Fillable Form 2809 - Health Benefits Election Form (Page 2 of 2) in pdf

Form 2809 - Health Benefits Election Form Page 2

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Part B - FEHB Plan You Are Currently Enrolled In

Part C - FEHB Plan You Are Enrolling In or Changing To

(if applicable)

Plan name

2. Enrollment code

Plan name

2. Enrollment code

Part D - Event That Permits You To Enroll, Change, or Cancel

Part E - Election NOT to Enroll

(see page 2)

(Employees Only)

Event code

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

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)

_ _ / _ _ / _ _ _ _

3. Email address

4. Preferred telephone number

(

)

Part I -To be completed by agency or retirement system

REMARKS

Date received (mm/dd/yyyy)

2. Effective date of action (mm/dd/yyyy)