Appendix III, Instructions on Completing the SF 2810

SF 2810, Notice of Change in Health Benefits Enrollment
Part A - Identifying Information

Field	Description
Name	Enter the enrollee's name (Last, first, and middle initial).
Date of birth	Enter the date of birth (mm/dd/yyyy).
Social security number	Enter the enrollee's SSN.
Home address	Enter the enrollee's home address (including ZIP Code).
Payroll office number	Enter the Payroll office number.
Enrollment code number	Enter the enrollment code number.
SF 2811 Report number	Enter the SF 2811 Report number.
Date this action becomes effective	Enter the date this action became effective.

Note: Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions. Keep this form unless enrollment is terminated and applying for conversion.

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. If termination is due to death of enrollee, enter date of death. Place an "X" in the box if the enrollee wishes to terminate.

Part C - Transfer In

Place an "X" in the box if the new payroll office has accepted transfer of this enrollment.

Part D - Reinstatement

Place an "X" in the box if enrollment has been reinstated.

Part E - Change in Name of Enrollee

Field	Description

Name	Enter the name under which this enrollment is carried has been changed to (Last, first, and middle initial).
Date of birth	Enter the date of birth (mm/dd/yyyy).
Address	If different from Part A, item 4, above (including ZIP Code). Place an "X" in the box if name under which this enrollment is carried has been changed.
Address

Part F - Change in Enrollment - Survivor Annuitant

Place an "X" in the box if enrollment has been changed from family coverage to self only. Your plan will send you a new identification card. A new enrollment code number will be issued.

Part G - Remarks

Enter the appropriate remarks. Also, please enter the name and telephone number of the person completing this form in the Remarks block.

Example: Form Completed by: Jane Doe, Telephone No. (123) 456-7890.

Part H - Date of Notice

Name and address of Agency	Enter the name and address of the Agency, including ZIP Code.
Personnel contact and telephone number	Enter the Personnel contact person and telephone number.
Payroll contact and telephone number	Enter the Payroll contact person and telephone number.
Signature of authorized agency official	Enter the signature of the authorized Agency official.
Date	Enter the date the authorized Agency official signed the form. Note: If the document is not signed, it will be returned.

Direct Premium Remittance System (DPRS)