Direct Premium Remittance System (DPRS)

New Enrollee SF2809 Part A Family Information

The SF 2809 Part A is used to establish enrollment for a family policy.

To Establish Enrollment for a Family Policy:

1. On the SF 2809 Part A page, select the Family Info option to enter the dependent information. The SF2809 Part A Family Information page is displayed.

   

2. Complete SF2809 Part A, Enrollee Info fields as follows:

   First Name

   Middle Initial

   Last Name

   Social Security Number

   Date of Birth

   Sex

   Relationship

   Country

   Domestic

   Address 1

   Address 2

   City

   State

   Zip

   Home Phone

   Work Phone

   Cell Phone

   Email

   Other Insurance

   Medicare Claim Number

   Other Insurance Name

   Insurance Policy Number

3. Select the Add Family button.
4. Once the required fields are completed, select the Save SF2809 button.

   Note: If there are errors upon saving, an error message will appear. A list of the fields that are missing the required information will be displayed. If an error occurred upon saving the record, return to Part A and verify that all fields are completed.

To Edit Enrollment for Family Policy

1. To make a change to a family member, select the family member.
2. Select the Edit button.
3. Update the required fields.
4. Select the Update Family button.

   

5. Once the dependent is updated, the dependent's information will display at the bottom of the page.

   Note: To edit or delete the dependent's information, select the Edit or Delete button.

   Edit

   Delete

6. If no additional information is needed, select the Save SF2809 button to continue to Part B.

   Note: To add more family members, select Add Family button. To clear the family information fields for unsaved changes, select the Reset Family button.