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Click ‘Get Form’ to open the OMB No. 3206 0141 2011 form in the editor.
Begin with Part A, where you will enter your legal name, Social Security number, date of birth, and sex. Ensure all information is accurate.
Provide your mailing address and indicate if you are married. If applicable, check the boxes for Medicare coverage and provide your Medicare Claim Number.
List any family members you wish to enroll by entering their names, Social Security numbers, dates of birth, and relationship codes in the designated fields.
In Part B, specify the FEHB plan you are currently enrolled in by entering the plan name and enrollment code.
If changing plans or canceling enrollment, complete Part C and D by providing the new plan name and event code that permits this change.
Finally, sign and date Part F to authorize your application. Review all entries for accuracy before submitting.
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The SF 2809 was written for all Federal employees and not all parts of the SF 2809 apply to tribal employees. You must complete the SF 2809 in order to: enroll in the FEHB Program during your Initial Enrollment Opportunity. enroll, change, or cancel your FEHB enrollment during the annual Open Season.
How do I find my FEHb enrollment code in OPM?
Enrollment codes are found on the front cover of each plans brochure.
What is the enrollment code for FEP?
The FEP FEHB membership cards are identified by coverage codes 104, 105, and 106 for the FEP Blue Standard Option and 111, 112, and 113 for the FEP Blue Basic Option. FEP Blue Focus enrollment codes are 131, 132, and 133.
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OPM Form 2809. Revised March 2011. Previous editions are not usable. Health Benefits Election Form. Form Approved: OMB No. 3206-0141. Page 2. Items 1 and 2
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