Dd Form 2877 - Tricare Prime Disenrollment Request Page 2
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3TRICARE PRIME DISENROLLMENT REQUEST
(Please read Agency Disclosure Notice, Privacy Act Statement, and
Instructions before completing this form.)
SECTION I - SPONSOR INFORMATION
(Must be completed on all requests)
1. SPONSOR SOCIAL SECURITY
2. SPONSOR NAME
3. SPONSOR DATE OF BIRTH
(Last, First, Middle Initial)
NUMBER (SSN)
(Must match DEERS)
(YYYYMMDD)
SECTION II - INDIVIDUAL(S) REQUESTING DISENROLLMENT
(Print extra copies of this page if more than 6 family members disenrolling)
(Number)
a. NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT
You may be subject to a 12-month lockout.
(X one)
Other Voluntary Disenrollment
Moved
Other Health Insurance
(Explain)
e. REQUESTED DISENROLLMENT DATE
(YYYYMMDD)
f. TELEPHONE NUMBERS
(Include Area Code)
(If different from above. Must not be more than 30 days in the
(1) HOME
(2) WORK
future.)
(
)
(
)
(Number)
a. NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT
You may be subject to a 12-month lockout.
(X one)
Other Voluntary Disenrollment
Moved
Other Health Insurance
(Explain)
e. REQUESTED DISENROLLMENT DATE
(YYYYMMDD)
f. TELEPHONE NUMBERS
(Include Area Code)
(If different from above. Must not be more than 30 days in the
(1) HOME
(2) WORK
future.)
(
)
(
)
(Number)
a. NAME
b. DATE OF BIRTH
(Last, First, Middle Initial) (Must match DEERS)
(YYYYMMDD)
c. RELATIONSHIP TO SPONSOR
Self
Spouse
Former Spouse
Child
d. REASON FOR DISENROLLMENT
You may be subject to a 12-month lockout.
(X one)
Other Voluntary Disenrollment
Moved
Other Health Insurance
(Explain)
e. REQUESTED DISENROLLMENT DATE
(YYYYMMDD)
f. TELEPHONE NUMBERS
(Include Area Code)
(If different from above. Must not be more than 30 days in the
(1) HOME
(2) WORK
future.)
(
)
(
)
DD FORM 2877, FEB 2011
Page 2 of 3 Pages
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