SF2809
Health Benefits Election Form
Standard Form 2809 (SF 2809) is the Health Benefits Election Form for the Federal Employees Health Benefits (FEHB) Program. The form carries the name of the U.S. Office of Personnel Management (OPM), and its Privacy Act statement explains why OPM collects the information. GSA hosts a copy in its forms library.
The form lists six uses: enroll or reenroll in FEHB, elect not to enroll (employees only), change your enrollment, cancel it, suspend it (annuitants or former spouses only), or switch your designated eligible family member. The instructions and the Tables of Permissible Changes in Enrollment fill the first 16 pages, and the form itself is two pages.
The form says CSRS and FERS annuitants, and former spouses and children of CSRS or FERS annuitants, use form OPM 2809 instead. OPM estimates an average of 30 minutes to complete it. You can fill it out free in your browser on this page and download the result without an account.
Items 1 to 12 ask for your name, Social Security Number, date of birth, sex, marital status, address, Medicare parts and Medicare Beneficiary Identifier, other insurance, email and phone. Items 13 to 48 repeat these for up to three family members, with a relationship code.
The plan name from the front cover of the plan brochure and your current enrollment code from your plan ID card. The instructions say this part is completed when changing, cancelling or suspending an enrollment.
The name and enrollment code of the plan you are enrolling in or changing to. The code is on the brochure cover and shows the plan, the option and Self Only, Self Plus One or Self and Family.
The event code for your Qualifying Life Event from the Table of Permissible Changes that applies to you, and the date of the event. For open season, the instructions say to enter the date the open season begins.
Part E is an election not to enroll (employees only), Part F cancels an enrollment, and Part G suspends one (annuitants and former spouses only). Each is a single box marked with an X.
Part H holds your signature and date under a warning about false statements (18 U.S.C. 1001). Part I is for the agency or retirement system only and is left blank.
Pages 6 to 16 hold the Tables of Permissible Changes, grouped into five enrollee categories: employees in premium conversion, annuitants, Spouse Equity former spouses, TCC enrollees, and employees who waived premium conversion.
Each event code is a number for your category and a letter for the Qualifying Life Event, such as 1A for an employee's initial opportunity to enroll. Its row also shows when the form is filed.
Type or print. Add each family member covered by a Self Plus One or Self and Family enrollment. For more family members, the form says to list them on a separate sheet and attach it.
Copy the plan name and enrollment code from the plan brochure into Part C, and your current plan into Part B when changing. Or mark Part E, F or G instead.
Sign and date Part H. Someone registering for another person under a written authorization signs and attaches it. A court-appointed guardian of a Spouse Equity former spouse or a TCC enrollee attaches evidence of the guardianship.
Hand the form to the office of the agency or retirement system that handles your health benefits. The form says many agencies also offer an automated system, such as Employee Express.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form defines the employing office as the office of an agency or retirement system responsible for health benefits actions for an employee, annuitant, Spouse Equity former spouse or person eligible for TCC.
Each event code row in the tables gives the time limit for filing with the employing office, for example within 60 days after becoming eligible (1A) or as announced by OPM for open season.
Except for open season, the form says most enrollments and changes take effect on the first day of the pay period after the employing office receives the form and that follows a pay period during any part of which the employee is in pay status. The employing office can give the exact date.
The form says your signature in Part H authorizes deductions from your salary, annuity or compensation to cover your cost of the enrollment, unless you make direct payments to the employing office.
The agency gives a copy of the completed form to the Official Personnel Folder, the new carrier, the old carrier, the payroll office and the enrollee.
The form lists four groups who may use it, and points one group to a different form.
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The form says CSRS and FERS annuitants, and former spouses and children of CSRS or FERS annuitants, use form OPM 2809 instead, available at www.opm.gov/forms/OPM-forms or from the Retirement Information Office at 1-888-767-6738. To cancel or suspend, it points them to form RI 79-9.
For the plan you are enrolling in (Part C), the code is on the front cover of that plan's brochure. For your current plan (Part B), the form says to use the code on your plan ID card.
It depends on the event code. Each row of the Tables of Permissible Changes lists when the form is filed with the employing office, such as within 60 days after becoming eligible for an employee's initial opportunity to enroll, or as announced by OPM for open season.
Except for open season, the form says most enrollments and changes take effect on the first day of the pay period after the employing office receives the form and that follows a pay period during any part of which the employee is in pay status. The employing office can give the specific date.
The form has room for three family members in items 13 to 48. For more, the form says to list them on a separate sheet and attach it.
The instructions for item 14 say to leave it blank, and that benefits will not be withheld.
The form says many agencies use automated systems, such as Employee Express, that let employees make changes by touch-tone telephone or computer instead of a form. It says to contact your employing office if you are not sure the option is available.
