Standard Form 2810 - Notice Of Change In Health Benefits Enrollment Page 4
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1
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4Instructions for Employing Offices
Purpose of Form
This form covers health benefits actions e x c e p t enrollments, changes from one plan to another, changes of coverage within a plan and
cancellations, which are processed on the Health Benefits Registration Form (Standard Form 2809). When an action requires a change in
health benefits enrollment, prepare SF 2810 As Soon As The Effective Date Is Known and give the appropriate copies to the enrollee and
payroll office Immediately. Preparation and distribution of copies should not be delayed pending SF 50 action in the case of transfers to
another payroll office.
Prompt Action Required for Conversion
Give this form to the enrollee within 60 days after the date shown in Part A, item 8. To be eligible to convert to a nongroup contract, the
enrollee must send a written request for information about conversion to a nongroup contract to his or her plan within 31 days after the date
shown in Part H, but not later than 91 days after the date shown in Part A, item 8.
Completion of Form
Part A - Identifying Information
Part C - Transfer In
1.
For items 1, 2, and 6, transcribe from the last SF 2809 of SF
Gaining office uses this box to report transfer actions such as
2810, whichever is the most recent.
Acceptance of transfer from another agency to payroll office
2.
Item 4, use most recent known address.
number.
3.
Item 5, use payroll office number of office authorized to process
Retired - Acceptance of transfer by retirement system because
withholdings.
employee is eligible to continue enrollment as an annuitant.
4.
Item 8, date as follows for action reported in:
Death - Acceptance of transfer by retirement system because
B.
Termination - Last day of pay period in which separation (or
survivor is eligible to continue enrollment as a survivor
other action terminating enrollment) occurs except, when
annuitant.
coverage terminates because of completion of 365 days in
Transfer accepted by Office of Workers’ Compensation
nonpay status, use the last day of the pay period which
Programs.
includes the 365th day of continuous nonpay status; and
Note: Retirement systems (including OWCP) accepting transfer
when coverage terminates because of military duty not
in, show also in “Remarks” whether enrollment is for an
limited to 30 days or less, use date employee is separated,
“Employee Annuitant” or “Survivor Annuitant.”
was furloughed or placed on leave of absence for military
duty.
Part D - Reinstatement
C.
Transfer In - Actual date (first day on gaining employing
State in “Remarks” reason for any action not applicable to active
office or retirement system rolls).
military duty, such as “Reinstatement of Erroneous separation.”
D.
Reinstatement - Actual date.
E.
Change In Name Of Enrollee - Actual Date.
Part E - Change in Name of Enrollee
F.
Change in Enrollment-Survivor Annuitant - Effective date of
Use this box only for reporting changes in name where change of
sole survivor’s annuity.
coverage within a plan by SF 2809 is not involved. Show date of birth
only where enrollment is changed from employee’s or annuitant’s
Part B - Termination
name to name of survivor annuitant.
These most frequently occuring actions terminate enrollment:
Separated.
Part F - Change in Enrollment - Survivor Annuitant
Retired - not eligible to continue enrollment.
Only agencies administering retirement systems will make this
Died - no survivor eligible to continue enrollment.
determination on the basis of documentary evidence that there is
Termination of title to annuity or compensation.
only one survivor annuitant.
Changed to excluded position or category.
365 days nonpay status completed.
Part G - Remarks
Temporary continuation of coverage expired.
Use this box to bring to the attention of the employee, annuitant, or
insurance carrier any pertinent information to clarify or support the
Note: If termination is due to death of the enrollee enter date-
action being taken.
of-death in block in Part B.
Part H - Date of Notice
Facsimile signature is acceptable. Date as of day of issuance.
Disposition
Copy 1
-
Deliver (or mail) to employee, annuitant or survivor
, but before 60 days from the date shown
at the earliest possible date
in Part A, item 8.
Copies 2 and 3
-
Send to appropriate insurance carrier and payroll office.
Copy 4
-
File in Official Personnel Folder (or its equivalent).
Back, Copy 4
Standard Form 2810
Revised June 1996
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