Transcription of Health Benefits Election Form - OPM.gov
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Health Benefits Election Form Form Approved: OMB No. 3206-0141 Who May Use OPM Form 2809 Annuitants retired under the Civil Service Retirement System (CSRS) or federal Employees Retirement System (FERS) Survivor annuitants under CSRS or FERS Former spouses Children and former spouses who are eligible for temporary continuation of coverage Instructions for Completing OPM 2809 Type or print firmly. Part A Enrollee and Family Member Information. You must complete this part. Item 1. Enter your legal name. Item 2. Provide your Social Security number. Item 3. Enter your date of birth. Item 4. Enter your sex. Item 5. If you are separated but not divorced, you are still married.
Health Benefits Election Form Form Approved: OMB No. 3206-0141 Who May Use OPM Form 2809 • Annuitants retired under the Civil Service Retirement System (CSRS) or Federal Employees Retirement System (FERS) • Survivor annuitants under CSRS or FERS • Former spouses • Children and former spouses who are eligible for temporary continuation of coverage
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