Form SF 2809 SF 2809 Health Benefits Election Form

Health Benefits Election Form

SF 2809 November 2014

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⚠️ Notice: This form may be outdated.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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Health Benefits Election Form

Form Approved:
OMB No. 3206-0160

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

Item 8.

If you have Medicare, enter your Medicare Claim Number.
This number is on your Medicare Card.

•

Enroll or reenroll in the FEHB Program; or

Item 9.

•

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

If you are covered by other health insurance, either in your
name or under a family member’s policy, check yes and
complete item 10.

•

Change your FEHB enrollment; or

Item 10.

•

Cancel your FEHB enrollment; or

•

Suspend your FEHB enrollment (annuitants or former spouses
only).

Provide the information requested on any other health
insurance that covers you. An FEHB Self and Family
enrollment covers all eligible family members. If you or a
family member is covered under another FEHB enrollment,
check the FEHB box and
. Contact your Human Resources
office or retirement system immediately as this is a dual
coverage situation. Examples of how this could occur are:

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 in retirement systems other than the Civil Service
Retirement System (CSRS) or Federal Employees Retirement
System (FERS), including individuals receiving monthly
compensation from the Office of Workers’ Compensation Programs
(OWCP).
Note: Civil Service Retirement System (CSRS) and Federal
Employees Retirement System (FERS) annuitants and former
spouses and children of CSRS/FERS annuitants -- Do not use
this form. Instead, use form OPM 2809, which is available at
www.opm.gov/forms/OPM-forms, or call the Retirement Information
Office toll-free at 1-888-767-6738.

•

You are enrolling in an FEHB Self Only plan while
your spouse has an FEHB Self and Family plan (which
automatically covers you).

•

You are enrolling in an FEHB Self and Family plan
while your spouse has an FEHB Self Only or Self and
Family plan.

•

You are an employee under age 26 and have no
dependents. You are enrolling in your own FEHB plan
while you are covered under your parent’s FEHB Self
and Family plan.

•

You are an annuitant who is reemployed in the Federal
government. You are enrolling in an FEHB plan as an
employee while you are covered under your own or a
family member’s FEHB plan.

No person may be covered under more than one FEHB
enrollment. However, in certain unusual circumstances, your
agency may allow you to enroll in order to:

3. Former spouses eligible to enroll in or currently enrolled in the
FEHB Program under the Spouse Equity law or similar statutes.
4. Individuals eligible for Temporary Continuation of Coverage (TCC)
under the FEHB Program, including:

•

Enable an employee under age 26 who is covered under
a parent’s Self and Family FEHB enrollment to enroll in
FEHB to cover his or her own spouse and/or child;

•

Enable an employee under age 26 who is covered under
a parent’s Self and Family FEHB enrollment, but lives
outside his or her parent’s HMO service area, to have
FEHB coverage;

Instructions for Completing SF 2809
Type or Print. We have not provided instructions for
those items that have an explanation on the form.

•

Enable an employee who separates or divorces to enroll
in FEHB to cover family members who move outside
the HMO service area of the covering FEHB Self and
Family enrollment.

Part A — Enrollee and Family Member Information

In these unusual situations, each enrollee must notify his or
her plan as to which family members are covered under
which enrollment. See Dual Enrollment information on
page 4.

•

Former employees (who separated from service);

•

Children who lose FEHB coverage; and

•

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

You must complete this part.
Item 2.

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

Item 5.

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

Item 7.

If you have Medicare, check which Parts you have, including
prescription drug coverage under Medicare Part D.

Previous edition is not usable

Standard Form 2809
Revised November 2014

Other relatives (for example, your parents) are not eligible for coverage
even if they live with you and are dependent upon you.

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

If you are a former spouse or survivor annuitant, family members
eligible for coverage under your Self and Family enrollment are the
natural or adopted children under age 26 of both you and your former
or deceased spouse.

The instructions for completing items 13 through 24 for your initial
family member also apply to the information you provide for additional
family members.
Item 14.

Provide the Social Security Number for this family member if
he/she has one. If your family member does not have a Social
Security Number, leave blank; benefits will not be withheld.
(See Privacy Act Statement on page 5.)

Item 17.

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

In some cases, a disabled child age 26 or older is eligible for coverage
under your Self and Family enrollment if you provide adequate medical
certification of a mental or physical disability that existed before his/her
26th birthday and renders the child incapable of self-support.
Note: Your employing office can give you additional details about
family member eligibility including any certification or documentation
that may be required for coverage. Contact your employing office for
more information about covering foster child(ren), or child(ren) of your
same-sex domestic partner who you would marry but for your state’s
marriage law. “Employing office” means the office of an agency or
retirement system that is responsible for health benefits actions for an
employee, annuitant, former spouse eligible for coverage under the
Spouse Equity provisions, or individual eligible for TCC.

Family Relationship

Spouse

Child under age 26

Adopted Child under age 26

Stepchild under age 26

Foster Child under age 26

Disabled child age 26 or older who is incapable
of self support because of a physical or mental
disability that began before his/her 26th birthday.

Survivor Benefits
For your surviving family members to continue your FEHB enrollment
after your death, all of the following requirements must be met:

•

You must have been enrolled for Self and Family at the time of your
death; and
At least one family member must be entitled to an annuity as your
survivor.

Item 18.

If your family member does not live with you, enter his/her
home address.

•

Item 19.

If your family member has Medicare, check which Parts
he/she has, including prescription drug coverage under
Medicare Part D.

Item 20.

If your family member has Medicare, enter his/her Medicare
Claim Number. This number is on his/her Medicare Card.

All of your survivors who meet the definition of “family member” can
continue their health benefits coverage under your enrollment as long as
any one of them is entitled to a survivor annuity. If the survivor
annuitant is the only eligible family member, the retirement system will
automatically change the enrollment to Self Only.

Item 21.

If your family member is covered by other group insurance,
such as private, state, or Medicaid, check the box and
complete item 22.

Part B — FEHB Plan You Are Currently Enrolled In

Provide the information requested on any other health
insurance that covers this family member. If your family
member is covered under another FEHB plan, see
instructions for item 10.

Item 1.

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 from your plan ID card.

Item 22.

Item 23.

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

Item 24.

Enter preferred telephone number, if applicable, for this
family member.

You must complete this part if you are changing, cancelling, or
suspending your enrollment.

Part C — FEHB Plan You Are Enrolling In or
Changing To
Complete this part to enroll or change your enrollment in the FEHB
Program.

Family Members Eligible for Coverage
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 children under age 26.

Item 1.

Enter the name of the plan you are enrolling in or changing
to. The plan name is on the front cover of the brochure of the
plan you want to be enrolled in.

Item 2.

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

Eligible children include your children born within marriage or adopted
children; stepchildren (may include children of your same-sex domestic
partner*); recognized natural children; or foster children who live with
you in a regular parent-child relationship.

*If you would marry but you live in a state that does not allow same-sex couples to marry.
2

Standard Form 2809
Revised November 2014

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

Part B. Be sure to read the information titled Employees Who Elect Not
to Enroll or Who Cancel Their Enrollment.

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.

Note For Parts E and F. If you are Electing Not to Enroll or
Cancelling your enrollment because you are covered as a spouse or
child under another FEHB plan, your agency must enter the enrollee’s
name, Social Security number, and FEHB enrollment code in
REMARKS.

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.

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.

Part D — Event That Permits You To Enroll, Change,
Or Cancel
Item 1.

Enter the event code that permits you to enroll, change, or
cancel based on a Qualifying Life Event (QLE) from the
Table of Permissible Changes in Enrollment that applies to
you.

Explanation of Table of Permissible Changes in Enrollment

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

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.

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

The tables have been organized by enrollee category. Each category is
designated by a number, which identifies the enrollee group, as follows:

Under a retirement system for Federal civilian employees, and

•

On an immediate annuity.

In addition, you must be currently enrolled in a plan under the FEHB
Program and must have been enrolled (or covered as a family member)
in a plan under the Program for:

1. Employees who participate in premium conversion
2. Annuitants (other than CSRS/FERS annuitants), including
individuals receiving monthly compensation from the Office of
Workers’ Compensation Programs
3. Former spouses eligible for coverage under the Spouse Equity
provision of FEHB law
4. TCC enrollees
5. Employees who waived participation in premium conversion

•

The 5 years of service immediately before retirement (i.e.,
commencing date of annuity entitlement), or

•

If fewer than 5 years, all service since your first opportunity to
enroll. (Generally, your first opportunity to enroll is within 60 days
after your first appointment [in your Federal career] to a position
under which you are eligible to enroll under conditions that permit a
Government contribution toward the enrollment.)

If you do not enroll at your first opportunity or if you cancel your
enrollment, you may later enroll or reenroll only under the circumstances
explained in the table beginning on page 7. Some employees delay their
enrollment or reenrollment until they are nearing 5 years before
retirement in order to qualify for FEHB coverage as a retiree; however,
there is always the risk that they will retire earlier than expected and not
be able to meet the 5-year requirement for continuing FEHB coverage
into retirement. When you elect not to enroll or cancel your enrollment
you are voluntarily accepting this risk. An alternative would be to
enroll in or change to a lower cost plan so that you meet the
requirements for continuation of your FEHB enrollment after retirement.

Following each number is a letter, which identifies a specific Qualifying
Life Event (QLE); for example, the event code “1A” refers to the initial
opportunity to enroll for an employee who elected to participate in
premium conversion.
Item 2.

•

Enter the date of the QLE using numbers to show month, day,
and complete year; e.g., 06/30/2011. If you are electing to
enroll, enter the date you became eligible to enroll (for
example, the date your appointment began). If you are
making an open season enrollment or change, enter the date
on which the open season begins.

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 only if you are an employee and you do NOT
wish to enroll in the FEHB Program. Be sure to read the information
titled Employees Who Elect Not to Enroll or Who Cancel Their
Enrollment.

Annuitants Who Cancel Their Enrollment
CSRS and FERS annuitants and their dependents should not use this
form but use form RI 79-9, Health Benefits Cancellation/Suspension
Confirmation, which is available at
www.opm.gov/forms/Retirement-and-Insurance-Forms, or call
1-888-767-6738.

Part F — Cancellation of FEHB
Place an “X” in the box only if you wish to cancel your FEHB
enrollment. Also enter your present plan name and enrollment code in
3

Standard Form 2809
Revised November 2014

Generally, you cannot reenroll as an annuitant unless you are
continuously covered as a family member under another person’s
enrollment in the FEHB Program during the period between your
cancellation and reenrollment. Your employing office or retirement
system can advise you on events that allow eligible annuitants to
reenroll. If you cancel your enrollment because you are covered under
another FEHB enrollment, you can reenroll from 31 days before through
60 days after you lose that coverage under the other enrollment.
If you cancel your enrollment for any other reason, you cannot later
reenroll, and you and any family members covered by your enrollment
are not entitled to a 31-day temporary extension of coverage or to
convert to an individual policy.

•

A Medicare Advantage plan or Medicare HMO,

•

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

•

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

•

CHAMPVA, or

•

Peace Corps.

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

Former Spouses (Spouse Equity) Who Cancel Their Enrollment
Generally, if you cancel your enrollment in the FEHB Program, you
cannot reenroll as a former spouse. However, if you cancel the
enrollment because you become covered under FEHB as a new spouse
or employee, your eligibility for FEHB coverage under the Spouse
Equity provisions continues. You may reenroll as a former spouse from
31 days before through 60 days after you lose coverage under the other
FEHB enrollment.

You must submit documentation of eligibility for coverage under the
non-FEHB Program to the office that maintains your enrollment. That
office must enter in REMARKS the reason for your suspension.
Part H — Signature
Your agency, retirement system, or office maintaining your enrollment
cannot process your request unless you complete this part.

If you 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.

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.

Temporary Continuation of Coverage (TCC) Enrollees Who
Cancel Their Enrollment

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.

If you cancel your TCC enrollment, you cannot reenroll. Your family
members who lose coverage because of your cancellation cannot enroll
for TCC in their own right nor can they convert to a nongroup policy.
Family members who are Federal employees or annuitants may enroll in
the FEHB Program when you cancel your coverage if they are eligible
for FEHB coverage in their own right.

Part I - Agency or Retirement System Information
and Remarks
Leave this section blank as it is for agency or retirement system use only.

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).

Guides to Federal Benefits and Plan Brochures
Guides to Federal Benefits contain plan and rate information. Be sure
you have the correct guide for your enrollee category, as more than one
guide is issued.
FEHB Plan brochures contain detailed information about plan benefits
and the contractual description of coverage.
Where to Obtain Guides and Brochures
The Guides, plan brochures, and other information, including links to
plan websites, are available on the FEHB website at
www.opm.gov/insure/healthcare-insurance/healthcare.

Note 2: Former spouses (Spouse Equity) and TCC enrollees who fail to
pay their premiums within specified timeframes are considered to have
voluntarily cancelled their enrollment.

Part G — Suspension of FEHB

Guides and plan brochures may be available from your employing office
or the office that maintains your enrollment.

CSRS and FERS annuitants and their dependents should not use this
form but use form RI 79-9, Health Benefits Cancellation/Suspension
Confirmation, which is available at
www.opm.gov/forms/Retirement-and-Insurance-Forms, or call
1-888-767-6738.

Your plan will send you its paper brochure when you first enroll. You
may also get copies of plan brochures by contacting the plans directly at
the telephone numbers shown in the Guide.

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
plan name and enrollment code in Part B.

Electronic Enrollments
Many agencies use automated systems that allow their employees to
make changes using a touch-tone telephone, or a computer instead of
a form. This may be Employee Express or another automated system.
If you are not sure whether the electronic enrollment option is available
to you, contact your employing office.

You may suspend your FEHB enrollment because you are enrolling in
one of the following programs:
4

Standard Form 2809
Revised November 2014

spouse to enroll with the employing office is within 60 days after the
Qualifying Life Event, or receiving notice of eligibility, whichever is
later.

Dual Enrollment
No person (enrollee or family member) is entitled to receive benefits
under more than one enrollment in the FEHB Program. Normally, you
are not eligible to enroll if you are covered as a family member under
someone else’s enrollment in the Program. However, such dual
enrollments may be permitted under certain circumstances in order to:

•

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

•

Enable an employee who is under age 26 and covered under a
parent’s enrollment and becomes the parent of a child to enroll for
Self and Family 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 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
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.

Each enrollee must notify his or her plan of the names of the persons to
be covered under his or her enrollment who are not covered under the
other enrollment. See instructions for item 10 for more information.

Temporary Continuation of Coverage (TCC)

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.

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.

Agency Distribution of SF 2809

•

For the eligible child of an enrollee, the enrollee must notify the
employing office within 60 days after the qualifying event occurs;
e.g., child reaches age 26.

•

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.

Agencies must distribute one copy of the completed SF 2809 to each of
the following, as appropriate:

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

•

Official Personnel Folder

•

New Carrier

•

Old Carrier

•

Payroll Office

•

Enrollee

Privacy Act and Public Burden Statements
The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program under Chapter 89, title 5, U.S.
Code. The principal use of this information will be to share it with the health insurance carrier you select so that it may (1) identify your enrollment in the plan,
(2) verify your and/or your family’s eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment of claims with other carriers
with whom you might also make a claim for payment of benefits. Other routine uses include disclosures to other Federal agencies or Congressional offices which may
have a need to know it in connection with your application for a job, license, grant, or other benefit. It may also be shared and is subject to verification, via paper,
electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or Social Security administrative agencies to
determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the
extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local
law enforcement agency. While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your
enrollment.
We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB Program, and for other purposes. Executive
Order 13478 (November 18, 2009) allows Federal agencies to use Social Security Numbers as individual identifiers to distinguish between people of same or similar
names. In addition, a mandatory insurer reporting law (Section 111 of Public Law number 110-173) requires your health insurance carrier to report your Social Security
Number or your Medicare Claim Number in order to properly coordinate benefits between your health plan and Medicare. Also, Section 6055 of the Internal Revenue
Code requires your health insurance plan to report, to the Internal Revenue Service (IRS), information necessary to confirm that you and your covered family members
have minimum essential coverage from your health plan. The information required from your health insurance plan includes a Social Security Number for yourself and
each of your covered family members. Failure to furnish your Social Security Number and/or Medicare Claim Number may result in the US. Office of Personnel
Management’s (OPM) inability to ensure the prompt payment of your and/or family’s claims for health benefits services or supplies, proper coordination with Medicare
and proper health insurance status reporting to the IRS.
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed
form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel
Management, Retirement Services Publications Team, (3206-0160), Washington, D.C. 20415-3430. The OMB number, 3206-0160 is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.

Standard Form 2809
Revised November 2014

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 QLE’s. If you are covering child(ren) of your same-sex
domestic partner who you would marry but for your state’s marriage law, contact your employing office for more information on premium conversion availability and other tax considerations. For more
information about premium conversion, please visit www.opm.gov/healthcare-insurance/healthcare.

Qualifying Life Events (QLE’s) that May
Permit Change in FEHB Enrollment or
Premium Conversion Election
Event
Code

Event

FEHB Enrollment Change that May
Be Permitted

From One
Plan or
Option to
Another

Cancel or
Change to
Self Only

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

Yes

As announced by OPM

Yes

Within 60 days after change in
family status

Employee electing to receive or receiving premium conversion tax benefits

Initial opportunity to enroll, for example:

1B
1C

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

•

Yes

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
Birth, adoption, acquiring foster child or stepchild, issuance of court
order requiring employee to provide coverage for child
Last child loses coverage, for example, child reaches age 26, disabled
child becomes capable of self-support, child acquires other coverage by
court order
Death of spouse or dependent

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

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

Open Season

Time Limits in which
Change
May Be Permitted

From Self
Only to Self
and Family

From Not
Enrolled
to
Enrolled

•
•
•

Premium Conversion
Election Change that May
Be
Permitted

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 (QLE’s) that May
Permit Change in FEHB Enrollment or
Premium Conversion Election
Event
Code

Event

Employee, spouse or dependent:
•
•
•
•

FEHB Enrollment Change that May
Be Permitted

Premium 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 1P)

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 (QLE’s) that May
Permit Change in FEHB Enrollment or
Premium Conversion Election
Event
Code

Event

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

•
•
•

Premium 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

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

Yes9

Yes

Within 60 days after QLE

Yes9

Yes

Within 60 days after QLE

Yes

Yes9

Yes

Within 60 days after the date
the employee or family member
becomes eligible for assistance.

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.
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 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)

Employee or eligible family member becomes eligible for assistance under
Medicaid or a State Children’s Health Insurance Program (CHIP).

(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 is available in the Frequently Asked Questions section of the FEHB website at
www.opm.gov/healthcare-insurance/healthcare.

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.

Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage. Employees may cancel enrollment outside of Open Season
only if the QLE caused the enrollee and all eligible family members to acquire other health insurance coverage.

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

Event
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, or divorce.

Yes

From 31 days before through 60
days after the event.

Reenrollment of annuitant who suspended FEHB enrollment
to enroll in a Medicare Advantage plan, Medicaid or similar
State-sponsored program, or to use TRICARE (including Uniformed Services Family Health Plan and TRICARE for Life),
Peace Corps, or CHAMPVA, and who later involuntarily
loses this coverage under one of these programs.

May Reenroll

N/A

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

Reenrollment of annuitant who suspended FEHB enrollment
to enroll in a Medicare Advantage plan, Medicaid, or similar
State-sponsored program, or to use TRICARE (including Uniformed Services Family Health Plan or TRICARE for Life),
Peace Corps, or CHAMPVA, and who wants to reenroll in the
FEHB Program for any reason other than an involuntary loss
of coverage.

May Reenroll

N/A

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

Event
Code

Event

Annuitant or eligible family member loses coverage under
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 suspended FEHB enrollment to enroll in a Medicare Advantage plan, Medicaid, or
similar State-sponsored program, or to use TRICARE (including Uniformed Services Family Health Plan or TRICARE for
Life), Peace Corps, or CHAMPVA, and who later involuntarily loses this coverage under one of these programs.

May reenroll

N/A

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

Reenrollment of former spouse who suspended FEHB enrollment to enroll in a Medicare Advantage plan, Medicaid, or
similar State-sponsored program, or to use TRICARE (including Uniformed Services Family Health Plan or TRICARE for
Life), Peace Corps, or CHAMPVA, and who wants to reenroll
in the FEHB Program for any reason other than an involuntary
loss of coverage.

May reenroll

N/A

During open season.

QLE’s That Permit
Enrollment or Change

Event
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

As announced by OPM.

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.

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

Event
Code

Event

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

Change Permitted

Time Limits

From Not
Enrolled to
Enrolled

From Self
Only to
Self and
Family

Yes

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

From One
Plan or
Option to
Another

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

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, 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

Event
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

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

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.

Employee or eligible family member becomes eligible for
assistance under Medicaid or a State Children’s Health
Insurance Program (CHIP).

Yes

Within 60 days after the date the
employee or family member
becomes eligible for assistance.

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 (mm/dd/yyyy)

4. Sex

5. Are you married?

6. Home mailing address (including ZIP Code)

M
F
Yes
7. If you are covered by Medicare, 8. Medicare Claim Number
check all that apply.

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

A
B
D
9. Are you covered by insurance other than Medicare?
Yes, indicate in item 10 below.

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

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

11. Email address

12. Preferred telephone number

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

14. Social Security Number 15. Date of birth (mm/dd/yyyy)

16. Sex

17. Relationship code

18. Address (if different from enrollee)

M
F
19. If this family member is covered 20. Medicare Claim Number
by Medicare, check all that apply.

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

A
B
D
21. Is this family member covered by insurance other than Medicare?
Yes, indicate in item 22 below.

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

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

23. Email address (if applicable, enter email address of your spouse or adult child)

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

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

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

28. Sex

29. Relationship code

30. Address (if different from enrollee)

M
F
31. If this family member is covered 32. Medicare Claim Number
by Medicare, check all that apply.

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

A
B
D
33. Is this family member covered by insurance other than Medicare?
Yes, indicate in item 34 below.

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

Other

Name of other insurance: ______________________________________________

Policy Number: _____________________

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

35. Email address (if applicable, enter email address of your spouse or adult child)

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

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

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

40. Sex

41. Relationship code

42. Address (if different from enrollee)

M
F
43. If this family member is covered 44. Medicare Claim Number
by Medicare, check all that apply.

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

A
B
D
45. Is this family member covered by insurance other than Medicare?
Yes, indicate in item 46 below.

46. Indicate the type(s) of other insurance
TRICARE
Other
Name of other insurance: ______________________________________________
Policy Number: _____________________
FEHB An FEHB self and family enrollment covers all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for
item 10 on page 1.
47. Email address (if applicable, enter email address of your spouse or adult child)
48. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)
(Continued on the reverse)
U.S. Office of Personnel Management

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

Standard Form 2809
Revised November 2014
Previous edition is not usable.

Enrollee name: _________________________________________________________

Date of birth: ____________________________

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

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

1. Plan name

2. Enrollment code

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

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 of FEHB

Part G - Suspension of FEHB (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)

Part I -To be completed by agency or retirement system
REMARKS

1. Date received (mm/dd/yyyy)

2. Effective date of action (mm/dd/yyyy)

3. Personnel telephone number

(

)

5. Authorizing official (please print)

4. Name and address of agency or retirement system

6. Signature of authorized agency official

7. Payroll office number

8. Payroll office contact (please print)

9. Payroll telephone number

(

)

Standard Form 2809
Reverse of revised November 2014
Previous edition is not usable

File Type	application/pdf
File Title	P:\RSSP\ASB\FORMS\FORMS FOLDER\SF\SF 2809\Ventura\November 2014\SF 2809.vp
Author	PRPINKNE
File Modified	2014-08-18
File Created	2014-02-03