Transcription of Health Benefits Election Form - OPM.gov
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Health Benefits Election Form - OPM.gov
form Approved: Health Benefits Election form OMB No. 3206-0160. Uses for Standard form (SF) 2809 Item 9. If you are covered by other Health insurance, either in your Use this form to: name or under a family member's policy, check yes and 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 Elect not to enroll in the FEHB Program (employees only); or enrollment covers the enrollee and one eligible family member designated by the enrollee. An FEHB Self and Change your FEHB enrollment; or Family enrollment covers the enrollee and all eligible family members. If you or a family member is covered under Cancel your FEHB enrollment; or another FEHB enrollment, check the FEHB box and.
Health Benefits Election Form Form Approved: OMB No. 3206-0160 Standard Form 2809 Previous edition is not usable Revised November 2015 . …
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