Standard Form 2809 - Health Benefits Election Form

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Form 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

4. Sex

5. Are you married?

_ _ / _ _ / _ _ _ _

Yes

6. Home mailing address (including ZIP Code)

7. Medicare (See note - page 2)

8. TRICARE

9. Other insurance

10.Name of insurance

11.Insurance policy no.

12. Name of family member (last, first, middle initial)

13.Social Security number 14.Date of birth

15.Sex

16.Relationship code

_ _ / _ _ / _ _ _ _

17. Address (if different from enrollee)

18.Medicare (See note - page 2)

19.TRICARE

20.Other insurance

21.Name of insurance

22.Insurance policy no.

Name of family member (last, first, middle initial)

Social Security number

Date of birth

Sex

Relationship code

_ _ / _ _ / _ _ _ _

Address (if different from enrollee)

TRICARE

Other insurance

Medicare (See note - page 2)

Name of insurance

Insurance policy no.

Name of family member (last, first, middle initial)

Social Security number

Date of birth

Sex

Relationship code

_ _ / _ _ / _ _ _ _

Address (if different from enrollee)

TRICARE

Other insurance

Medicare (See note - page 2)

Name of insurance

Insurance policy no.

Name of family member (last, first, middle initial)

Social Security number

Date of birth

Sex

Relationship code

_ _ / _ _ / _ _ _ _

Address (if different from enrollee)

TRICARE

Other insurance

Medicare (See note - page 2)

Name of insurance

Insurance policy no.

Part B - Present Plan

Part C - New Plan

1. Plan name

2. Enrollment code

Plan name

2. Enrollment code

Part D - Event Code

Part E - Employees Only (Election NOT to Enroll)

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

Part G - Suspension (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. Daytime telephone number

Part I -To be completed by agency or retirement system

REMARKS

Date received

2. Effective date of action

3. Personnel telephone number

4. Name and address of agency or retirement system

_ _ / _ _ / _ _ _ _

(