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Form opm 3206 0160-2026

The document is the Employee Health Benefits Election Form (SF 2809) used for enrolling in, changing, or canceling participation in the Federal Employees Health Benefits (FEHB) Program. It outlines eligibility criteria for employees, former spouses, and individuals eligible for temporary continuation of coverage. The form includes instructions for completion, details on permissible changes in enrollment due to life events, and privacy information regarding the handling of personal data.

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Click ‘Get Form’ to open it in the editor.
In Part A, enter your last name, first name, and middle initial. Provide your Social Security Number and date of birth in the specified format.
Fill in your home mailing address and indicate your sex and marital status by placing an 'X' in the appropriate boxes.
Provide a daytime telephone number where you can be reached during business hours.
In Part B, select the health benefits plan you wish to enroll in by entering the plan name and enrollment code from the brochure.
If enrolling for Self and Family, complete items 2a through 2f with family members' details including names, dates of birth, and relationship codes.
Complete Part G by signing and dating the form. Ensure all information is accurate before submission.

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