Health Benefits Registration Form Federal Employees Health Benefits Program
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1Form Approved:
HEALTH BENEFITS REGISTRATION FORM
OMB No. 3206-0160
Federal Employees Health Benefits Program
.
Complete Part A and Parts B, C,
.
.
Type or Print Firmly
D, and E as applicable
Do not separate the copies. Your employing office will certify the completed form and return your copy to you.
.
Sign and date in Part F.
PART A -
Fill in this part.
1. Name (Last, first, middle initial)
2. Social Security number
3. Date of birth (mo., day, yr.)
4. Your home mailing address (include ZIP code)
5. Sex
6. Are you now married?
Yes
No
Male
Female
7. Daytime telephone number
PART B -
Fill in this part if you wish to enroll or change your enrollment in the Federal Employees Health Benefits (FEHB) Program.
1. I elect to enroll in a health benefits plan as shown below. (Copy the information requested below from front cover of brochure of the plan you select.)
Name of plan
Enrollment
code
2b. ZIP code
2c. Date of birth
2d. Sex
2e. Relationship
2f. Social Security number
2a. Name of family members
(mo., day, yr.)
"code"
(See Instructions)
3a. Do you, your spouse or any other eligible family members have any group health insurance coverage other than
the FEHB plan in which you are now enrolling or enrolled?
No
Yes
Complete 3b
Medicare
Indicate part(s)
3b. Type of insurance
CHAMPUS
Other private (specify name)
No
Yes
PART C -
Fill in this part , as well as PART B, to change enrollment.
1. Present Plan name
2. Present Plan
3. Number of event that
4. Date of event that permits
permits change
change
(mo., day, yr.)
enrollment
(See Table of
code
Permissible Changes)
PART D -
PART E -
Employees Only
CANCELLATION
Place an "X" in the box below if you wish NOT TO ENROLL in the FEHB
Place an "X" in the box below if you wish to CANCEL
Present Plan enrollment code
Program.
your enrollment.
I elect to cancel my enrollment in the Federal
I elect not to enroll in the Federal Employees Health Benefits Program.
Employees Health Benefits Program. I am currently
enrolled under the code shown at the right.
My signature in Part F certifies that I have read the information in the
My signature in Part F certifies that I have read and understand the
instructions regarding cancellation of enrollment and that I understand that I
information regarding this election.
must meet the 5-year requirement to qualify for FEHB coverage after
retirement.
PART F -
Fill in this part.
WARNING: Any intentionally false statement in this application or willful mis
epresentation relative thereto is a violation of the law punishable by a
r
fine of not more than $10,000 or imprisonment of not more than 5 years, or bot
. (18 U.S.C. 1001.)
h
1. Your Signature (Do not print)
2. Date
PART G -
To be completed by agency
2. Date received in employing office 3. Effective date of action
4. SF 2811 report number
1. Name and address of employing office
5. Payroll office number
6. Payroll contact and telephone number
7. Personnel contact and telephone number
8. Signature of authorized agency official
9. Phone number
Remarks
Office of Personnel Management
Previous editions
Standard Form 2809
FPM Supplement 890-1
are not usable
Rev. August 1992
Clear Form
This form was electronically produced by National Production Services Staff
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