.

Salary of temporary employee insufficient to make withholdings for plan in which enrolled.

N/A

Yes

Within 60 days after receiving
notice from employing office.

Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Federal Employees
Health Benefits Program

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

__/__/____

M
7. Medicare (See note - page 2) 8. TRICARE

6. Home mailing address (including ZIP Code)

A
B
10.Name of insurance
12. Name of family member (last, first, middle initial)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

__/__/____

Date of birth

__/__/____

Date of birth

__/__/____

Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.

Part C - New Plan

1. Plan name

2. Enrollment code

1. Plan name

Part D - Event Code
1. Event code

Date of birth

Medicare (See note - page 2)
A
B
D
Name of insurance

Part B - Present Plan

20.Other insurance
22.Insurance policy no.

Medicare (See note - page 2)
A
B
D
Name of insurance

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

Medicare (See note - page 2)
A
B
D
Name of insurance

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

16.Relationship code

15.Sex

M
18.Medicare (See note - page 2) 19.TRICARE

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

Yes
No
9. Other insurance
11.Insurance policy no.

__/__/____

A
B
21.Name of insurance

13.Social Security number 14.Date of birth

17. Address (if different from enrollee)

5. Are you married?

4. Sex

2. Enrollment code

Part E - Employees Only (Election NOT to Enroll)
2. Date of event

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.

__/__/____
Part F - Cancellation

Part G - Suspension (Annuitants/Former Spouses Only)

I CANCEL my enrollment.

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of enrollment.
Part H - Signature

My signature in Part H certifies that I have read and understand the
information on page 4 regarding suspension of enrollment.

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)
3. Daytime telephone number

Part I -To be completed by agency or retirement system
REMARKS
1. Date received

2. Effective date of action

5. Authorizing official (please print)

6. Signature of authorized agency official

7. Payroll office number

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

__/__/____

3. Personnel telephone number 4. Name and address of agency or retirement system

(

(
This edition supersedes all previous editions of SF 2809 and SF 2809-1.

)

NSN 7540-01-231-6227

Standard Form 2809
Revised October 2004
Previous editions are not usable.

Copy 1 - Official Personnel Folder

U.S. Office of Personnel Management

Print Form

Save Form

Clear Form

Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Federal Employees
Health Benefits Program

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

__/__/____

M
7. Medicare (See note - page 2) 8. TRICARE

6. Home mailing address (including ZIP Code)

A
B
10.Name of insurance
12. Name of family member (last, first, middle initial)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

__/__/____

Date of birth

__/__/____

Date of birth

__/__/____

Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.

Part C - New Plan

1. Plan name

2. Enrollment code

1. Plan name

Part D - Event Code
1. Event code

Date of birth

Medicare (See note - page 2)
A
B
D
Name of insurance

Part B - Present Plan

20.Other insurance
22.Insurance policy no.

Medicare (See note - page 2)
A
B
D
Name of insurance

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

Medicare (See note - page 2)
A
B
D
Name of insurance

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

16.Relationship code

15.Sex

M
18.Medicare (See note - page 2) 19.TRICARE

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

Yes
No
9. Other insurance
11.Insurance policy no.

__/__/____

A
B
21.Name of insurance

13.Social Security number 14.Date of birth

17. Address (if different from enrollee)

5. Are you married?

4. Sex

2. Enrollment code

Part E - Employees Only (Election NOT to Enroll)
2. Date of event

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.

__/__/____
Part F - Cancellation

Part G - Suspension (Annuitants/Former Spouses Only)

I CANCEL my enrollment.

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of 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
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)
3. Daytime telephone number

Part I -To be completed by agency or retirement system
REMARKS
1. Date received

2. Effective date of action

5. Authorizing official (please print)

6. Signature of authorized agency official

7. Payroll office number

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

__/__/____

3. Personnel telephone number 4. Name and address of agency or retirement system

(

(
This edition supersedes all previous editions of SF 2809 and SF 2809-1.
U.S. Office of Personnel Management

Print Form

)

NSN 7540-01-231-6227

Standard Form 2809
Revised October 2004
Previous editions are not usable.

Copy 2- New Carrier

Save Form

Clear Form

Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Federal Employees
Health Benefits Program

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

M
7. Medicare (See note - page 2) 8. TRICARE

6. Home mailing address (including ZIP Code)

A
B
10.Name of insurance
12. Name of family member (last, first, middle initial)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

__/__/____

Date of birth

__/__/____

Date of birth

__/__/____

Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.

Part C - New Plan

1. Plan name

2. Enrollment code

1. Plan name

Part D - Event Code
1. Event code

Date of birth

Medicare (See note - page 2)
A
B
D
Name of insurance

Part B - Present Plan

20.Other insurance
22.Insurance policy no.

Medicare (See note - page 2)
A
B
D
Name of insurance

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

Medicare (See note - page 2)
A
B
D
Name of insurance

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

16.Relationship code

15.Sex

M
18.Medicare (See note - page 2) 19.TRICARE

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

Yes
No
9. Other insurance
11.Insurance policy no.

__/__/____

A
B
21.Name of insurance

13.Social Security number 14.Date of birth

17. Address (if different from enrollee)

5. Are you married?

4. Sex

2. Enrollment code

Part E - Employees Only (Election NOT to Enroll)
2. Date of event

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.
Part F - Cancellation

Part G - Suspension (Annuitants/Former Spouses Only)

I CANCEL my enrollment.

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of enrollment.

My signature in Part H certifies that I have read and understand the
information on page 4 regarding suspension of enrollment.

Part I -To be completed by agency or retirement system
REMARKS
1. Date received

2. Effective date of action

5. Authorizing official (please print)

6. Signature of authorized agency official

7. Payroll office number

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

__/__/____

3. Personnel telephone number 4. Name and address of agency or retirement system

(

(
This edition supersedes all previous editions of SF 2809 and SF 2809-1.
U.S. Office of Personnel Management

Print Form

)

NSN 7540-01-231-6227

Standard Form 2809
Revised October 2004
Previous editions are not usable.

Copy 3 - Old Carrier

Save Form

Clear Form

Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Federal Employees
Health Benefits Program

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

__/__/____

M
7. Medicare (See note - page 2) 8. TRICARE

6. Home mailing address (including ZIP Code)

A
B
10.Name of insurance
12. Name of family member (last, first, middle initial)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

Social Security number

Address (if different from enrollee)

Date of birth

__/__/____

Date of birth

__/__/____

Date of birth

__/__/____

Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex

Medicare (See note - page 2)
A
B
D
Name of insurance

Part B - Present Plan

20.Other insurance
22.Insurance policy no.

Medicare (See note - page 2)
A
B
D
Name of insurance

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

Medicare (See note - page 2)
A
B
D
Name of insurance

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

M
TRICARE

F
Other insurance
Insurance policy no.

Part C - New Plan

1. Plan name

2. Enrollment code

1. Plan name

Part D - Event Code
1. Event code

16.Relationship code

15.Sex

M
18.Medicare (See note - page 2) 19.TRICARE

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

Yes
No
9. Other insurance
11.Insurance policy no.

__/__/____

A
B
21.Name of insurance

13.Social Security number 14.Date of birth

17. Address (if different from enrollee)

5. Are you married?

4. Sex

2. Enrollment code

Part E - Employees Only (Election NOT to Enroll)
2. Date of event

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.

__/__/____
Part F - Cancellation

Part G - Suspension (Annuitants/Former Spouses Only)

I CANCEL my enrollment.

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of enrollment.

My signature in Part H certifies that I have read and understand the
information on page 4 regarding suspension of enrollment.

__/__/____

(

)

Part I -To be completed by agency or retirement system
REMARKS
1. Date received

2. Effective date of action

5. Authorizing official (please print)

6. Signature of authorized agency official

7. Payroll office number

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

__/__/____

3. Personnel telephone number 4. Name and address of agency or retirement system

(

(
This edition supersedes all previous editions of SF 2809 and SF 2809-1.
U.S. Office of Personnel Management

Print Form

)

NSN 7540-01-231-6227

Standard Form 2809
Revised October 2004
Previous editions are not usable.

Copy 4 - Payroll Office

Save Form

Clear Form

Form Approved:
OMB No. 3206-0160

Health Benefits Election Form

Federal Employees
Health Benefits Program

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

__/__/____

M
7. Medicare (See note - page 2) 8. TRICARE

6. Home mailing address (including ZIP Code)

A
B
10.Name of insurance
12. Name of family member (last, first, middle initial)

Social Security number

__/__/____

Social Security number

Date of birth

__/__/____

Address (if different from enrollee)

Social Security number

Date of birth

__/__/____

Address (if different from enrollee)

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.
Relationship code

Sex
M
TRICARE

F
Other insurance
Insurance policy no.

Part C - New Plan

1. Plan name

2. Enrollment code

1. Plan name

Part D - Event Code
1. Event code

M
TRICARE

Medicare (See note - page 2)
A
B
D
Name of insurance

Part B - Present Plan

Relationship code

Sex

Medicare (See note - page 2)
A
B
D
Name of insurance

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

20.Other insurance
22.Insurance policy no.

Medicare (See note - page 2)
A
B
D
Name of insurance

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

Date of birth

Address (if different from enrollee)

16.Relationship code

15.Sex

M
18.Medicare (See note - page 2) 19.TRICARE

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

Yes
No
9. Other insurance
11.Insurance policy no.

__/__/____

A
B
21.Name of insurance

13.Social Security number 14.Date of birth

17. Address (if different from enrollee)

5. Are you married?

4. Sex

2. Enrollment code

Part E - Employees Only (Election NOT to Enroll)
2. Date of event

I do NOT want to enroll in the FEHB Program.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.

__/__/____
Part F - Cancellation

Part G - Suspension (Annuitants/Former Spouses Only)

I CANCEL my enrollment.

I SUSPEND my enrollment.

My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of enrollment.

My signature in Part H certifies that I have read and understand the
information on page 4 regarding suspension of enrollment.

Part I -To be completed by agency or retirement system
REMARKS
1. Date received

2. Effective date of action

5. Authorizing official (please print)

6. Signature of authorized agency official

7. Payroll office number

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

__/__/____

3. Personnel telephone number 4. Name and address of agency or retirement system

(

(
This edition supersedes all previous editions of SF 2809 and SF 2809-1.
U.S. Office of Personnel Management

Print Form

)

NSN 7540-01-231-6227

Standard Form 2809
Revised October 2004
Previous editions are not usable.

Copy 5 - Enrollee

Save Form

Clear Form

File Type	application/pdf
File Title	H:\CorelVentura\sf2809.vp
Author	csbenson
File Modified	2004-11-08
File Created	2004-10-05