Form Approved:

Health Benefits Election Form OMB No. 3206-0160

Uses for Standard Form (SF) 2809 Item 9. If you are covered by other health insurance, either in your
Use this form to: name or under a family member’s policy, check yes and
complete item 10.
• Switch designated eligible family member; or
Item 10. Provide the information requested on any other health
 Enroll or reenroll in the FEHB Program; or insurance that covers you. An FEHB Self Plus One
 Elect not to enroll in the FEHB Program (employees only); or enrollment covers the enrollee and one eligible family
member designated by the enrollee. An FEHB Self and
 Change your FEHB enrollment; or Family enrollment covers the enrollee and all eligible family
members. If you or a family member is covered under
 Cancel your FEHB enrollment; or another FEHB enrollment, check the FEHB box and
 Suspend your FEHB enrollment (annuitants or former spouses stop. Contact your Human Resources office or retirement
only). system immediately as this is a dual coverage situation.
Some examples of how this could occur are:
Who May Use SF 2809  You are enrolling in an FEHB Self Only plan while
1. Employees eligible to enroll in or currently enrolled in the FEHB your spouse has either an FEHB Self Plus One or Self
Program. Employees automatically participate in premium and Family plan, in which you are already covered.
conversion unless they waive it, see page 6.  You are enrolling in an FEHB Self Plus One plan while
2. Annuitants in retirement systems other than the Civil Service you are also covered under your spouse’s FEHB Self
Retirement System (CSRS) or Federal Employees Retirement Plus One plan or FEHB Self and Family plan.
System (FERS), including individuals receiving monthly  You are enrolling in an FEHB Self and Family plan
compensation from the Office of Workers’ Compensation Programs while your spouse is already enrolled in either a FEHB
(OWCP). Self Only plan, an FEHB Self Plus One plan that covers
you, or an FEHB Self and Family plan that covers you.
Note: Civil Service Retirement System (CSRS) and Federal
Employees Retirement System (FERS) annuitants and former  You are an employee under age 26 and have no eligible
spouses and children of CSRS/FERS annuitants -- Do not use family members. You are enrolling in your own FEHB
this form. Instead, use form OPM 2809, which is available at plan while you are covered under your parent’s FEHB
[Link]/forms/OPM-forms, or call the Retirement Information Self Plus One plan or Self and Family plan.
Office toll-free at 1-888-767-6738.
 You are an annuitant who is reemployed in the Federal
3. Former spouses eligible to enroll in or currently enrolled in the government. You are enrolling in an FEHB plan as an
FEHB Program under the Spouse Equity law or similar statutes. employee while you are covered under your own or a
family member’s FEHB plan.
4. Individuals eligible for Temporary Continuation of Coverage (TCC)
under the FEHB Program, including: No person may be covered under more than one FEHB
enrollment. However, in certain unusual circumstances, your
 Former employees (who separated from service); agency may allow you to enroll in order to:

 Children who lose FEHB coverage; and  Enable an employee under age 26 who is covered under
a parent’s Self Plus One or Self and Family FEHB
 Former spouses who are not eligible for FEHB under item 3 enrollment to enroll in FEHB to cover his or her own
above. spouse and/or child;

 Enable an employee under age 26 who is covered under

Instructions for Completing SF 2809 a parent’s Self Plus One or Self and Family FEHB
Type or Print. We have not provided instructions for enrollment, but lives outside his or her parent’s HMO
those items that have an explanation on the form. service area, to have FEHB coverage;

Part A — Enrollee and Family Member Information  Enable an employee who separates or divorces to enroll
You must complete this part. in FEHB to cover family members who move outside
the HMO service area of the covering FEHB Self Plus
Item 2. See the Privacy Act and Public Burden Statements on page 5. One or Self and Family enrollment.
Item 5. If you are separated but not divorced, you are still married. In these unusual situations, each enrollee must notify his or
Item 7. her plan as to which family members are covered under
If you have Medicare, check which Parts you have, including
which enrollment. See Dual Enrollment information on
prescription drug coverage under Medicare Part D.
page 5.
Item 8. If you have Medicare, enter your Medicare Beneficiary
Identifier (MBI). This number is on your Medicare Card.
1 Standard Form 2809
Previous edition is not usable Revised November 2019
If your enrollment is for Self Plus One or Self and Family, complete the Eligible children include your children born within marriage or adopted
family member information as appropriate. (If you need extra space for children; stepchildren; recognized natural children; or foster children
additional family members, list them on a separate sheet and attach.) who live with you in a regular parent-child relationship.

Important: In order for your Self Plus One FEHB enrollment election to Other relatives (for example, your parents) are not eligible for coverage
be processed, you must complete the family member information for even if they live with you and are dependent upon you.
your designated family member.
If you are a former spouse or survivor annuitant, family members
The instructions for completing items 13 through 24 for your initial eligible for coverage under your Self Plus One or Self and Family
family member also apply to the information you provide for additional enrollment are the natural or adopted children under age 26 of both you
family members. and your former or deceased spouse.
Item 14. Provide the Social Security Number for this family member if
he/she has one. If your family member does not have a Social In some cases, a disabled child age 26 or older is eligible for coverage
Security Number, leave blank; benefits will not be withheld. under your Self Plus One or Self and Family enrollment if you provide
(See Privacy Act Statement on page 5.) adequate medical certification of a mental or physical disability that
existed before his/her 26th birthday and renders the child incapable of
Item 17. Provide the code which indicates the relationship of each self-support.
eligible family member to you.
Note: Your employing office can give you additional details about
Code Family Relationship family member eligibility including any certification or documentation
that may be required for coverage. Contact your employing office for
01 Spouse more information about covering foster child(ren),“Employing office”
19 Child under age 26 means the office of an agency or retirement system that is responsible for
09 Adopted Child under age 26 health benefits actions for an employee, annuitant, former spouse
eligible for coverage under the Spouse Equity provisions, or individual
17 Stepchild under age 26 eligible for TCC.
10 Foster Child under age 26
99 Disabled child age 26 or older who is incapable Survivor Benefits
of self support because of a physical or mental For your surviving family members to continue your FEHB enrollment
disability that began before his/her 26th birthday. after your death, all of the following requirements must be met:

Self Plus One

Item 18. If your family member does not live with you, enter his/her  You must have been enrolled for Self Plus One at the time of your
home address. death; and
 Your designated family member must be entitled to an annuity as
Item 19. If your family member has Medicare, check which Parts
your survivor.
(Part A [Hospital Insurance] and/or Part B [Medical
Note: The only survivor eligible to continue the health benefits enroll-
Insurance]) he/she has, including prescription drug
ment is the designated family member covered under FEHB on the date
coverage under Medicare Part D.
of death as long as that individual is entitled to a survivor annuity. No
Item 20. If your family member has Medicare, enter his/her Medicare other family members are entitled to continue the enrollment even
Beneficiary Identifier (MBI). This number is on his/her though they may be entitled to a survivor annuity.
Medicare Card.
Self and Family
Item 21. If your family member is covered by other group insurance,
such as private, state, or Medicaid, check the box and  You must have been enrolled for Self and Family at the time of your
complete item 22. death; and
 At least one family member must be entitled to an annuity as your
Item 22. Provide the information requested on any other health survivor.
insurance that covers this family member. If your family
Note: All of your survivors who meet the definition of “family member”
member is covered under another FEHB plan, see
can continue their health benefits coverage under your enrollment as
instructions for item 10.
long as any one of them is entitled to a survivor annuity. If the survivor
Item 23. Enter email address, if applicable, for this family member. annuitant is the only eligible family member, the retirement system will
automatically change the enrollment to Self Only.
Item 24. Enter preferred telephone number, if applicable, for this
family member.

Family Members Eligible for Coverage

Unless you are a former spouse or survivor annuitant, family members
eligible for coverage under your Self Plus One enrollment include one
eligible family member (spouse or child under age 26) designated by
you. A Self and Family enrollment includes you and all of your eligible
family members.

2 Standard Form 2809

Revised November 2019
Part B — FEHB Plan You Are Currently Enrolled In
You must complete this part if you are changing, cancelling, or Following each number is a letter, which identifies a specific Qualifying
suspending your enrollment. Life Event (QLE); for example, the event code “1A” refers to the initial
opportunity to enroll for an employee who elected to participate in
Item 1. Enter the name of the plan you are enrolled in from the front premium conversion.
cover of the plan brochure.
Item 2. Enter the date of the QLE using numbers to show month, day,
Item 2. Enter your current enrollment code from your plan ID card. and complete year; e.g., 06/30/2011. If you are electing to
enroll, enter the date you became eligible to enroll (for
Part C — FEHB Plan You Are Enrolling In or example, the date your appointment began). If you are
Changing To making an open season enrollment or change, enter the date
on which the open season begins.
Complete this part to enroll or change your enrollment in the FEHB
Program.
Item 1. Enter the name of the plan you are enrolling in or changing Part E — Election NOT to Enroll
to. The plan name is on the front cover of the brochure of the Place an “X” in the box only if you are an employee and you do NOT
plan you want to be enrolled in. wish to enroll in the FEHB Program. Be sure to read the information
titled Employees Who Elect Not to Enroll or Who Cancel Their
Item 2. Enter the enrollment code of the plan you are enrolling in or Enrollment.
changing to. The enrollment code is on the front cover of the
brochure of the plan you want to be enrolled in, and shows
the plan and option you are electing and whether you are
Part F — Cancellation of FEHB
enrolling for Self Only, Self Plus One, or Self and Family. Place an “X” in the box only if you wish to cancel your FEHB
enrollment. Also enter your current plan name and enrollment code in
Part B. Be sure to read the information titled Employees Who Elect Not
To enroll in a Health Maintenance Organization (HMO), you must live to Enroll or Who Cancel Their Enrollment.
(or in some cases work) in a geographic area specified by the carrier.
Note For Parts E and F. If you are Electing Not to Enroll or
To enroll in an employee organization plan, you must be or become a Cancelling your enrollment because you are covered as a spouse or
member of the plan’s sponsoring organization, as specified by the child under another FEHB enrollment, your agency must enter the
carrier. enrollee’s name, Social Security number, and FEHB enrollment code
in REMARKS.
Your signature in Part H authorizes deductions from your salary,
annuity, or compensation to cover your cost of the enrollment you elect Cancellation of Enrollment
in this item, unless you are required to make direct payments to the Employees participating in premium conversion may cancel their FEHB
employing office. enrollment only during the open season or when they experience a
Qualifying Life Event. Employees who waived participation in premium
Part D — Event That Permits You To Enroll, Change, conversion, annuitants, former spouses, and individuals enrolled under
Or Cancel TCC may cancel their enrollment at any time. However, if you cancel,
neither you nor any family member covered by your enrollment are
Item 1. Enter the event code that permits you to enroll, change, or entitled to a 31-day temporary extension of coverage, or to convert to
cancel based on a Qualifying Life Event (QLE) from the an individual, nongroup policy. Moreover, family members who lose
Table of Permissible Changes in Enrollment that applies to coverage because of your cancellation are not eligible for TCC. Be sure
you. to read the additional information below about cancelling your FEHB
enrollment.
Explanation of Table of Permissible Changes in Enrollment
Employees Who Elect Not to Enroll (Part E) or Who Cancel
The tables on pages 6 through 16 illustrate when: an employee who
participates in premium conversion; annuitant; former spouse; person Their Enrollment (Part F)
eligible for TCC; or employee who waived participation in premium To be eligible for an FEHB enrollment after you retire, you must retire:
conversion may enroll or change enrollment. The tables show those  Under a retirement system for Federal civilian employees, and
permissible events that are found in the regulations at 5 CFR Parts 890
and 892.  On an immediate annuity.

The tables have been organized by enrollee category. Each category is In addition, you must be currently enrolled in a plan under the FEHB
designated by a number, which identifies the enrollee group, as follows: Program and must have been enrolled (or covered as a family member)
in a plan under the Program for:
1. Employees who participate in premium conversion
 The 5 years of service immediately before retirement (i.e.,
2. Annuitants (other than CSRS/FERS annuitants), including commencing date of annuity entitlement), or
individuals receiving monthly compensation from the Office of
Workers’ Compensation Programs  If fewer than 5 years, all service since your first opportunity to
enroll. (Generally, your first opportunity to enroll is within 60 days
3. Former spouses eligible for coverage under the Spouse Equity after your first appointment [in your Federal career] to a position
provision of FEHB law under which you are eligible to enroll under conditions that permit a
Government contribution toward the enrollment.)
4. TCC enrollees
If you do not enroll at your first opportunity or if you cancel your
5. Employees who waived participation in premium conversion enrollment, you may later enroll or reenroll only under the circumstances
3
Standard Form 2809 Revised November 2019
explained in the table beginning on page 6. Some employees delay their Note 1: If you become covered by a regular enrollment in the FEHB
enrollment or reenrollment until they are nearing 5 years before Program, either in your own right or under the enrollment of someone
retirement in order to qualify for FEHB coverage as a retiree; however, else, your TCC enrollment is suspended. You will need to send
there is always the risk that they will retire earlier than expected and not documentation of the new enrollment to the employing office
be able to meet the 5-year requirement for continuing FEHB coverage maintaining your TCC enrollment so that they can stop the TCC
into retirement. When you elect not to enroll or cancel your enrollment enrollment. If your new FEHB coverage stops before the TCC
you are voluntarily accepting this risk. An alternative would be to enrollment would have expired, the TCC enrollment can be reinstated
enroll in or change to a lower cost plan so that you meet the for the remainder of the original eligibility period (18 months for
requirements for continuation of your FEHB enrollment after retirement. separated employees or 36 months for eligible family members who lose
coverage).
Note for temporary [under 5 U.S.C. 8906a] employees eligible for
FEHB without a Government contribution: Your decision not to enroll Note 2: Former spouses (Spouse Equity) and TCC enrollees who fail to
or to cancel your enrollment will not affect your future eligibility to pay their premiums within specified timeframes are considered to have
continue FEHB enrollment after retirement. voluntarily cancelled their enrollment.

Annuitants Who Cancel Their Enrollment Part G — Suspension of FEHB

CSRS and FERS annuitants and their eligible family members should CSRS and FERS annuitants and their eligible family members should
not use this form but use form RI 79-9, Health Benefits not use this form but use form RI 79-9, Health Benefits
Cancellation/Suspension Confirmation, which is available at Cancellation/Suspension Confirmation, which is available at
[Link]/forms/Retirement-and-Insurance-Forms, or call [Link]/forms/Retirement-and-Insurance-Forms, or call
1-888-767-6738. 1-888-767-6738.

Generally, you cannot reenroll as an annuitant unless you are Place an “X” in the box only if you are an annuitant or former spouse
continuously covered as a family member under another person’s and wish to suspend your FEHB enrollment. Also enter your current plan
enrollment in the FEHB Program during the period between your name and enrollment code in Part B.
cancellation and reenrollment. Your employing office or retirement
system can advise you on events that allow eligible annuitants to You may suspend your FEHB enrollment because you are enrolling in
reenroll. If you cancel your enrollment because you are covered under one of the following programs:
another FEHB enrollment, you can reenroll from 31 days before through
 A Medicare Advantage plan or Medicare HMO,
60 days after you lose that coverage under the other enrollment.
 Medicaid or similar State-sponsored program of medical assistance
If you cancel your enrollment for any other reason, you cannot later for the needy,
reenroll, and you and any family members covered by your enrollment
are not entitled to a 31-day temporary extension of coverage or to  TRICARE (including Uniformed Services Family Health Plan or
TRICARE for Life),
convert to an individual policy.
 CHAMPVA, or
Former Spouses (Spouse Equity) Who Cancel Their Enrollment
 Peace Corps.
Generally, if you cancel your enrollment in the FEHB Program, you
cannot reenroll as a former spouse. However, if you cancel the
You can reenroll in the FEHB Program if your other coverage ends.
enrollment because you become covered under FEHB as a new spouse
If your coverage ends involuntarily, you can reenroll from 31 days
or employee, your eligibility for FEHB coverage under the Spouse
before your other coverage ends through 60 days after your other
Equity provisions continues. You may reenroll as a former spouse from
coverage ends. If your coverage ends voluntarily because you disenroll,
31 days before through 60 days after you lose coverage under the other
you can reenroll during the next open season.
FEHB enrollment.

You must submit documentation of eligibility for coverage under the

If you cancel your enrollment for any other reason, you cannot later
non-FEHB Program to the office that maintains your enrollment. That
reenroll, and you and any family members covered by your enrollment
office must enter in REMARKS the reason for your suspension.
are not entitled to a 31-day temporary extension of coverage or to
convert to an individual policy.
Part H — Signature
Temporary Continuation of Coverage (TCC) Enrollees Who Your agency, retirement system, or office maintaining your enrollment
cannot process your request unless you complete this part.
Cancel Their Enrollment
If you cancel your TCC enrollment, you cannot reenroll. Your family
members who lose coverage because of your cancellation cannot enroll If you are registering for someone else under a written authorization
for TCC in their own right nor can they convert to a nongroup policy. from him or her to do so, sign your name in Part H and attach the written
Family members who are Federal employees or annuitants may enroll in authorization.
the FEHB Program when you cancel your coverage if they are eligible
for FEHB coverage in their own right. If you are registering for a former spouse eligible for coverage under the
Spouse Equity provisions or for an individual eligible for TCC as his
or her court-appointed guardian, sign your name in Part H and attach
evidence of your court-appointed guardianship.

4 Standard Form 2809

Revised November 2019
Part I - Agency or Retirement System Information  For the eligible former spouse of an enrollee, the enrollee or the
and Remarks former spouse must notify the employing office within 60 days after
Leave this section blank as it is for agency or retirement system use only. the former spouse’s change in status; e.g., the date of the divorce.

Electronic Enrollments An individual eligible for TCC who wants to continue FEHB coverage
Many agencies use automated systems that allow their employees to may choose any plan, option, and type of enrollment for which he or she
make changes using a touch-tone telephone, or a computer instead of is eligible. The time limit for a former employee, child, or former spouse
a form. This may be Employee Express or another automated system. to enroll with the employing office is within 60 days after the Qualifying
If you are not sure whether the electronic enrollment option is available Life Event, or receiving notice of eligibility, whichever is later.
to you, contact your employing office.
Effective Dates
Dual Enrollment Except for open season, most enrollments and changes of enrollment are
No person (enrollee or family member) is entitled to receive benefits effective on the first day of the pay period after the employing office
under more than one enrollment in the FEHB Program. Normally, you receives this form and that follows a pay period during any part of which
are not eligible to enroll if you are covered as a family member under the employee is in pay status. Your employing office can give you the
someone else’s enrollment in the Program. However, such dual specific date on which your enrollment or enrollment change will take
enrollments may be permitted under certain circumstances in order to: effect.

Note 1: If you are changing your FEHB enrollment from Self Plus One
 Protect the interests of children who otherwise would lose coverage
or Self and Family to Self Only so that your spouse can enroll for Self
as family members, or
Only, you should coordinate the effective date of your spouse’s
 Enable an employee who is under age 26 and covered under a enrollment with the effective date of your enrollment change to avoid a
parent’s enrollment and marries or becomes the parent of a child to gap in your spouse’s coverage.
enroll for Self Plus One or Self and Family coverage.
Note 2: If you are cancelling your FEHB enrollment and intend to be
Each enrollee must notify his or her plan of the names of the persons to covered under someone else’s enrollment at the time you cancel, you
be covered under his or her enrollment who are not covered under the should coordinate the effective date of your cancellation with the
other enrollment. See instructions for item 10 for more information. effective date of your new coverage to avoid a gap in your coverage.

Temporary Continuation of Coverage (TCC) Agency Distribution of SF 2809

The employing office must notify a former employee of his or her Agencies must distribute one copy of the completed SF 2809 to each of
eligibility for TCC. The enrollee, child, former spouse, or their the following, as appropriate:
representative must notify the employing office when a child or former
 Official Personnel Folder
spouse becomes eligible.
 New Carrier
 For the eligible child of an enrollee, the enrollee must notify the  Old Carrier
employing office within 60 days after the qualifying event occurs;
e.g., child reaches age 26.  Payroll Office
 Enrollee

Privacy Act Statement

Pursuant to 5 U.S.C. § 552a (e)(3), this Privacy Act Statement explains why OPM is requesting the information on this form. Authority: OPM is authorized to collect the
information requested on this form pursuant to Title 5, U.S.C. Chapter 89 and Title 5 of the Code of Federal Regulations, Part 890 pertaining to enrollment in the Federal
Employees Health Benefits (FEHB) Program. OPM is authorized to collect your Social Security Number (SSN) by Executive Order 9397 (November 22, 1943), as amended by
Executive Order 13478 (November 18, 2008). Purpose: The principal use of this information will be to share it with the health insurance carrier you select so that it may (1)
identify your enrollment in the plan, (2) verify your and/or your family’s eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment
of claims with other insurance carriers with whom you might also make a claim for payment of benefits. Your SSN and the SSNs of your covered family members may be used
as individual identifiers in the FEHB Program. Routine Uses: The information you provide on this form may also be disclosed externally to other Federal agencies or
Congressional offices which may have a need to know it in connection with your application for a job, license, grant, or other benefit. It may also be shared and is subject to
verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or Social Security administrative
agencies to determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under the FEHB program. In
addition, to the extent this information indicates a possible violation of civil or criminal law, it may be shared and verified with an appropriate Federal, state, or local law
enforcement agency. A list of routine uses associated with this form can be found in the Privacy Act System of Records Notice (SORN), OPM/CENTRAL 1 Civil Service
Retirement and Insurance, available at [Link]/privacy. Consequences of Failure to Provide Information: Providing this information is voluntary, however failure to
provide it may result in a delay in processing your enrollment. In addition, failure to furnish your SSN and/or Medicare Beneficiary Identifier may result in the OPM’s inability
to ensure the prompt payment of your and/or your family members’ claims for health benefits services or supplies, proper coordination with Medicare, or proper health
insurance status reporting to the IRS.

Public Burden Statement

We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form.
Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management,
Retirement Services Publications Team, (3206-0160), Washington, D.C. 20415-0001. The OMB number, 3206-0160 is currently valid. OPM may not collect this information,
and you are not required to respond, unless this number is displayed.

5
Standard Form 2809
Revised November 2019
 Federal Employees Receiving Premium Conversion Tax Benefits
Table of Permissible Changes in FEHB Enrollment and Premium Conversion Election
Premium Conversion allows employees who are eligible for FEHB the opportunity to pay for their share of FEHB premiums with pre-tax dollars. Premium conversion
plans are governed by Section 125 of the Internal Revenue Code, and IRS rules govern when a participant may change his or her election outside of the annual open
season. All employees who enroll in the FEHB Program automatically receive premium conversion tax benefits, unless they waive participation. When an
employee experiences a Qualifying Life Event (QLE) as described below, certain changes to the employee’s FEHB coverage (including change to Self Only and
cancellation) and premium conversion election may be permitted, so long as they are because of and consistent with the QLE’s. For more information about
premium conversion, please visit [Link]/healthcare-insurance/healthcare.

Qualifying Life Events (QLE’s) that Change that May Be Permitted Premium Time Limits in
May Permit Change in FEHB Conversion Change which Change
Enrollment, Designated Family that May Be May Be
Member or Premium Conversion Permitted Permitted
Election

Event Event From Not From Self From One Cancel or Switch Participate Waive When You Must
Code Enrolled To Only to Self Plan or Change to Designated File Health Benefits
Enrolled Plus One or Option to Self Plus Family Election Form With
Self and Another One or Self Member Your Employing
Family Only Office

1 Employee electing to receive or receiving premium conversion tax benefits

1A Initial opportunity to enroll, for Yes N/A N/A N/A N/A Automatic Yes Within 60 days
example: Unless after becoming
Waived eligible
• New employee
• Change from excluded
position
• Temporary employee who
completes 1 year of service
and is eligible to enroll under
5 USC 8906a

1B Open Season Yes Yes Yes Yes Yes Yes Yes As announced by
OPM
1C Change in family status that Yes Yes Yes Yes1 Yes Yes Yes Within 60 days after
results in increase or decrease in Employees Employees Employees change in family
number of eligible family may enroll may enroll may enroll status
members, for example: or change or change or change
• Marriage, divorce, annulment beginning beginning beginning
• Birth, adoption, acquiring 31 days 31 days 31 days
foster child or stepchild, before the before the before the
issuance of court order event. event. event.
requiring employee to provide
coverage for child
• Last child loses coverage, for
example, child reaches age
26, disabled child becomes
capable of self-support, child
acquires other coverage by
court order
• Death of spouse or eligible
family member

1D Any change in employee’s Yes N/A N/A N/A No Automatic Yes Within 60 days
employment status that could Unless after employment
result in entitlement to coverage, Waived status change
for example:
• Reemployment after a break
in service of more than 3 days
• Return to pay status from
nonpay status, or return to
receiving pay sufficient to
cover premium withholdings,
if coverage terminated (If
coverage did not terminate,
see 1G.)

6
 Qualifying Life Events (QLE’s) that Change that May Be Permitted Premium Time Limits in
May Permit Change in FEHB Conversion Change which Change
Enrollment, Designated Family that May Be May Be
Member or Premium Conversion Permitted Permitted
Election

Event Event From Not From Self From One Cancel or Switch Participate Waive When You Must
Code Enrolled To Only to Self Plan or Change to Designated File Health Benefits
Enrolled Plus One or Option to Self Plus Family Election Form With
Self and Another One or Self Member Your Employing
Family Only Office

1E Any change in employee’s Yes Yes Yes Yes No Yes Yes Within 60 days
employment status that could after employment
affect cost of insurance, including: status change
• Change from temporary
appointment with eligibility
for coverage under 5 USC
8906a to appointment that
permits receipt of government
contribution
• Change from full time to part-
time career or the reverse
1F Employee restored to civilian Yes Yes Yes Yes No Yes Yes Within 60 days after
position after serving in uniformed return to civilian
services2. position

1G Employee, spouse or eligible No No No Yes No Yes Yes Within 60 days

family member: after employment
• Begins nonpay status or status change
insufficient pay3 or
• Ends nonpay status or
insufficient pay if coverage
continued
• (If employee’s coverage
terminated, see 1D.)
• (If spouse’s or eligible family
member’s coverage
terminated, see 1M.)

1H Salary of temporary employee N/A No Yes Yes No Yes Yes Within 60 days
insufficient to make withholdings after receiving
for plan in which enrolled. notice from
employing office

1I Employee (or covered family N/A Yes Yes N/A Yes No No Upon notifying
member) enrolled in FEHB health employing office of
maintenance organization (HMO) move
(see 1M) (see 1M) (see
moves or becomes employed
1M)
outside the geographic area from
which the FEHB carrier accepts
enrollments or, if already outside
the area, moves further from this
area.4
1J Transfer from post of duty within Yes Yes Yes Yes Yes Yes Yes Within 60 days after
a State of the United States or the . Employees Employees Employees arriving at new post
District of Columbia to post of may enroll may enroll may enroll
duty outside a State of the United or change or change or change
States or District of Columbia, or beginning beginning beginning
reverse. 31 days 31 days 31 days
before before before
leaving the leaving the leaving the
old post of old post of old post of
duty. duty. duty.
1K Separation from Federal Yes Yes Yes N/A No N/A N/A During employee’s
employment when the employee or final pay period
employee’s spouse is pregnant.

7
 Qualifying Life Events (QLE’s) that Change that May Be Permitted Premium Time Limits in
May Permit Change in FEHB Conversion Change which Change
Enrollment, Designated Family that May Be May Be
Member or Premium Conversion Permitted Permitted
Election

Event Event From Not From Self From One Cancel or Switch Participate Waive When You Must
Code Enrolled To Only to Self Plan or Change to Designated File Health Benefits
Enrolled Plus One or Option to Self Plus Family Election Form With
Self and Another One or Self Member Your Employing
Family Only Office

1L Employee becomes entitled to No No Yes N/A No N/A N/A Any time beginning
Medicare and wants to change to on the 30th day
another plan or option.5 before becoming
(Changes (see 1P) (see 1P) (see
eligible for
may be 1P)
Medicare
made
only
once.)
1M Employee or eligible family Yes Yes Yes Yes Yes Yes Yes Within 60 days after
member loses coverage under loss of coverage
Employees Employees Employees
FEHB or another group insurance
may enroll may enroll may enroll
plan including the following:
or change or change or change
• Loss of coverage under beginning beginning beginning
another FEHB enrollment due 31 days 31 days 31 days
to termination, cancellation, or before the before the before the
change to Self Plus One or event. event. event.
Self Only of the covering
enrollment
• Loss of coverage due to
termination of membership in
employee organization
sponsoring the FEHB plan6
• Loss of coverage under
another federally-sponsored
health benefits program,
including: TRICARE,
Medicare, Indian Health
Service
• Loss of coverage under
Medicaid or similar State-
sponsored program of medical
assistance for the needy
• Loss of coverage under a non-
Federal health plan, including
foreign, state or local
government, private sector
• Loss of coverage due to
change in worksite or
residence (Employees in an
FEHB HMO, also see 1I.)

1N Loss of coverage under a non Yes Yes Yes Yes Yes Yes Yes From 31 days
Federal group health plan because before the
an employee moves out of the employee leaves
commuting area to accept another the commuting
position and the employee’s non- area to 180 days
Federally employed spouse after arriving in the
terminates employment to new commuting
accompany the employee. area
1O Employee or eligible family Yes Yes Yes Yes Yes Yes Yes During open season,
member loses coverage due to unless OPM sets a
discontinuance in whole or part of different time
FEHB plan.7

8
 Qualifying Life Events (QLE’s) that Change that May Be Permitted Premium Time Limits in
May Permit Change in FEHB Conversion Change which Change
Enrollment, Designated Family that May Be May Be
Member or Premium Conversion Permitted Permitted
Election

Event Event From Not From Self From One Cancel or Switch Participate Waive When You Must
Code Enrolled To Only to Self Plan or Change to Designated File Health Benefits
Enrolled Plus One or Option to Self Plus Family Election Form With
Self and Another One or Self Member Your Employing
Family Only Office

1P Enrolled employee or eligible No No No Yes9 Yes Yes Yes Within 60 days after
family member gains coverage QLE
under FEHB or another group
insurance plan, including the
following:
• Medicare (Employees who
become eligible for Medicare
and want to change plans or
options, see 1L.)
• TRICARE for Life, due to
enrollment in Medicare.
• TRICARE due to change in
employment status, including:
(1) entry into active military
service, (2) retirement from
reserve military service under
Chapter 67, title 10.
• Health insurance acquired due
to change of worksite or
residence that affects
eligibility for coverage
• Health insurance acquired due
to spouse’s or eligible family
member’s change in
employment status (includes
state, local, or foreign
government or private sector
employment).8

1Q Change in spouse’s or eligible No No No Yes9 Yes Yes Yes Within 60 days after
family member’s coverage options QLE
under a health plan, for example:
• Employer starts or stops
offering a different type of
coverage (If no other
coverage is available, also see
1M.)
• Change in cost of coverage
• HMO adds a geographic
service area that now makes
spouse eligible to enroll in
that HMO
• HMO removes a geographic
area that makes spouse
ineligible for coverage under
that HMO, but other plans or
options are available (If no
other coverage is available,
see 1M)

1R Employee or eligible family Yes Yes Yes Yes9 Yes Yes Yes Within 60 days
member becomes eligible for after the date the
assistance under Medicaid or a employee or
State Children’s Health Insurance family member
Program (CHIP). becomes eligible
for assistance.

9
(If you are a United States Postal Service employee, these rules may be different. Consult your employing office or information provided by your agency.)

1. Employees may change to Self Only outside of open season only if the QLE caused the enrollee to be the last eligible family member under the FEHB enrollment.
Employees may change to Self Plus One outside ofOpen Season only if the QLE causes only one family member to be eligible under the FEHB enrollment.
Employees may cancel enrollment outside of open season only if the QLE caused the enrollee and all eligible family members to acquire other health insurance
coverage.

2. Employees who enter active military service are given the opportunity to terminate coverage. Termination for this reason does not count against the employee for
purposes of meeting the requirements for continuing coverage after retirement. Additional information on the FEHB coverage of employees who return from
active military service is available in the Frequently Asked Questions section of the FEHB website at [Link]/healthcare-insurance/healthcare.

3. Employees who begin nonpay status or insufficient pay must be given an opportunity to elect to continue or terminate coverage. A termination differs from a
cancellation as it allows conversion to nongroup coverage and does not count against the employee for purposes of meeting the requirements for continuing
coverage after retirement.

4. This code reflects the FEHB regulation that gives employees enrolled in an FEHB HMO who change from Self Only or Self Plus One to Self and Family or from
one plan or option to another a different timeframe than that allowed under 1M. For change to Self-Only or Self Plus One, cancellation, or change in premium
conversion status, see 1M.

5. This code reflects the FEHB regulation that gives employees enrolled in FEHB a one-time opportunity to change plans or options under a different timeframe than
that allowed by 1P. For change to Self Only or Self Plus One, cancellation, or change in premium conversion status, see 1P.

6. If employee’s membership terminates (e.g., for failure to pay membership dues), the employee organization will notify the agency to terminate the enrollment.

7. Employee’s failure to select another FEHB plan is deemed a cancellation for purposes of meeting the requirements for continuing coverage after retirement.

8. Under IRS rules, this includes start/stop of employment or nonpay status, strike or lockout, and change in worksite.

9. Employees may change to Self Only outside of Open Season only if the QLE caused all eligible family members to acquire other health insurance coverage.
Employees may change to Self Plus One outside of Open Season only if the QLE caused all but one eligible family member to acquire other health insurance
coverage. Employees may cancel enrollment outside of Open Season only if the QLE caused the enrollee and all eligible family members to acquire other health
insurance coverage.

10
 Tables of Permissible Changes in FEHB Enrollment for Individuals Who Are Not Participating
in Premium Conversion
Enrollment May Be Cancelled or Changed from Self and Family to Self Plus One or Self Only or from Self Plus
One to Self Only at Any Time

QLE’s That Permit

Change that May Be Permitted Time Limits
Enrollment or Change

From Self From

Switch
From Not Only to Self One When You Must File Health
Event Designated
Event Enrolled to Plus One or Plan or Benefits Election Form With
Code Family
Enrolled Self Option Your Employing Office
Member
and Family to
Another

2 Annuitant (Includes Compensationers)

Note for enrolled survivor annuitants: A change in family status based on additional family members can only occur if the additional
eligible family members are family members of the deceased employee or annuitant.
2A Open Season No Yes Yes Yes As announced by OPM.
2B Change in family status; for example: marriage, birth or No Yes Yes Yes From 31 days before through 60
death of family member, adoption, or divorce. days after the event.
2C Reenrollment of annuitant who suspended FEHB May Reenroll N/A N/A No From 31 days before through 60
enrollment to enroll in a Medicare Advantage plan, days after involuntary loss of
Medicaid or similar State-sponsored program, or to use coverage.
TRICARE (including Uniformed Services Family Health
Plan and TRICARE for Life), Peace Corps, or
CHAMPVA, and who later involuntarily loses this
coverage under one of these programs.
2D Reenrollment of annuitant who suspended FEHB enroll- May Reenroll N/A N/A No During open season.
ment to enroll in a Medicare Advantage plan, Medicaid,
or similar State-sponsored program, or to use TRICARE
(including Uniformed Services Family Health Plan or
TRICARE for Life), Peace Corps, or CHAMPVA, and
who wants to reenroll in the FEHB Program for any
reason other than an involuntary loss of coverage.
2E Restoration of annuity or compensation (OWCP) Yes N/A N/A No Within 60 days after the retire-
payments, for example: ment system or OWCP mails a
• Disability annuitant who was enrolled in FEHB, and notice of insurance eligibility.
whose annuity terminated due to restoration of earning
capacity or recovery from disability, and whose
annuity is restored;
 Compensationer whose compensation terminated
because of recovery from injury or disease and whose
compensation is restored due to a recurrence of
medical condition;
 Surviving spouse who was covered by FEHB
immediately before survivor annuity terminated
because of remarriage and whose annuity is restored;
 Surviving child who was covered by FEHB
immediately before survivor annuity terminated
because student status ended and whose survivor
annuity is restored;
 Surviving child who was covered by FEHB immedi-
ately before survivor annuity terminated because of
marriage and whose survivor annuity is restored.
2F Annuitant or eligible family member loses FEHB Yes Yes Yes Yes From 31 days before through 60
coverage due to termination, cancellation, or change to days after date of loss of cover-
Self Plus One or Self Only of the covering enrollment. age.

11
 QLE’s That Permit
Change that May Be Permitted Time Limits
Enrollment or Change

From Self From

Switch
From Not Only to Self One When You Must File Health
Event Designated
Event Enrolled to Plus One or Plan or Benefits Election Form With
Code Family
Enrolled Self Option Your Employing Office
Member
and Family to
Another

2G Annuitant or eligible family member loses coverage No Yes Yes Yes From 31 days before through 60
under another group insurance plan, for example: days after loss of coverage.
 Loss of coverage under another federally-sponsored
health benefits program;
 Loss of coverage due to termination of membership in
the employee organization sponsoring the FEHB plan;
 Loss of coverage under Medicaid or similar
State-sponsored program (but see events 2C and 2D);
 Loss of coverage under a non-Federal health plan.
2H Annuitant or eligible family member loses coverage due N/A Yes Yes Yes During open season, unless
to the discontinuance, in whole or part, of an FEHB plan. OPM sets a different time.
2I Annuitant or covered family member in a Health N/A Yes Yes Yes Upon notifying the employing
Maintenance Organization (HMO) moves or becomes office of the move or change of
employed outside the geographic area from which the place of employment.
carrier accepts enrollments, or if already outside this area,
moves or becomes employed further from this area.
2J Employee in an overseas post of duty retires or dies. No Yes Yes Yes Within 60 days after retirement
or death.
2K An enrolled annuitant separates from duty after serving N/A Yes Yes No Within 60 days after separation
31 days or more in a uniformed service. from the uniformed service.
2L On becoming eligible for Medicare. N/A No Yes No At any time beginning on the
30th day before becoming eligi-
(This change may be made only once in a lifetime.) ble for Medicare.
2M Annuitant’s annuity is insufficient to make withholdings N/A No Yes No Employing office will advise
for plan in which enrolled. annuitant of the options.

3 Former Spouse Under The Spouse Equity Provisions

Note: Former spouse may change to Self Plus One or Self and Family only if family members are also eligible family members of the
employee or annuitant.
3A Initial opportunity to enroll. Former spouse must be Yes N/A N/A N/A Generally, must apply within
eligible to enroll under the authority of the Civil Service 60 days after dissolution of
Retirement Spouse Equity Act of 1984 (P.L. 98-615), as marriage. However, if a retiring
amended, the Intelligence Authorization Act of 1986 employee elects to provide a
(P.L. 99-569), or the Foreign Relations Authorization former spouse annuity or
Act, Fiscal Years 1988 and 1989 (P.L. 100-204). insurable interest annuity for
the former spouse, the former
spouse must apply within 60
days after OPM’s notice of
eligibility for FEHB. May enroll
any time after employing office
establishes eligibility.
3B Open Season. No Yes Yes Yes As announced by OPM.
3C Change in family status based on addition of family No Yes Yes Yes From 31 days before through 60
members who are also eligible family members of the days after change in family
employee or annuitant. status.
3D Reenrollment of former spouse who suspended FEHB May reenroll N/A N/A No From 31 days before through 60
enrollment to enroll in a Medicare Advantage plan, days after involuntary loss of
Medicaid, or similar State-sponsored program, or to coverage.
use TRICARE (including Uniformed Services Family
Health Plan or TRICARE for Life), Peace Corps, or
CHAMPVA, and who later involuntarily loses this
coverage under one of these programs.

12
 QLE’s That Permit
Change that May Be Permitted Time Limits
Enrollment or Change

From Self
From Switch
From Not Only to Self When You Must File Health
Event One Designated
Event Enrolled to Plus One or Benefits Election Form With
Code Plan or Family
Enrolled Self Your Employing Office
Option to Member
and Family
Another

3E Reenrollment of former spouse who suspended FEHB May reenroll N/A N/A No During open season.
enrollment to enroll in a Medicare Advantage plan,
Medicaid, or similar State-sponsored program, or to use
TRICARE (including Uniformed Services Family Health
Plan or TRICARE for Life), Peace Corps, or
CHAMPVA, and who wants to reenroll in the FEHB
Program for any reason other than an involuntary loss of
coverage.
3F Former spouse or eligible child loses FEHB coverage Yes Yes Yes Yes From 31 days before through 60
due to termination, cancellation, or change to Self Only days after date of loss of cover-
of the covering enrollment. age.
3G Enrolled former spouse or eligible child loses coverage N/A Yes Yes Yes From 31 days before through 60
under another group insurance plan, for example: days after loss of coverage.
 Loss of coverage under another federally-sponsored
health benefits program;
 Loss of coverage due to termination of membership in
the employee organization sponsoring the FEHB plan;
 Loss of coverage under Medicaid or similar
State-sponsored program (but see 3D and 3E);
 Loss of coverage under a non-Federal health plan.
3H Former spouse or eligible family member loses coverage N/A Yes Yes Yes During open season, unless
due to the discontinuance, in whole or part, of an FEHB OPM sets a different time.
plan.
3I Former spouse or covered family member in a Health N/A Yes Yes Yes Upon notifying the employing
Maintenance Organization (HMO) moves or becomes office of the move or change of
employed outside the geographic area from which the place of employment.
carrier accepts enrollments, or if already outside this
area, moves or becomes employed further from this area.
3J On becoming eligible for Medicare N/A No Yes No At any time beginning the 30th
day before becoming eligible for
Medicare.
(This change may be made only once in a lifetime.)
3K Former spouse’s annuity is insufficient to make FEHB No No Yes No Retirement system will advise
withholdings for plan in which enrolled. former spouse of options.

4 Temporary Continuation of Coverage (TCC) For Eligible Former Employees, Former Spouses, and Children.

Note: Former spouse may change to Self Plus One or Self and Family only if family members are also eligible family members of the
employee or annuitant.
4A Opportunity to enroll for continued coverage under TCC Within 60 days after the qualify-
provisions: ing event, or receiving notice of
 Former employee Yes Yes Yes N/A eligibility, whichever is later.
Yes N/A N/A
 Former spouse
Yes N/A N/A
 Child who ceases to qualify as a family
member
4B Open Season: As announced by OPM.
 Former employee No Yes Yes Yes
No Yes Yes
 Former spouse
No Yes Yes
 Child who ceases to qualify as a family
member
4C Change in family status (except former spouse); for No Yes Yes Yes From 31 days before through 60
example, marriage, birth or death of family member, days after event.
adoption, or divorce.

13
 QLE’s That Permit
Change that May Be Permitted Time Limits
Enrollment or Change

From Self From

Switch
From Not Only to Self One When You Must File Health
Event Designated
Event Enrolled to Plus One or Plan or Benefits Election Form With
Code Family
Enrolled Self and Option Your Employing Office
Member
Family to
Another

4D Change in family status of former spouse, based on No Yes Yes Yes From 31 days before through 60
addition of family members who are eligible family days after event.
members of the employee or annuitant.
4E Reenrollment of a former employee, former spouse, or May reenroll N/A N/A No From 31 days before through 60
child whose TCC enrollment was terminated because of days after the event. Enrollment
other FEHB coverage and who loses the other FEHB is retroactive to the date of the
coverage before the TCC period of eligibility (18 or 36 loss of the other FEHB cover-
months) expires. age.
4F Enrollee or eligible family member loses coverage No Yes Yes Yes From 31 days before through 60
under FEHB or another group insurance plan, for days after loss of coverage.
example:
 Loss of coverage under another FEHB enrollment
due to termination, cancellation, or change to Self
Plus One or Self Only of the covering enrollment
(but see event 4E);
 Loss of coverage under another federally-sponsored
health benefits program;
 Loss of coverage due to termination of membership
in the employee organization sponsoring the FEHB
plan;
 Loss of coverage under Medicaid or similar
State-sponsored program;
 Loss of coverage under a non-Federal health plan.
4G Enrollee or eligible family member loses coverage due N/A Yes Yes Yes During open season, unless
to the discontinuance, in whole or part, of an FEHB OPM sets a different time.
plan.
4H Enrollee or covered family member in a Health N/A Yes Yes No Upon notifying the employing
Maintenance Organization (HMO) moves or becomes office of the move or change of
employed outside the geographic area from which the place of employment.
carrier accepts enrollments, or if already outside this
area, moves or becomes employed further from this
area.
4I On becoming eligible for Medicare. N/A No Yes No At any time beginning on the
30th day before becoming eligi-
ble for Medicare.
(This change may be made only once in a lifetime.)

5 Employees Who Are Not Participating In Premium Conversion

5A Initial opportunity to enroll. Yes N/A N/A N/A Within 60 days after becoming
eligible.
5B Open Season. Yes Yes Yes Yes As announced by OPM.
5C Change in family status; for example: marriage, birth or Yes Yes Yes Yes From 31 days before through 60
death of family member, adoption, or divorce days after event.

14
 QLE’s That Permit
Change that May Be Permitted Time Limits
Enrollment or Change

From Self From

Switch
From Not Only to Self One When You Must File Health
Event Designated
Event Enrolled to Plus One or Plan or Benefits Election Form With
Code Family
Enrolled Self and Option Your Employing Office
Member
Family to
Another

5D Change in employment status, for example: Yes Yes Yes No Within 60 days of employment
 Reemployment after a break in service of more than 3 status change.
days;
 Return to pay status following loss of coverage due to
expiration of 365 days of LWOP status or termination
of coverage during LWOP;
 Return to pay sufficient to make withholdings
after termination of coverage during a period of
insufficient pay;
 Restoration to civilian position after serving in
uniformed services;
 Change from temporary appointment to appointment
that entitles employee receipt of Government
contribution;
 Change to or from part-time career employment.
5E Separation from Federal employment when the Yes Yes Yes No Enrollment or change must
employee or employee’s spouse is pregnant. occur during final pay period of
employment.
5F Transfer from a post of duty within the United States to Yes Yes Yes Yes From 31 days before leaving old
a post of duty outside the United States, or reverse. post through 60 days after arriv-
ing at new post.
5G Employee or eligible family member loses coverage Yes Yes Yes Yes From 31 days before through 60
under FEHB or another group insurance plan, for days after loss of coverage.
example:
 Loss of coverage under another FEHB enrollment
due to termination, cancellation, or change to Self
Plus One or Self Only of the covering enrollment;
 Loss of coverage under another federally-sponsored
health benefits program;
 Loss of coverage due to termination of membership
in the employee organization sponsoring the FEHB
plan;
 Loss of coverage under Medicaid or similar
State-sponsored program;
 Loss of coverage under a non-Federal health plan.
5H Enrollee or eligible family member loses coverage due N/A Yes Yes Yes During open season, unless
to the discontinuance, in whole or part, of an FEHB OPM sets a different time.
plan.
5I Loss of coverage under a non-Federal group health plan Yes Yes Yes Yes From 31 days before the
because an employee moves out of the commuting area employee leaves the commuting
to accept another position and the employee’s area through 180 days after
non-federally employed spouse terminates employment arriving in the new commuting
to accompany the employee. area.
5J Employee or covered family member in a Health N/A Yes Yes Yes Upon notifying the employing
Maintenance Organization (HMO) moves or becomes office of the move or change of
employed outside the geographic area from which the place of employment.
carrier accepts enrollments, or if already outside the
area, moves or becomes employed further from this
area.

15
 QLE’s That Permit
Change that May Be Permitted Time Limits
Enrollment or Change

From Self From

Switch
From Not Only to Self One When You Must File Health
Event Designated
Event Enrolled to Plus One or Plan or Benefits Election Form With
Code Family
Enrolled Self Option Your Employing Office
Member
and Family to
Another

5K On becoming eligible for Medicare N/A No N/A No At any time beginning on the
30th day before becoming
(This change may be made only once in a lifetime.) eligible for Medicare.
5L Temporary employee completes one year of continuous Yes N/A N/A No Within 60 days after becoming
service in accordance with 5 U.S.C. Section 8906a. eligible.
5M Salary of temporary employee insufficient to make N/A No Yes No Within 60 days after receiving
withholdings for plan in which enrolled. notice from employing office.
5N Employee or eligible family member becomes eligible for Yes Yes Yes Yes Within 60 days after the date the
assistance under Medicaid or a State Children’s Health employee or family member
Insurance Program (CHIP). becomes eligible for assistance.

16
 Form Approved:
OMB No. 3206-0160

Federal Employees
Health Benefits Program
Health Benefits Election Form
Part A - Enrollee and Family Member Information (for additional family members use a separate sheet and attach)
1. Enrollee name (last, first, middle initial) 2. Social Security Number 3. Date of birth (mm/dd/yyyy) 4. Sex 5. Are you married?

M F Yes No
6. Home mailing address (including ZIP Code) 7. If you are covered by Medicare, 8. Medicare Beneficiary Identifier
check all that apply.
A B D
-------------------------------------------------------------------
9. Are you covered by insurance other than Medicare?

Yes, indicate in item 10 below. No

10. Indicate the type(s) of other insurance:
TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________
FEHB An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the
enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.
11. Email address 12. Preferred telephone number

13. Name of family member (last, first, middle initial) 14. Social Security Number 15. Date of birth (mm/dd/yyyy) 16. Sex 17. Relationship code

M F
18. Address (if different from enrollee) 19. If this family member is covered 20. Medicare Beneficiary Identifier
by Medicare, check all that apply.
A B D
-------------------------------------------------------------------
21. Is this family member covered by insurance other than Medicare?

Yes, indicate in item 22 below. No

22. Indicate the type(s) of other insurance:
TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________
FEHB An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the
enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.
23. Email address (if applicable, enter email address of your spouse or adult child) 24. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)

25. Name of family member (last, first, middle initial) 26. Social Security Number 27. Date of birth (mm/dd/yyyy) 28. Sex 29. Relationship code

M F
30. Address (if different from enrollee) 31. If this family member is covered 32. Medicare Beneficiary Identifier
by Medicare, check all that apply.
A B D
-------------------------------------------------------------------
33. Is this family member covered by insurance other than Medicare?

Yes, indicate in item 34 below. No

34. Indicate the type(s) of other insurance:
TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________
FEHB An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the
enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.
35. Email address (if applicable, enter email address of your spouse or adult child) 36. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)

37. Name of family member (last, first, middle initial) 38. Social Security Number 39. Date of birth (mm/dd/yyyy) 40. Sex 41. Relationship code

M F
42. Address (if different from enrollee) 43. If this family member is covered 44. Medicare Beneficiary Identifier
by Medicare, check all that apply.
A B D
-------------------------------------------------------------------
45. Is this family member covered by insurance other than Medicare?

Yes, indicate in item 46 below. No

46. Indicate the type(s) of other insurance

TRICARE Other Name of other insurance: ______________________________________________ Policy Number: _____________________

FEHB An FEHB Self Plus One enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Family enrollment covers the
enrollee and all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item 10 on page 1.
47. Email address (if applicable, enter email address of your spouse or adult child) 48. Preferred telephone number (if applicable, enter preferred phone number of
your spouse or adult child)

(Continued on the reverse) Standard Form 2809

U.S. Office of Personnel Management Revised November 2019
For agency distribution of copies, see page 5 of the instructions.
Enrollee name: _________________________________________________________ Date of birth: ____________________________

Part B - FEHB Plan You Are Currently Enrolled In (if applicable) Part C - FEHB Plan You Are Enrolling In or Changing To
1. Plan name 2. Enrollment code 1. Plan name 2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel (see page 6) Part E - Election NOT to Enroll (Employees Only)
1. Event code 2. Date of event I do NOT want to enroll in the FEHB Program.
My signature in Part H certifies that I have read and understand the
information on page 3 regarding this election.

Part F - Cancellation of FEHB Part G - Suspension of FEHB (Annuitants/Former Spouses Only)

I CANCEL my enrollment. I SUSPEND my enrollment.
My signature in Part H certifies that I have read and understand the My signature in Part H certifies that I have read and understand the
information on page 3 regarding cancellation of enrollment. information on page 4 regarding suspension of enrollment.
Part H - Signature
WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than
$10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001.)
1. Your signature (do not print) 2. Date (mm/dd/yyyy)

Part I -To be completed by agency or retirement system

REMARKS

1. Date received (mm/dd/yyyy) 2. Effective date of action (mm/dd/yyyy) 3. Personnel telephone number

( )
4. Name and address of agency or retirement system 5. Authorizing official (please print)

6. Signature of authorized agency official

7. Payroll office number 8. Payroll office contact (please print) 9. Payroll telephone number

( )

PRINT SAVE CLEAR

Standard Form 2809

Reverse of revised November 2019
Previous edition is not usable