Standard Form 2810 - Notice Of Change In Health Benefits Enrollment
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4Released 6/13/99.
FEHB
Notice of Change in Health Benefits Enrollment
Federal Employees
Health Benefits Program
Part A - Identifying Information
1. Name (Last, first, middle initial)
2. Date of birth
3. Social security number
4. Home address (including ZIP Code)
5. Payroll office number
6. Enrollment code number
7. SF 2811 Report number
8.
Date this action becomes
effective
Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.
Keep this form for your records.
Part B - Termination
Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.
Important Notice:
You have the right to covert to an individual (nongroup) contract with the carrier of your plan. You also
See Part B - Termination on the back of this form for
may have the right to temporarily continue your group coverage.
information about 31-day extension of coverage, conversion, and temporary continuation of coverage.
If termination is due to death of enrollee enter date of death
Date of death (mo, dy, yr)
Part C - Transfer In
Part D - Reinstatement
The new Payroll Office (or Retirement System) shown in
Your enrollment has been reinstated effective on the date
Part H below has accepted transfer of this enrollment and will
in Part A, item 8, above.
continue it.
Part E - Change in Name of Enrollee
Part F - Change in Enrollment-Survivor Annuitant
The name under which this enrollment is carried has been
Your enrollment has been changed from family coverage to
changed to:
self only. Your plan will send you a new identification card.
Your new enrollment code number is shown below
Name
Date of birth
(Note: This item is completed by Retirement Systems only.)
Address
(including ZIP Code) if different from Part A, item 4, above.
New Enrollment Code Number
Part G - Remarks
Part H - Date of Notice
Note: Instructions for Employing Offices are on the back of Copy 4 of this form.
Name and address of agency (including ZIP Code)
Personnel contact and telephone number
Payroll contact and telephone number
Signature of authorized agency official
Date
U.S. Office of Personnel Management
Standard Form 2810
CSRS/FERS Handbook for Personnel and Payroll Offices
NSN 7540-01-232-1234
2810-104
Previous edition is usable
Revised June 1996
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