OPM Form SF-2809 "Employee Health Benefits Registration Form"

What Is OPM Form SF-2809?

This is a legal form that was released by the U.S. Office of Personnel Management on November 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest available edition released by the U.S. Office of Personnel Management;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of OPM Form SF-2809 by clicking the link below or browse more documents and templates provided by the U.S. Office of Personnel Management.

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Form Approved:
Health Benefits Election Form
OMB No. 3206-0160
Item 9.
If you are covered by other health insurance, either in your
Uses for Standard Form (SF) 2809
name or under a family member’s policy, check yes and
Use this form to:
complete item 10.
Switch designated eligible family member; or
Item 10. Provide the information requested on any other health
Enroll or reenroll in the FEHB Program; or
insurance that covers you. An FEHB Self Plus One
enrollment covers the enrollee and one eligible family
Elect not to enroll in the FEHB Program (employees only); or
member designated by the enrollee. An FEHB Self and
Family enrollment covers the enrollee and all eligible family
Change your FEHB enrollment; or
members. If you or a family member is covered under
Cancel your FEHB enrollment; or
another FEHB enrollment, check the FEHB box and
.
Contact your Human Resources office or retirement system
Suspend your FEHB enrollment (annuitants or former spouses
immediately as this is a dual coverage situation. Some
only).
examples of how this could occur are:
Who May Use SF 2809
You are enrolling in an FEHB Self Only plan while
your spouse has either an FEHB Self Plus One or Self
1. Employees eligible to enroll in or currently enrolled in the FEHB
and Family plan, in which you are already covered.
Program. Employees automatically participate in premium
conversion unless they waive it, see page 7.
You are enrolling in an FEHB Self Plus One plan while
you are also covered under your spouse’s FEHB Self
2. Annuitants in retirement systems other than the Civil Service
Plus One plan or FEHB Self and Family plan.
Retirement System (CSRS) or Federal Employees Retirement
System (FERS), including individuals receiving monthly
You are enrolling in an FEHB Self and Family plan
compensation from the Office of Workers’ Compensation Programs
while your spouse is already enrolled in either a FEHB
(OWCP).
Self Only plan, an FEHB Self Plus One plan that covers
you, or an FEHB Self and Family plan that covers you.
Note: Civil Service Retirement System (CSRS) and Federal
Employees Retirement System (FERS) annuitants and former
You are an employee under age 26 and have no eligible
spouses and children of CSRS/FERS annuitants -- Do not use
family members. You are enrolling in your own FEHB
this form. Instead, use form OPM 2809, which is available at
plan while you are covered under your parent’s FEHB
www.opm.gov/forms/OPM-forms, or call the Retirement Information
Self Plus One plan or Self and Family plan.
Office toll-free at 1-888-767-6738.
You are an annuitant who is reemployed in the Federal
government. You are enrolling in an FEHB plan as an
3. Former spouses eligible to enroll in or currently enrolled in the
employee while you are covered under your own or a
FEHB Program under the Spouse Equity law or similar statutes.
family member’s FEHB plan.
4. Individuals eligible for Temporary Continuation of Coverage (TCC)
No person may be covered under more than one FEHB
under the FEHB Program, including:
enrollment. However, in certain unusual circumstances, your
agency may allow you to enroll in order to:
Former employees (who separated from service);
Enable an employee under age 26 who is covered under
Children who lose FEHB coverage; and
a parent’s Self Plus One or Self and Family FEHB
Former spouses who are not eligible for FEHB under item 3
enrollment to enroll in FEHB to cover his or her own
above.
spouse and/or child;
Enable an employee under age 26 who is covered under
Instructions for Completing SF 2809
a parent’s Self Plus One or Self and Family FEHB
Type or Print. We have not provided instructions for
enrollment, but lives outside his or her parent’s HMO
those items that have an explanation on the form.
service area, to have FEHB coverage;
Enable an employee who separates or divorces to enroll
Part A — Enrollee and Family Member Information
in FEHB to cover family members who move outside
You must complete this part.
the HMO service area of the covering FEHB Self Plus
Item 2.
See the Privacy Act and Public Burden Statements on page 5.
One or Self and Family enrollment.
Item 5.
If you are separated but not divorced, you are still married.
In these unusual situations, each enrollee must notify his or
her plan as to which family members are covered under
Item 7.
If you have Medicare, check which Parts you have, including
which enrollment. See Dual Enrollment information on
prescription drug coverage under Medicare Part D.
page 5.
Item 8.
If you have Medicare, enter your Medicare Claim Number.
This number is on your Medicare Card.
Standard Form 2809
Revised November 2015
Previous edition is not usable
1
Form Approved:
Health Benefits Election Form
OMB No. 3206-0160
Item 9.
If you are covered by other health insurance, either in your
Uses for Standard Form (SF) 2809
name or under a family member’s policy, check yes and
Use this form to:
complete item 10.
Switch designated eligible family member; or
Item 10. Provide the information requested on any other health
Enroll or reenroll in the FEHB Program; or
insurance that covers you. An FEHB Self Plus One
enrollment covers the enrollee and one eligible family
Elect not to enroll in the FEHB Program (employees only); or
member designated by the enrollee. An FEHB Self and
Family enrollment covers the enrollee and all eligible family
Change your FEHB enrollment; or
members. If you or a family member is covered under
Cancel your FEHB enrollment; or
another FEHB enrollment, check the FEHB box and
.
Contact your Human Resources office or retirement system
Suspend your FEHB enrollment (annuitants or former spouses
immediately as this is a dual coverage situation. Some
only).
examples of how this could occur are:
Who May Use SF 2809
You are enrolling in an FEHB Self Only plan while
your spouse has either an FEHB Self Plus One or Self
1. Employees eligible to enroll in or currently enrolled in the FEHB
and Family plan, in which you are already covered.
Program. Employees automatically participate in premium
conversion unless they waive it, see page 7.
You are enrolling in an FEHB Self Plus One plan while
you are also covered under your spouse’s FEHB Self
2. Annuitants in retirement systems other than the Civil Service
Plus One plan or FEHB Self and Family plan.
Retirement System (CSRS) or Federal Employees Retirement
System (FERS), including individuals receiving monthly
You are enrolling in an FEHB Self and Family plan
compensation from the Office of Workers’ Compensation Programs
while your spouse is already enrolled in either a FEHB
(OWCP).
Self Only plan, an FEHB Self Plus One plan that covers
you, or an FEHB Self and Family plan that covers you.
Note: Civil Service Retirement System (CSRS) and Federal
Employees Retirement System (FERS) annuitants and former
You are an employee under age 26 and have no eligible
spouses and children of CSRS/FERS annuitants -- Do not use
family members. You are enrolling in your own FEHB
this form. Instead, use form OPM 2809, which is available at
plan while you are covered under your parent’s FEHB
www.opm.gov/forms/OPM-forms, or call the Retirement Information
Self Plus One plan or Self and Family plan.
Office toll-free at 1-888-767-6738.
You are an annuitant who is reemployed in the Federal
government. You are enrolling in an FEHB plan as an
3. Former spouses eligible to enroll in or currently enrolled in the
employee while you are covered under your own or a
FEHB Program under the Spouse Equity law or similar statutes.
family member’s FEHB plan.
4. Individuals eligible for Temporary Continuation of Coverage (TCC)
No person may be covered under more than one FEHB
under the FEHB Program, including:
enrollment. However, in certain unusual circumstances, your
agency may allow you to enroll in order to:
Former employees (who separated from service);
Enable an employee under age 26 who is covered under
Children who lose FEHB coverage; and
a parent’s Self Plus One or Self and Family FEHB
Former spouses who are not eligible for FEHB under item 3
enrollment to enroll in FEHB to cover his or her own
above.
spouse and/or child;
Enable an employee under age 26 who is covered under
Instructions for Completing SF 2809
a parent’s Self Plus One or Self and Family FEHB
Type or Print. We have not provided instructions for
enrollment, but lives outside his or her parent’s HMO
those items that have an explanation on the form.
service area, to have FEHB coverage;
Enable an employee who separates or divorces to enroll
Part A — Enrollee and Family Member Information
in FEHB to cover family members who move outside
You must complete this part.
the HMO service area of the covering FEHB Self Plus
Item 2.
See the Privacy Act and Public Burden Statements on page 5.
One or Self and Family enrollment.
Item 5.
If you are separated but not divorced, you are still married.
In these unusual situations, each enrollee must notify his or
her plan as to which family members are covered under
Item 7.
If you have Medicare, check which Parts you have, including
which enrollment. See Dual Enrollment information on
prescription drug coverage under Medicare Part D.
page 5.
Item 8.
If you have Medicare, enter your Medicare Claim Number.
This number is on your Medicare Card.
Standard Form 2809
Revised November 2015
Previous edition is not usable
1
If your enrollment is for Self Plus One or Self and Family, complete the
family member information as appropriate. (If you need extra space for
Eligible children include your children born within marriage or adopted
additional family members, list them on a separate sheet and attach.)
children; stepchildren (may include children of your same-sex domestic
partner*); recognized natural children; or foster children who live with
you in a regular parent-child relationship.
Important: In order for your Self Plus One FEHB enrollment election to
be processed, you must complete the family member information for
your designated family member.
Other relatives (for example, your parents) are not eligible for coverage
even if they live with you and are dependent upon you.
The instructions for completing items 13 through 24 for your initial
family member also apply to the information you provide for additional
If you are a former spouse or survivor annuitant, family members
family members.
eligible for coverage under your Self Plus One or Self and Family
enrollment are the natural or adopted children under age 26 of both you
Item 14.
Provide the Social Security Number for this family member if
and your former or deceased spouse.
he/she has one. If your family member does not have a Social
Security Number, leave blank; benefits will not be withheld.
In some cases, a disabled child age 26 or older is eligible for coverage
(See Privacy Act Statement on page 5.)
under your Self Plus One or Self and Family enrollment if you provide
Item 17.
Provide the code which indicates the relationship of each
adequate medical certification of a mental or physical disability that
eligible family member to you.
th
existed before his/her 26
birthday and renders the child incapable of
self-support.
Code
Family Relationship
Note: Your employing office can give you additional details about
01
Spouse
family member eligibility including any certification or documentation
19
Child under age 26
that may be required for coverage. Contact your employing office for
more information about covering foster child(ren), or child(ren) of your
09
Adopted Child under age 26
same-sex domestic partner who you would marry but for your state’s
17
Stepchild under age 26
marriage law. “Employing office” means the office of an agency or
10
Foster Child under age 26
retirement system that is responsible for health benefits actions for an
employee, annuitant, former spouse eligible for coverage under the
99
Disabled child age 26 or older who is incapable
Spouse Equity provisions, or individual eligible for TCC.
of self support because of a physical or mental
th
disability that began before his/her 26
birthday.
Survivor Benefits
For your surviving family members to continue your FEHB enrollment
after your death, all of the following requirements must be met:
Item 18.
If your family member does not live with you, enter his/her
home address.
Self Plus One
Item 19.
If your family member has Medicare, check which Parts
You must have been enrolled for Self Plus One at the time of your
(Part A [Hospital Insurance] and/or Part B [Medical
death; and
Insurance]) he/she has, including prescription drug
coverage under Medicare Part D.
Your designated family member must be entitled to an annuity as
your survivor.
Item 20.
If your family member has Medicare, enter his/her Medicare
Note: The only survivor eligible to continue the health benefits enroll­
Claim Number. This number is on his/her Medicare Card.
ment is the designated family member covered under FEHB on the date
Item 21.
If your family member is covered by other group insurance,
of death as long as that individual is entitled to a survivor annuity. No
such as private, state, or Medicaid, check the box and
other family members are entitled to continue the enrollment even
complete item 22.
though they may be entitled to a survivor annuity.
Item 22.
Provide the information requested on any other health
Self and Family
insurance that covers this family member. If your family
member is covered under another FEHB plan, see
You must have been enrolled for Self and Family at the time of your
instructions for item 10.
death; and
Item 23.
Enter email address, if applicable, for this family member.
At least one family member must be entitled to an annuity as your
survivor.
Item 24.
Enter preferred telephone number, if applicable, for this
Note: All of your survivors who meet the definition of “family member”
family member.
can continue their health benefits coverage under your enrollment as
long as any one of them is entitled to a survivor annuity. If the survivor
Family Members Eligible for Coverage
annuitant is the only eligible family member, the retirement system will
Unless you are a former spouse or survivor annuitant, family members
automatically change the enrollment to Self Only.
eligible for coverage under your Self Plus One enrollment include one
eligible family member (spouse or child under age 26) designated by
you. A Self and Family enrollment includes you and all of your eligible
family members.
*If you would marry but you live in a state that does not allow same-sex couples to marry.
Standard Form 2809
Revised November 2015
2
Part B — FEHB Plan You Are Currently Enrolled In
You must complete this part if you are changing, cancelling, or
Following each number is a letter, which identifies a specific Qualifying
Life Event (QLE); for example, the event code “1A” refers to the initial
suspending your enrollment.
opportunity to enroll for an employee who elected to participate in
Item 1.
Enter the name of the plan you are enrolled in from the front
premium conversion.
cover of the plan brochure.
Item 2.
Enter the date of the QLE using numbers to show month, day,
Item 2.
Enter your current enrollment code from your plan ID card.
and complete year; e.g., 06/30/2011. If you are electing to
enroll, enter the date you became eligible to enroll (for
example, the date your appointment began). If you are
Part C — FEHB Plan You Are Enrolling In or
making an open season enrollment or change, enter the date
Changing To
on which the open season begins.
Complete this part to enroll or change your enrollment in the FEHB
Program.
Part E — Election NOT to Enroll
Item 1.
Enter the name of the plan you are enrolling in or changing
Place an “X” in the box only if you are an employee and you do NOT
to. The plan name is on the front cover of the brochure of the
wish to enroll in the FEHB Program. Be sure to read the information
plan you want to be enrolled in.
titled Employees Who Elect Not to Enroll or Who Cancel Their
Item 2.
Enter the enrollment code of the plan you are enrolling in or
Enrollment.
changing to. The enrollment code is on the front cover of the
brochure of the plan you want to be enrolled in, and shows
Part F — Cancellation of FEHB
the plan and option you are electing and whether you are
Place an “X” in the box only if you wish to cancel your FEHB
enrolling for Self Only, Self Plus One, or Self and Family.
enrollment. Also enter your current plan name and enrollment code in
Part B. Be sure to read the information titled Employees Who Elect Not
To enroll in a Health Maintenance Organization (HMO), you must live
to Enroll or Who Cancel Their Enrollment.
(or in some cases work) in a geographic area specified by the carrier.
Note For Parts E and F. If you are Electing Not to Enroll or
To enroll in an employee organization plan, you must be or become a
Cancelling your enrollment because you are covered as a spouse or
member of the plan’s sponsoring organization, as specified by the
child under another FEHB enrollment, your agency must enter the
carrier.
enrollee’s name, Social Security number, and FEHB enrollment code
in REMARKS.
Your signature in Part H authorizes deductions from your salary,
Cancellation of Enrollment
annuity, or compensation to cover your cost of the enrollment you elect
in this item, unless you are required to make direct payments to the
Employees participating in premium conversion may cancel their FEHB
employing office.
enrollment only during the open season or when they experience a
Qualifying Life Event. Employees who waived participation in premium
conversion, annuitants, former spouses, and individuals enrolled under
Part D — Event That Permits You To Enroll, Change,
TCC may cancel their enrollment at any time. However, if you cancel,
Or Cancel
neither you nor any family member covered by your enrollment are
Item 1.
Enter the event code that permits you to enroll, change, or
entitled to a 31-day temporary extension of coverage, or to convert to
cancel based on a Qualifying Life Event (QLE) from the
an individual, nongroup policy. Moreover, family members who lose
Table of Permissible Changes in Enrollment that applies to
coverage because of your cancellation are not eligible for TCC. Be sure
you.
to read the additional information below about cancelling your FEHB
enrollment.
Explanation of Table of Permissible Changes in Enrollment
Employees Who Elect Not to Enroll (Part E) or Who Cancel
The tables on pages 7 through 14 illustrate when: an employee who
Their Enrollment (Part F)
participates in premium conversion; annuitant; former spouse; person
To be eligible for an FEHB enrollment after you retire, you must retire:
eligible for TCC; or employee who waived participation in premium
conversion may enroll or change enrollment. The tables show those
Under a retirement system for Federal civilian employees, and
permissible events that are found in the regulations at 5 CFR Parts 890
On an immediate annuity.
and 892.
In addition, you must be currently enrolled in a plan under the FEHB
The tables have been organized by enrollee category. Each category is
Program and must have been enrolled (or covered as a family member)
designated by a number, which identifies the enrollee group, as follows:
in a plan under the Program for:
1. Employees who participate in premium conversion
The 5 years of service immediately before retirement (i.e.,
commencing date of annuity entitlement), or
2. Annuitants (other than CSRS/FERS annuitants), including
individuals receiving monthly compensation from the Office of
Workers’ Compensation Programs
If fewer than 5 years, all service since your first opportunity to
enroll. (Generally, your first opportunity to enroll is within 60 days
3. Former spouses eligible for coverage under the Spouse Equity
after your first appointment [in your Federal career] to a position
provision of FEHB law
under which you are eligible to enroll under conditions that permit a
Government contribution toward the enrollment.)
4. TCC enrollees
If you do not enroll at your first opportunity or if you cancel your
5. Employees who waived participation in premium conversion
enrollment, you may later enroll or reenroll only under the circumstances
Standard Form 2809
3
Revised November 2015
explained in the table beginning on page 7. Some employees delay their
Note 1: If you become covered by a regular enrollment in the FEHB
enrollment or reenrollment until they are nearing 5 years before
Program, either in your own right or under the enrollment of someone
retirement in order to qualify for FEHB coverage as a retiree; however,
else, your TCC enrollment is suspended. You will need to send
there is always the risk that they will retire earlier than expected and not
documentation of the new enrollment to the employing office
be able to meet the 5-year requirement for continuing FEHB coverage
maintaining your TCC enrollment so that they can stop the TCC
into retirement. When you elect not to enroll or cancel your enrollment
enrollment. If your new FEHB coverage stops before the TCC
you are voluntarily accepting this risk. An alternative would be to
enrollment would have expired, the TCC enrollment can be reinstated
enroll in or change to a lower cost plan so that you meet the
for the remainder of the original eligibility period (18 months for
requirements for continuation of your FEHB enrollment after retirement.
separated employees or 36 months for eligible family members who lose
coverage).
Note for temporary [under 5 U.S.C. 8906a] employees eligible for
FEHB without a Government contribution: Your decision not to enroll
Note 2: Former spouses (Spouse Equity) and TCC enrollees who fail to
or to cancel your enrollment will not affect your future eligibility to
pay their premiums within specified timeframes are considered to have
continue FEHB enrollment after retirement.
voluntarily cancelled their enrollment.
Annuitants Who Cancel Their Enrollment
Part G — Suspension of FEHB
CSRS and FERS annuitants and their eligible family members should
CSRS and FERS annuitants and their eligible family members should
not use this form but use form RI 79-9, Health Benefits
not use this form but use form RI 79-9, Health Benefits
Cancellation/Suspension Confirmation, which is available at
Cancellation/Suspension Confirmation, which is available at
www.opm.gov/forms/Retirement-and-Insurance-Forms, or call
www.opm.gov/forms/Retirement-and-Insurance-Forms, or call
1-888-767-6738.
1-888-767-6738.
Place an “X” in the box only if you are an annuitant or former spouse
Generally, you cannot reenroll as an annuitant unless you are
and wish to suspend your FEHB enrollment. Also enter your current plan
continuously covered as a family member under another person’s
enrollment in the FEHB Program during the period between your
name and enrollment code in Part B.
cancellation and reenrollment. Your employing office or retirement
system can advise you on events that allow eligible annuitants to
You may suspend your FEHB enrollment because you are enrolling in
reenroll. If you cancel your enrollment because you are covered under
one of the following programs:
another FEHB enrollment, you can reenroll from 31 days before through
A Medicare Advantage plan or Medicare HMO,
60 days after you lose that coverage under the other enrollment.
Medicaid or similar State-sponsored program of medical assistance
for the needy,
If you cancel your enrollment for any other reason, you cannot later
reenroll, and you and any family members covered by your enrollment
TRICARE (including Uniformed Services Family Health Plan or
are not entitled to a 31-day temporary extension of coverage or to
TRICARE for Life),
convert to an individual policy.
CHAMPVA, or
Former Spouses (Spouse Equity) Who Cancel Their Enrollment
Peace Corps.
Generally, if you cancel your enrollment in the FEHB Program, you
cannot reenroll as a former spouse. However, if you cancel the
You can reenroll in the FEHB Program if your other coverage ends.
enrollment because you become covered under FEHB as a new spouse
If your coverage ends involuntarily, you can reenroll from 31 days
or employee, your eligibility for FEHB coverage under the Spouse
before your other coverage ends through 60 days after your other
Equity provisions continues. You may reenroll as a former spouse from
coverage ends. If your coverage ends voluntarily because you disenroll,
31 days before through 60 days after you lose coverage under the other
you can reenroll during the next open season.
FEHB enrollment.
You must submit documentation of eligibility for coverage under the
If you cancel your enrollment for any other reason, you cannot later
non-FEHB Program to the office that maintains your enrollment. That
reenroll, and you and any family members covered by your enrollment
office must enter in REMARKS the reason for your suspension.
are not entitled to a 31-day temporary extension of coverage or to
convert to an individual policy.
Part H — Signature
Your agency, retirement system, or office maintaining your enrollment
Temporary Continuation of Coverage (TCC) Enrollees Who
cannot process your request unless you complete this part.
Cancel Their Enrollment
If you cancel your TCC enrollment, you cannot reenroll. Your family
If you are registering for someone else under a written authorization
members who lose coverage because of your cancellation cannot enroll
from him or her to do so, sign your name in Part H and attach the written
for TCC in their own right nor can they convert to a nongroup policy.
authorization.
Family members who are Federal employees or annuitants may enroll in
the FEHB Program when you cancel your coverage if they are eligible
If you are registering for a former spouse eligible for coverage under the
for FEHB coverage in their own right.
Spouse Equity provisions or for an individual eligible for TCC as his
or her court-appointed guardian, sign your name in Part H and attach
evidence of your court-appointed guardianship.
Standard Form 2809
Revised November 2015
4
Part I - Agency or Retirement System Information
For the eligible former spouse of an enrollee, the enrollee or the
and Remarks
former spouse must notify the employing office within 60 days after
the former spouse’s change in status; e.g., the date of the divorce.
Leave this section blank as it is for agency or retirement system use only.
An individual eligible for TCC who wants to continue FEHB coverage
Electronic Enrollments
may choose any plan, option, and type of enrollment for which he or she
Many agencies use automated systems that allow their employees to
is eligible. The time limit for a former employee, child, or former spouse
make changes using a touch-tone telephone, or a computer instead of
to enroll with the employing office is within 60 days after the Qualifying
a form. This may be Employee Express or another automated system.
Life Event, or receiving notice of eligibility, whichever is later.
If you are not sure whether the electronic enrollment option is available
to you, contact your employing office.
Effective Dates
Except for open season, most enrollments and changes of enrollment are
Dual Enrollment
effective on the first day of the pay period after the employing office
No person (enrollee or family member) is entitled to receive benefits
receives this form and that follows a pay period during any part of which
under more than one enrollment in the FEHB Program. Normally, you
the employee is in pay status. Your employing office can give you the
are not eligible to enroll if you are covered as a family member under
specific date on which your enrollment or enrollment change will take
someone else’s enrollment in the Program. However, such dual
effect.
enrollments may be permitted under certain circumstances in order to:
Note 1: If you are changing your FEHB enrollment from Self Plus One
Protect the interests of children who otherwise would lose coverage
or Self and Family to Self Only so that your spouse can enroll for Self
as family members, or
Only, you should coordinate the effective date of your spouse’s
enrollment with the effective date of your enrollment change to avoid a
Enable an employee who is under age 26 and covered under a
gap in your spouse’s coverage.
parent’s enrollment and marries or becomes the parent of a child to
enroll for Self Plus One or Self and Family coverage.
Note 2: If you are cancelling your FEHB enrollment and intend to be
Each enrollee must notify his or her plan of the names of the persons to
covered under someone else’s enrollment at the time you cancel, you
be covered under his or her enrollment who are not covered under the
should coordinate the effective date of your cancellation with the
other enrollment. See instructions for item 10 for more information.
effective date of your new coverage to avoid a gap in your coverage.
Temporary Continuation of Coverage (TCC)
Agency Distribution of SF 2809
The employing office must notify a former employee of his or her
Agencies must distribute one copy of the completed SF 2809 to each of
eligibility for TCC. The enrollee, child, former spouse, or their
the following, as appropriate:
representative must notify the employing office when a child or former
Official Personnel Folder
spouse becomes eligible.
New Carrier
For the eligible child of an enrollee, the enrollee must notify the
Old Carrier
employing office within 60 days after the qualifying event occurs;
e.g., child reaches age 26.
Payroll Office
Enrollee
Privacy Act and Public Burden Statements
The information you provide on this form is needed to document your enrollment in the Federal Employees Health Benefits Program under Chapter 89, title 5, U.S.
Code. The principal use of this information will be to share it with the health insurance carrier you select so that it may (1) identify your enrollment in the plan,
(2) verify your and/or your family’s eligibility for payment of a claim for health benefits services or supplies, and (3) coordinate payment of claims with other carriers
with whom you might also make a claim for payment of benefits. Other routine uses include disclosures to other Federal agencies or Congressional offices which may
have a need to know it in connection with your application for a job, license, grant, or other benefit. It may also be shared and is subject to verification, via paper,
electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or Social Security administrative agencies to
determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the
extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local
law enforcement agency. While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your
enrollment.
We request that you provide your Social Security Number so that it may be used as your individual identifier in the FEHB Program, and for other purposes. Executive
Order 13478 (November 18, 2009) allows Federal agencies to use Social Security Numbers as individual identifiers to distinguish between people of same or similar
names. In addition, a mandatory insurer reporting law (Section 111 of Public Law number 110-173) requires your health insurance carrier to report your Social Security
Number or your Medicare Claim Number in order to properly coordinate benefits between your health plan and Medicare. Also, Section 6055 of the Internal Revenue
Code requires your health insurance plan to report, to the Internal Revenue Service (IRS), information necessary to confirm that you and your covered family members
have minimum essential coverage from your health plan. The information required from your health insurance plan includes a Social Security Number for yourself and
each of your covered family members. Failure to furnish your Social Security Number and/or Medicare Claim Number may result in the US. Office of Personnel
Management’s (OPM) inability to ensure the prompt payment of your and/or family’s claims for health benefits services or supplies, proper coordination with Medicare
and proper health insurance status reporting to the IRS.
We estimate this form takes an average of 30 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed
form. Send comments regarding our time estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel
Management, Retirement Services Publications Team, (3206-0160), Washington, D.C. 20415-3430. The OMB number, 3206-0160 is currently valid. OPM may not
collect this information, and you are not required to respond, unless this number is displayed.
Standard Form 2809
5
Revised November 2015