Federal Employees Health Benefits Program Notice of Change in Health Benefits Enrollment Part A - Identifying Information 2. Date of birth 5. Payroll office number 3. Social security number 6. Enrollment code number 1. Name (Last, first, middle initial) 4. Home address (including ZIP Code) 7. SF 2811 Report number 8. Date this action becomes effective Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions. Keep this form for your records. Part B - Termination Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date. Important Notice: You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have the right to temporarily continue your group coverage. See Part B - Termination on the back of this form for information about 31-day extension of coverage, conversion, and temporary continuation of coverage. If termination is due to death of enrollee enter date of death Date of death (mo, dy, yr) Part C - Transfer In The new Payroll Office (or Retirement System) shown in Part H below has accepted transfer of this enrollment and will continue it. Part D - Reinstatement Your enrollment has been reinstated effective on the date in Part A, item 8, above. Part E - Change in Name of Enrollee The name under which this enrollment is carried has been changed to: Name Date of Birth Part F - Change In Enrollment-Survivor Annuitant Your enrollment has been changed from family coverage to self only. Your plan will send you a new identification card. Your new enrollment code number is shown below. (Note: This item is completed by Retirement Systems only.) Address (including ZIP Code) if different from Part A, item 4, above. New Enrollment Code Number Part G - Remarks Part H - Date of Notice Note: Instructions for Employing Offices are on the back of Copy 4 of this form. Name and address of agency (including ZIP Code) Personnel contact and telephone number ( Payroll contact and telephone number ( Signature of authorized agency official Date ) ) U.S. Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices Copy 1 - To Enrollee NSN 7540-01-232-1234 Previous edition is usable 2810-104 Standard Form 2810 Revised June 1995 American LegalNet, Inc. www.FormsWorkFlow.com Part B - Termination If Part B on the other side of this form is checked, read the following instructions carefully. 31-Day Extension of Coverage Your enrollment terminates on the date shown in Part A, item 8, on the front of this form. Coverage under your enrollment continues temporarily for 31 days from the date shown. If you, or any covered member of your family, are a patient in a hospital on the 31st day of this temporary extension, benefits of the plan may continue for the rest of that confinement, but not beyond 60 more days. Conversion to Nongroup Contract You may convert your enrollment to a nongroup contract, without evidence of good health. The nongroup contract to which you may convert is one regularly offered by your plan. It may differ from your group plan in benefits, or cost, or both, and you will have to pay the entire cost of the nongroup contract directly to the plan. The nongroup contract is effective on the day after your 31-day extension of coverage ends. If you are interested in converting to a nongroup contract, write for information to the nearest office of the plan in which you have been enrolled (see the plan's brochure or ask your employing office for the address of the plan's nearest office). The plan will promptly send you an application form and details concerning benefits and rates of the nongroup contract to which you may convert. Time Limit on Conversion Normally, to be eligible for conversion, you must send your written request for information to your plan within 31 days after the date shown in Part H. However, if the date shown in Part H is more than 60 days after the date your enrollment terminates (Part A, item 8), you must forward it to your plan within 91 days after the date shown in Part A, item 8. If you are prevented by causes beyond your control from submitting a timely request for information about conversion to a nongroup contract, you should write to your plan as soon as possible asking approval of a belated conversion opportunity. Explain fully the circumstances that prevented earlier action and attach proof of the loss of group coverage (e.g., Standard Form 50 terminating Federal employment). A plan may consider requests filed within 6 months after group eligibility ends. If your plan needs assistance in processing your request, it should contact OPM. Temporary Continuation of Coverage If you are an employee whose enrollment is terminating because you are separating from service (including separation for retirement), you may be eligible to temporarily continue your benefits coverage under the Federal Employees Health Benefits Program after separation. Within 61 days after the date shown in Part A, item 8, on the front of this form, your employing office will formally notify you of your rights regarding temporary continuation of coverage and tell you where you may obtain additional information. You will have 60 days after the later of (1) your date of separation from service, or (2) the date you receive the notice from your employing office in which to elect temporary continuation of coverage. When your temporary continuation of coverage expires, you will be entitled to the 31-day extension of coverage and the opportunity to convert to a nongroup contract. Entry on Active Military Duty If you elected to terminate your enrollment because you are entering military service, you may convert to a nongroup contract even though your family members are entitled to care under the Uniformed Services Health Benefits Program. If you return to civilian duty in the exercise of reemployment rights, your enrollment will be reinstated effective on the day you return to active duty. If you return to civilian duty not in the exercise of reemployment rights, you must, if eligible for coverage, register again the same as a new employee. If you are an annuitant, your enrollment will be reinstated on the day you are separated from military service. You must notify your retirement system of this event by furnishing a copy of your separation papers. Part C - Transfer of Enrollment If Part C on the othe