Health Benefits Election Form Who May Use OPM Form 2809 Item 15. Item 16. Item 17. Survivor annuitants under CSRS or FERS Former spouses Children and former spouses who are eligible for temporary continuation of coverage Code Family Relationship Form Approved: OMB No. 3206-0141 Provide the date of birth of the family member. Provide sex of family member. Provide the code which indicates the relationship of each family member to you. · · · · Annuitants retired under the Civil Service Retirement System (CSRS) or Federal Employees Retirement System (FERS) Instructions for Completing OPM 2809 Type or print firmly. Part A -- Enrollee and Family Member Information. You must complete this part. Item 1. Item 2. Item 3. Item 4. Item 5. Item 6. Item 7. Item 8. Item 9. Enter your legal name. Provide your Social Security number. Enter your date of birth. Enter your sex. If you are separated but not divorced, you are still married. Enter your emailing address. If you have Medicare, check which Parts you have, including prescription drug coverage under Medicare Part D. If you have Medicare, enter your Medicare Claim Number. This number is on your Medicare card. If you are covered by other health insurance (private, state, Medicaid, Peace Corps, TRICARE, CHAMPVA, or another FEHB enrollment), either in your name or under a family member's policy, check yes and complete item 10. TRICARE is a health care program for active duty and retired members of the uniformed services, their families, and survivors. This includes TRICARE for Life for members age 65 and older. Item 10. Select or write the name of any other insurance that covers you. Item 11. If applicable, provide your email address. Item 12. Provide your day time telephone number. If your enrollment is for Self and Family, complete information for your family members. (If you need extra space for additional family members, list them on a separate sheet and attach.) The instructions for completing items 13 through 24 for your initial family member also apply to the information you provide for additional family members in items 25 through 48. Item 14. Please provide Social Security numbers for your dependents, if they have one. If your dependents do not have Social Security numbers, leave blank; benefits will not be withheld. (See Privacy Act Statement on page 4.) 1 01 19 09 17 10 99 Spouse Child under age 26 Adopted Child Stepchild Foster Child Disabled child age 26 or older who is incapable of self-support because of a physical or mental disability that began before his/her 26th birthday. Item 18. Item 19. If your family member does not live with you, enter his/her home address. If a family member has Medicare, check which Parts he/she has, including prescription drug coverage under Medicare Part D. If your family member has Medicare, enter his/her Medicare Claim Number. This Number is on his/her Medicare card. Indicate whether the family member has health coverage other than Medicare. If a family member has TRICARE (see item 9), or other group insurance (private, state, Medicaid, Peace Corps, or another FEHB enrollment), check the box. Give the name and policy number of any other insurance this family member has. Enter email address, if applicable, for your spouse or adult child. Enter the preferred telephone number, if applicable, of your spouse or adult child. Item 20. Item 21. Item 22. Item 23. Item 24. Family Members Eligible for Coverage Unless you are a former spouse or survivor annuitant, family members eligible for coverage under your Self and Family enrollment include your spouse and your children under age 26. Eligible children include your legitimate or adopted children, step children, recognized natural children, or foster children, who live with you in a regular parent-child relationship. Other relatives (for example, your parents) are not eligible for coverage even if they live with you and are dependent upon you. If you are a former spouse or survivor annuitant, family members eligible for coverage under your Self and Family enrollment are the natural or adopted children under age 26 of both you and your former or deceased spouse. OPM Form 2809 Revised December 2013 American LegalNet, Inc. www.FormsWorkFlow.com Previous editions are not usable. In some cases, a disabled child age 26 or older is eligible for coverage under your Self and Family enrollment if you provide adequate medical certification of a mental or physical disability that existed before his/her 26th birthday and renders the child incapable of self-support. Note: The Office of Personnel Management can give you additional details about family member eligibility including any certification or documentation that may be required for coverage. Following each number is a letter which identifies a specific Qualifying Life Event (QLE); for example, the event code 2A refers to open season. Item 2. Enter the date of the QLE using numbers to show month, day, 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 annuity was restored). If you are making an open season enrollment or change, enter the date on which the open season begins. Part B -- FEHB Plan You Are Currently Enrolled In. You must complete this part if you are changing, canceling, or suspending your enrollment. Item 1. Item 2. Enter the name of the plan you are enrolled in, from the front cover of the plan brochure. Enter the present enrollment code from your plan or ID card. Part E -- Suspension/Cancellation. Check a box only if you wish to suspend or cancel your FEHB enrollment. Also enter your present enrollment code in Part B. You may suspend your FEHB enrollment because you are enrolling in one of the following programs: Part C -- FEHB Plan You Are Enrolling In or Changing To. Complete this part to enroll or change your enrollment in the FEHB. Item 1. Enter the name of the plan you are enrolling in or changing to. The plan name is on the front cover of the brochure of the plan you want to be enrolled in. Enter the enrollment code of the plan you are enrolling in or changing to. The enrollment code is on the front cover of the brochure of the plan you want to be enrolled in, and shows the plan and option you are electing and whether you are enrolling for Self Only or Self and Family. · · · · · A Medicare HMO or Medicare Advantage plan, Medicaid or similar State-sponsored program of medical assistance for the needy, TR