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Omb no 3206 0141 2011 form

Omb no 3206 0141 2011 form-2025

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The document is the OPM Form 2809, a Health Benefits Election Form for annuitants and former spouses of annuitants under the Federal Employees Health Benefits (FEHB) Program. It provides instructions for completing the form, details on family member eligibility for health coverage, and guidelines for enrollment changes, cancellations, and suspensions. The form requires personal information such as names, Social Security numbers, dates of birth, and health insurance details for both the enrollee and their family members.

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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 email address in the designated fields. This ensures you receive any necessary communications regarding your enrollment.
Fill out family member information by entering their names, Social Security numbers, dates of birth, and relationship codes. Use the provided codes for clarity.
In Part B, indicate the FEHB plan you are currently enrolled in by entering the plan name and enrollment code.
If applicable, complete Part C to specify any changes to your FEHB plan or enroll in a new one.
Finally, sign and date the form in Part F to authorize your application. Review all entries for accuracy before submission.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (82 Votes)
2015	4.3 Satisfied (340 Votes)
2014	4.4 Satisfied (802 Votes)
2011	4 Satisfied (24 Votes)
2011	4.4 Satisfied (226 Votes)
2004	4 Satisfied (49 Votes)

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What is an enrollment code?

322 - Self and Family High Option Plan.

What is the health benefits election form?

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.