Form 2809 - Health Benefits Election Form
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1
2Form Approved:
OMB No. 3206-0160
Health Benefits Election Form
Federal Employees
Health Benefits Program
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
8.
Medicare Claim Number
Medicare, 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 and family enrollment covers all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item
10 on page 1.
.
11.
Name of family member (last, first, middle initial)
12.Social Security number
13.Date of birth (mm/dd/yyyy)
14.Sex
15.Relationship code
M
F
16. Address (if different from enrollee)
17.If you are covered by
18.Medicare Claim Number
Medicare, check all that apply.
A
B
D
19.Are you covered by insurance other than Medicare?
Yes, indicate in item 20 below.
No
20.Indicate the type(s) of other insurance:
TRICARE
Other:
Name of other insurance: ____________________________________________
Policy number: _______________________________
FEHB An FEHB self and family enrollment covers all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item
10 on page 1.
21.Email address (if home address is different from enrollee's)
22.Preferred telephone number (if home address is different from
enrollee's)
23. Name of family member (last, first, middle initial)
24.Social Security number
25.Date of birth (mm/dd/yyyy)
26.Sex
27.Relationship code
M
F
28. Address (if different from enrollee)
29.If you are covered by
30.Medicare Claim Number
Medicare, check all that apply.
A
B
D
31.Are you covered by insurance other than Medicare?
Yes, indicate in item 32 below.
No
32.Indicate the type(s) of other insurance:
TRICARE
Other:
Name of other insurance: ____________________________________________
Policy number: _______________________________
FEHB An FEHB self and family enrollment covers all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item
10 on page 1.
33.Email address (if home address is different from enrollee's)
34.Preferred telephone number (if home address is different from enrollee's)
35. Name of family member (last, first, middle initial)
36.Social Security number
37.Date of birth (mm/dd/yyyy)
38.Sex
39.Relationship code
M
F
40. Address (if different from enrollee)
41.If you are covered by
42.Medicare Claim Number
Medicare, check all that apply.
A
B
D
43.Are you covered by insurance other than Medicare?
Yes, indicate in item 44 below.
No
44.Indicate the type(s) of other insurance:
TRICARE
Other:
Name of other insurance: ____________________________________________
Policy number: _______________________________
FEHB An FEHB self and family enrollment covers all eligible family members. No person may be covered under more than one FEHB enrollment. See instructions for item
10 on page 1.
45.Email address (if home address is different from enrollee's)
46.Preferred telephone number (if home address is different from enrollee's)
Standard Form 2809
(continued on the reverse)
NSN 7540-01-231-6227
Revised August 2011
For agency distribution of copies, see page 5 of the instructions.
U.S. Office of Personnel Management
Previous edition is not usable
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Parent category: Medical