Standard Form (SF) 2809, Employees Health Benefits Registration Form

This section includes instructions and definitions of the fields on SF 2809.

The following fields are available on the SF 2809, Employees Health Benefits Registration form:

Add/Edit Family Member Information

Select the checkbox if you are editing the family member information. This field defaults to a blank checkbox.

Address Line 2

Enter the second line of the enrollee's address, if applicable.

Address Line 2

Enter the second line of the family member's address, if applicable.

Are you covered by Insurance other than Medicare?

Select the applicable radio button to indicate whether the enrollee is covered by insurance other than Medicare. Valid values are:

Are you covered by Insurance other than Medicare? - Family Member

Select the applicable radio button if the family member is covered by insurance other the Medicare. Valid values are:

Are You Married?

Select the enrollee's marital status. Valid values are:

Authorizing Official

Enter the authorizing official's name.

City - Enrollee

Enter the enrollee's city.

City - Family Member

Enter the city of the family member.

Date of Birth

Enter the enrollee's date of birth in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Date of Birth for the Family Member

Enter the family member's date of birth in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Date of Event

Enter the enrollee's event date in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Date Received

Enter the date received in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Effective Date of the Action

Enter effective date of coverage in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.

Email Address

Enter the enrollee's email address.

Email Address Family Member

Enter the email address of the family member.

Enrollee First Name

Enter the enrollee's first name.

Enrollment Code

Displays the enrollment code if the enrollee is currently enrolled in Federal Employees Health Benefits (FEHB).

Enrollment Code

Enter the enrollee's current enrollment code, if applicable.

Event Code

Enter the event code that permits the enrollee to enroll, change, or cancel FEHB coverage.

First Name - Enrollee

Enter the enrollee's first name.

First Name

Enter the family member's first name.

Home Mailing Address

Enter the enrollee's home mailing address.

Home Mailing Address

Enter the family member's mailing address.

I CANCEL My Enrollment

Select the checkbox if the enrollee is canceling their enrollment. This field defaults to a blank checkbox.

Indicate Other Types of Insurance

Select the enrollee's other types of insurance, if applicable. Valid values are:

Tricare
FEHB
Other

‎Indicate Other Types of Insurance

Select the family member's other types of insurance, if applicable. Valid values are:

Tricare
FEHB
Other

Information Only

Select this checkbox if the form is for information only. The default is a blank checkbox.

Last Name

Enter the enrollee's last name.

Last Name

Enter the family member's last name.

Medicare if you are covered by, Medicare, check all that apply - Family Member if applicable

Select if the family member is covered by Medicare. Valid values are:

Medicare Claim Number

Enter the enrollee's Medicare claim number.

Medicare Claim Number

Enter the family member's Medicare claim number.

Medicare if you are covered by, Medicare, check all that apply - Enrollee if applicable

Select if the enrollee is covered by Medicare. Valid values are:

Middle Name

Enter the enrollee's middle name, if applicable.

Middle Name

Enter the family member's middle name, if applicable.

Name and Address of the Tribal Employer

Enter the name and address of the tribal employer.

Name of Insurance - Enrollee

Enter the name of the enrollee's insurance if Other was selected on the Indicate other types of insurance field.

Name of Insurance - Family Member

Enter the name of the family member's insurance.

Part A - Enrollee Information Continued Member's Last Name

Enter the family member's last name.

Payroll Office Number

Displays the payroll office number.

Personnel Telephone Number

Enter the telephone number of the tribal office in (xxx) xxx-xxxx format.

Plan Name

Displays the plan name if the enrollee is currently enrolled in FEHB.

Plan Name - Currently Enrolled In

Displays the current plan name.

POI

Select the enrollee's POI.

Policy No.

Enter the enrollee's policy number if Other was selected on the Indicate other types of insurance field.

Policy No.

Enter the family member's policy number if Other was selected on the Indicate other types of insurance field.

Preferred Telephone Number - Enrollee

Enter the enrollee's preferred telephone number in (xxx) xxx-xxxx format.

Preferred Telephone Number

Enter the preferred telephone number for the enrollee's family member in (xxx) xxx-xxxx format.

Premium Conversion

Select the checkbox if the enrollee is eligible for premium conversion. Premium conversion designates whether the user has pre-tax premiums. If this checkbox is not checked, there are tax consequences resulting in the FEHB premium being taxed.

Note: This field defaults to the checkbox being checked.

Relationship Type

Select the relationship type.

Remarks

Enter any tribal employer remarks, if applicable.

Service Provider Contact

Displays the name of the service provider (e.g., National Finance Center).

Sex

Select the sex of the enrollee. Valid values are:

Male
Female

Sex

Select the sex of the family member. Valid values are:

Male
Female

Social Security Number

Enter the enrollee's SSN.

Social Security Number

Enter the family member's SSN.

State

Select the enrollee's State.

State

Select the family member's State.

Submit Date

Displays the current date.

Submit ID

Displays the ID of the current user.

Telephone Number

Enter the enrollee's telephone number in (xxx) xxx-xxxx format.

Tribe

Select the name of the tribe.

ZIP

Enter the enrollee's ZIP code.

ZIP

Enter the family member's ZIP code.