Direct Premium Remittance System (DPRS)

Forms That are Required for DPRS

Forms associated with DPRS activities are described below.

SF 2809, Employee 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 or re-enroll in the FEHB Program.
• Elect not to enroll in the FEHB Program (employee only).
• Change enrollee's plan.
• Change coverage within a plan.
• Cancel FEHB enrollment of an enrollee who elected to end coverage though continues to be eligible for it, and no extension of coverage is grant.
• Suspend FEHB enrollment (annuitants or former spouses only).

SF 2810, Notice of Change in Health Benefits Enrollment

This form is used to:

• Terminate:
  • Enrollee employed by the Federal Government who leaves Government service
  • Enrollee employed by the Federal Government who exceeds 365 days in non-pay status and is eligible for a 31-day extension of coverage
  • Conversion to Nongroup Contract
  • Time Limited on Conversion
  • Temporary Continuation of Coverage
  • Entry on Active Military Duty
• Transfer:
  • Employment
  • Retirement
  • Death
  • Employees' compensation
• Reinstate enrollment.
• Change the name of an enrollee.
• Change the enrollment to a survivor annuitant.

Note: The SF 2809 and SF 2810 options in DPRS are formatted to include data elements from the forms listed above, as well as the data elements from the SF 2809 and SF 2810 options in Employee Express.