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SF 2809, Health Benefits Election Form
This topic has been updated to replace SF 2809 with the latest version. The Medicare Claim Number field has been changed to Medicare Beneficiary Identifier.
See Appendix II, Instructions on Completing the SF 2809 for detailed instructions on completing SF 2809.
SF 2809, Health Benefits Election Form
Part A - Enrollee and Family Member's Information
Field |
Description/Instruction |
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Enrollee name |
Enter last, first, and middle initial. |
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Social Security Number |
Enter Social Security number (SSN). |
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Date of birth |
Enter Date of Birth (mm/dd/yyyy). |
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Sex |
Check the appropriate block (M - Male or F - Female). |
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Are you married? |
Check the appropriate block (Y - Yes or N - No). Note: If you are separated but not divorced, you are still married. |
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Home mailing address |
Enter enrollee's mailing address. |
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If you are coved by Medicare |
Check all that apply (A, B, or D). |
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Medicare Claim Number |
Enter Medicare Claim Number. Note: This number is on your Medicare card. |
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Are you covered by insurance other than Medicare? |
Check the appropriate block (Yes, indicate in item 10 below or No). |
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Indicate the type(s) of other insurance: |
Check all that apply (TRICARE, FEHB, or Other). |
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Email address |
Enter enrollee's email address. |
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Preferred telephone number |
Enter the enrollee's preferred telephone number. |
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Name of family member |
List all eligible family members (last, first, and middle initial). Spouse must be listed first. |
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Social Security number |
Enter the dependent's SSN. |
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Date of birth |
Enter the dependent's date of birth, (mm/dd/yyyy). |
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Sex |
Check the appropriate block, (M = Male or F = Female). |
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Relationship code |
Enter the appropriate code as follow:
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Address |
Enter the street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address, (number and street). |
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If this family member is covered by Medicare |
Check all that applies. Note: Including prescription drug coverage under Medicare Part D. |
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Medicare Claim Number |
Enter the Medicare Claim number. Note: This number is on your Medicare card. |
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Is this family member covered by insurance other than Medicare? |
Check the appropriate block, (Yes, indicate in item 34 below or No). |
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Indicate the type(s) of other insurance |
Check all that apply (TRICARE, FEHB, or Other). |
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Email address |
Enter the dependent's or enrollee's email address. |
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Preferred telephone number |
Enter the dependent's or enrollee's preferred telephone number. |
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Name of family member |
List all eligible family members (last, first, and middle initial). Spouse must be listed first. |
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Social Security number |
Enter the dependent's SSN. |
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Date of birth |
Enter the dependent's date of birth, (mm/dd/yyyy). |
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Sex |
Check the appropriate block, (M = Male or F = Female). |
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Relationship code |
Enter the appropriate code as follow:
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Address |
Enter the street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address, (number and street). |
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If this family member is covered by Medicare |
Check all that applies. Note: Including prescription drug coverage under Medicare Part D. |
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Medicare Claim Number |
Enter the Medicare Claim number. Note: This number is on your Medicare card. |
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Is this family member covered by insurance other than Medicare? |
Check the appropriate block, (Yes, indicate in item 34 below or No). |
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Indicate the type(s) of other insurance |
Check all that apply (TRICARE, FEHB, or Other). |
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Email address |
Enter the dependent's or enrollee's email address. |
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Preferred telephone number |
Enter the dependent's or enrollee's preferred telephone number. |
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Name of family member |
List all eligible family members (last, first, and middle initial). Spouse must be listed first. |
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Social Security number |
Enter the dependent's SSN. |
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Date of birth |
Enter the dependent's date of birth, (mm/dd/yyyy). |
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Sex |
Check the appropriate block, (M = Male or F = Female). |
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Relationship code |
Enter the appropriate code as follow:
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Address |
Enter the street or rural route, city, State, and ZIP Code of the separated employee, child, or ex-spouse's mailing address, (number and street). |
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If this family member is covered by Medicare |
Check all that applies. Note: Including prescription drug coverage under Medicare Part D. |
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Medicare Claim Number |
Enter the Medicare Claim number. Note: This number is on your Medicare card. |
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Is this family member covered by insurance other than Medicare? |
Check the appropriate block, (Yes, indicate in item 34 below or No). |
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Indicate the type(s) of other insurance |
Check all that apply (TRICARE, FEHB, or Other). |
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Email address |
Enter the dependent's or enrollee's email address. |
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Preferred telephone number |
Enter the dependent's or enrollee's preferred telephone number. |
Enter the Enrollee name and Date of birth at the top of the page.
Part B - FEHB Plan You Are Currently Enrolled In (if applicable)
Item Number |
Description |
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Plan name |
Enter the plan name. |
Enrollment code |
Enter the enrollment code. |
Part C - FEHB Plan You Are Enrolling In or Changing To
Item Number |
Description |
Plan name |
Enter the elected health benefits plan name. |
Enrollment code |
Enter the elected health benefits plan three digit enrollment code. |
Part D - Event That Permits You to Enroll, Change, or Cancel
Item Number |
Description |
Event code |
Enter the event code. |
Date of event |
Enter the date of event. |
Part E - Election NOT to Enroll (Employees Only)
I do NOT want to enroll in the FEHB Program Note: Signature in Part H certifies that they have read and understand the information on page 3 regarding this election. |
Part F - Cancellation of FEHB
I CANCEL my enrollment Note: Signature in Part H certifies that they have read and understand the information on page 3 regarding cancellation of enrollment. |
Part G - Suspension of FEHB (Annuitants/Former Spouses Only)
I SUSPEND my enrollment. Note: Signature in Part H certifies that they have read and understand the information on page 4 regarding suspension of enrollment. |
Part H - Signature
WARNING: Any intentionally false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years or both. (18 U.S.C. 1001.)
Item Number |
Description |
Your signature |
Sign the SF 2809 form, (do not print). |
Date |
Enter the date the form was signed, (mm/dd/yyyy). |
Part I - To Be Completed by Agency or Retirement System
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.
Item Number |
Description |
Date received |
Enter the date received, (mm/dd/yyyy). |
Effective date of action |
Enter the effective date of action, (mm/dd/yyyy). |
Personnel telephone number |
Enter the Personnel telephone number. |
name and address of agency or retirement system |
Enter the name and address of Agency or retirement system. |
Authorizing official |
Enter the name of the Authorizing official (please print) |
Signature of authorized agency official |
Enter Signature of authorized Agency official. |
Payroll office number |
Enter the Payroll office number. |
Payroll office contact |
Enter the Payroll office contact (please print) |
Payroll telephone number |
Enter the Payroll telephone number. |
See AlsoSF 2810, Notice of Change in Health Benefits Enrollment SF 2809, Types of New Enrollments SF 2810 and Original SF 2809 for Transfer Enrollees SF 2809 and SF 2810 for Corrections |