Health Benefits Election Form

OMB 3206-0160

The SF 2809 is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for benefits under the Spouse Equity Act of 1984 (P.L. 98-615), and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage (TCC) provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Services Program. The Privacy Act Statement has been revised due to a general systematic review by our Chief Privacy Officer.

The latest form for Health Benefits Election Form expires 2022-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SF 2809 Health Benefits Election Form Form and Instruction
SF2809_OMB_Supporting_Statement_2022_0505.docx Supporting Statement A
SF2809_Published30DayFRN_2022_05_03.pdf Supplementary Document
OMB_Justification_SF 2809_2022_03_07.docx Justification for No Material/Nonsubstantive Change
E8-5659.pdf Supplementary Document
Citations for SF 2809.pdf Supplementary Document
SF2809_60DayFRN_2021_11_01.pdf Supplementary Document
Health Benefits Election Form Form and Instruction

All Historical Document Collections

202204-3206-001 Approved with change	Revision of a currently approved collection	2022-05-05
202203-3206-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-03-07
201903-3206-002 Approved with change	Revision of a currently approved collection	2019-03-29
201510-3206-008 Approved with change	Revision of a currently approved collection	2015-10-30
201408-3206-004 Approved without change	Revision of a currently approved collection	2014-08-28
201106-3206-005 Approved with change	Revision of a currently approved collection	2011-06-22
200711-3206-003 Approved without change	Extension without change of a currently approved collection	2007-11-09
200406-3206-003 Approved without change	Revision of a currently approved collection	2004-06-30
200207-3206-001 Approved without change	Extension without change of a currently approved collection	2002-07-03
199901-3206-004 Approved without change	Revision of a currently approved collection	1999-01-29
199611-3206-002 Approved without change	Revision of a currently approved collection	1996-11-05
199306-3206-006 Approved without change	Revision of a currently approved collection	1993-06-03
199208-3206-003 Approved with change	No material or nonsubstantive change to a currently approved collection	1992-08-18
199207-3206-001 Approved without change	Revision of a currently approved collection	1992-07-27
199109-3206-004 Approved without change	Revision of a currently approved collection	1991-09-27
198808-3206-001 Approved without change	Revision of a currently approved collection	1988-08-26
198507-3206-005 Approved without change	New collection (Request for a new OMB Control Number)	1985-07-31