Health Benefits Election Form

OPM 2809, Health Benefits Election Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0141 can be found here:

Documents and Forms

Document Name Document Type
Form OPM Form 2809 Health Benefits Election Form Form and Instruction
OPM Form 2809 Health Benefits Election Form OPM2809_2017_05_MarkUp.pdf Form and Instruction
OPM 2809 Health Benefits Election Form OPM2809_2020_07_Revised.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Benefits Election Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR Ch. 1, Part 890.301 thru 307 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OPM Form 2809	Health Benefits Election Form	OPM2809_2017_05_MarkUp.pdf		Yes	No	Fillable Printable
Form and Instruction	OPM 2809	Health Benefits Election Form	OPM2809_2020_07_Revised.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 73 FR 15013

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30,000	0	30,000
Annual IC Time Burden (Hours)	11,667	0	11,667
Annual IC Cost Burden (Dollars)	313,500	313,500	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.