CLER for NFC

Forms

Forms associated with CLER Federal Employees Health Benefits, Centralized Enrollment Clearinghouse System activities are described below.

Note: The 2809 and 2810 options in CLER Federal Employees Health Benefits, Centralized Enrollment Clearinghouse System are formatted to include data elements from the forms listed below, as well as the data elements from the 2809 and 2810 options in Employee Express.

SF 2809, Health Benefits Election Form

This form is used by (1) Federal employees eligible to enroll in or currently enrolled in the FEHB Federal Employees Health Benefits program, (2) former spouses of Federal employees eligible to enroll in or currently enrolled in the FEHB Federal Employees Health Benefits program under the Spouse Equity law, and (3) individuals eligible for temporary continuation of coverage under the FEHB Federal Employees Health Benefits program to:

• Enroll eligible persons in the FEHB Federal Employees Health Benefits program.
• Elect not to enroll in the FEHB Federal Employees Health Benefits program.
• Change an enrollee’s plan.
• Change coverage within a plan.
• Cancel the FEHB Federal Employees Health Benefits enrollment of an enrollee who elected to end his/her coverage though he/she continues to be eligible for it, and no extension of coverage is granted.

SF 2809-1, Health Benefits Election Form

This form is used by (1) annuitants (other than Civil Service Retirement System (CSRS) and Federal Employees Retirement System (FERS) annuitants) eligible to enroll in or currently enrolled in the FEHB Federal Employees Health Benefits program, including individuals receiving monthly compensation from the Office of Workers’ Compensation Programs, (2) former spouses of annuitants (other than CSRS Civil Service Retirement System and FERS Federal Employees Retirement System annuitants) eligible to enroll in or currently enrolled in the FEHB Federal Employees Health Benefits program under the Spouse Equity law, and (3) individuals eligible for temporary continuation of coverage under the FEHB Federal Employees Health Benefits program to:

• Enroll in the FEHB Federal Employees Health Benefits program.
• Change FEHB Federal Employees Health Benefits enrollment from Self Only to Self and Family and/or from the present plan or option to another plan or option.
• Change FEHB Federal Employees Health Benefits enrollment from Self and Family to Self Only.
• Cancel FEHB Federal Employees Health Benefits enrollment.

SF 2810, Notice of Change in Health Benefits Enrollment

This form is used to:

• Terminate the enrollment of (1) an enrollee employed by the Federal Government who leaves Government service, or (2) an enrollee employed by the Federal Government who exceeds 365 days in non-pay status and is eligible for a 31-day extension of coverage.
• Reinstate enrollment.
• Change the name of an enrollee.
• Change the enrollment to a survivor annuitant.

CLERC, Security Access Form, Health Benefit Carrier Personnel

This form is completed by a carrier’s computer system security officer and submitted to NFC National Finance Center’s CLER Operations to request CLER Federal Employees Health Benefits, Centralized Enrollment Clearinghouse System access for carrier personnel.

CLERP, Security Access, Payroll Office/Human Resource Office Personnel

This form is completed by an Agency's computer system security officer and submitted to NFC National Finance Center's CLER Operations to request CLER Federal Employees Health Benefits, Centralized Enrollment Clearinghouse System access for Agency personnel.