Health Benefits Election Form

OMB 3206-0160

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.

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All Historical Document Collections
Revision of a currently approved collection 2022-05-05
Approved without change
No material or nonsubstantive change to a currently approved collection 2022-03-07
Approved with change
Revision of a currently approved collection 2019-03-29
Approved with change
Revision of a currently approved collection 2015-10-30
Approved without change
Revision of a currently approved collection 2014-08-28
Approved with change
Revision of a currently approved collection 2011-06-22
Approved without change
Extension without change of a currently approved collection 2007-11-09
Approved without change
Revision of a currently approved collection 2004-06-30
Approved without change
Extension without change of a currently approved collection 2002-07-03
Approved without change
Revision of a currently approved collection 1999-01-29
Approved without change
Revision of a currently approved collection 1996-11-05
Approved without change
Revision of a currently approved collection 1993-06-03
Approved with change
No material or nonsubstantive change to a currently approved collection 1992-08-18
Approved without change
Revision of a currently approved collection 1992-07-27
Approved without change
Revision of a currently approved collection 1991-09-27
Approved without change
Revision of a currently approved collection 1988-08-26
Approved without change
New collection (Request for a new OMB Control Number) 1985-07-31

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