SF2810

Notice of Change in Health Benefits Enrollment

Agency
GSA
Revision
Revised June 1995
Fillable fields
29
Pages
7
Official source
GSA form page
Checked
October 20, 2026
Fill SF2810 online
Page 1 of form SF2810

Standard Form 2810 (SF 2810): Notice of Change in Health Benefits Enrollment

Standard Form 2810 (SF 2810), Notice of Change in Health Benefits Enrollment, is a Federal Employees Health Benefits Program notice. It is a U.S. Office of Personnel Management (OPM) form, Revised June 1995, listed under the CSRS/FERS Handbook for Personnel and Payroll Offices. GSA hosts a copy in its forms library.

The Instructions for Employing Offices say it covers health benefits actions except enrollments, changes from one plan to another, changes of coverage within a plan and cancellations, which are processed on the Health Benefits Registration Form (SF 2809). The actions it reports are termination, transfer in, reinstatement, a change in the enrollee's name and a change to self only for a survivor annuitant.

An employing office or retirement system prepares the notice, and an authorized agency official signs it. The form has four copies: for the enrollee, the insurance carrier, the payroll office and the Official Personnel Folder. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Standard Form 2810 (SF 2810): Notice of Change in Health Benefits Enrollment, as printed by GSA

What's on SF 2810

Part A: identifying information

Name, date of birth, Social Security number, home address, payroll office number, enrollment code number, SF 2811 report number and the date the action becomes effective.

Part B: termination

The enrollment terminates on the date in item 8, and coverage is extended for 31 days after that date. If termination is due to the enrollee's death, the date of death is entered.

Parts C and D: transfer in and reinstatement

Part C shows that the new payroll office or retirement system in Part H has accepted the enrollment. Part D shows the enrollment was reinstated on the date in item 8.

Parts E and F: name change and survivor annuitant

Part E gives the new name under which the enrollment is carried. Part F changes a survivor annuitant's enrollment from family coverage to self only and shows the new enrollment code number.

Parts G and H: remarks and date of notice

Remarks that clarify or support the action, then the agency name and address, personnel and payroll contacts with telephone numbers, and the signature of an authorized agency official with the date.

Back of Copy 1: notes for the enrollee

Information on the 31-day extension of coverage, conversion to a nongroup contract, temporary continuation of coverage, entry on active military duty, and transfer of the enrollment on retirement, death or employees' compensation.

The front of each copy has Parts A to H. Only the part that is checked applies to the enrollment.

How SF 2810 is completed

  1. 1

    Copy Part A from the last record

    The instructions say to transcribe items 1, 2 and 6 from the last SF 2809 or SF 2810, whichever is most recent, use the most recent known address in item 4, and the payroll office number of the office authorized to process withholdings in item 5.

  2. 2

    Date the action in item 8

    For a termination, the last day of the pay period in which separation occurs, with separate rules for 365 days in nonpay status and military duty. For a transfer in, reinstatement or name change, the actual date.

  3. 3

    Check the part that applies

    Part B lists the most frequent terminating actions, such as separated, retired and not eligible to continue, and temporary continuation of coverage expired. For Part D, the reason for any action not tied to active military duty goes in Remarks.

  4. 4

    Sign and date Part H

    The instructions say a facsimile signature is acceptable and the notice is dated as of the day of issuance.

  5. 5

    Give Copy 1 to the enrollee

    Deliver or mail it to the employee, annuitant or survivor at the earliest possible date, but before 60 days from the date in Part A, item 8.

  6. 6

    Send and file the other copies

    Copies 2 and 3 go to the insurance carrier and the payroll office, and Copy 4 is filed in the Official Personnel Folder or its equivalent.

These steps follow the Instructions for Employing Offices on the back of Copy 4.

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Where the copies go and what the form says

Carrier copy

The disposition instructions say Copy 2 goes to the carrier attached to the SF 2811 at the earliest possible date, and that SF 2810s should under no circumstances be accumulated for longer than a week or delayed to coincide with payroll deductions.

Copy 4 on death or retirement

In cases of death or retirement under CSRS or FERS, Copy 4 goes to OPM with the Official Personnel Folder copy of each SF 2809, any Medical Certificates, the Individual Retirement Record (SF 2806 or SF 3100) and other applicable documents. For other retirement systems, including OWCP, they go to the office administering the system.

Conversion time limit

The back of Copy 1 says a written request for conversion information normally goes to the plan within 31 days after the date in Part H. If that date is more than 60 days after the enrollment terminates, the limit is 91 days after the date in Part A, item 8.

Temporary continuation of coverage

For employees separating from service, the form says the employing office will formally notify them of their rights within 61 days after the date in Part A, item 8, and they then have 60 days after the later of separation or receipt of that notice to elect it.

Related forms

Who prepares and receives SF 2810?

  • Employing offices

    The instructions say to prepare SF 2810 as soon as the effective date is known and give the copies to the enrollee and payroll office immediately, without waiting for SF 50 action on a transfer to another payroll office.

  • Retirement systems

    Only agencies administering retirement systems complete Part F. Retirement systems, including OWCP, that accept a transfer in also show in Remarks whether the enrollment is for an Employee Annuitant or a Survivor Annuitant.

  • Enrollees

    The employee, annuitant or survivor named in Part A receives Copy 1. The form says only the item that is checked affects the enrollment, and to keep the form for your records.

  • Insurance carriers and payroll offices

    Copy 2 goes to the insurance carrier, attached to the Transmittal Report to Carrier (SF 2811). Copy 3 goes to the payroll office, which may use it as a payroll action document.

SF 2810 is prepared by an agency office, not by the enrollee. The instructions on the back of Copy 4 describe each role.

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Questions about Form SF2810

Who issues SF 2810?

The form is printed as a U.S. Office of Personnel Management form, Revised June 1995, and lists the CSRS/FERS Handbook for Personnel and Payroll Offices. GSA hosts a copy in its forms library.

Is SF 2810 used to enroll or change plans?

No. The instructions say enrollments, changes from one plan to another, changes of coverage within a plan and cancellations are processed on the Health Benefits Registration Form (SF 2809). SF 2810 covers the other health benefits actions.

Who fills out SF 2810?

The employing office prepares it, and Part F is completed by retirement systems only. An authorized agency official signs Part H. The enrollee receives Copy 1, and the form has no signature line for the enrollee.

How long does coverage last after a termination?

Part B says coverage is extended for 31 days after the termination date in Part A, item 8. The back of Copy 1 says that if the enrollee or a covered family member is a hospital patient on the 31st day, plan benefits may continue for the rest of that confinement, but not beyond 60 more days.

What does the form say about converting to an individual contract?

The back of Copy 1 says the enrollment may be converted to a nongroup contract regularly offered by the plan without evidence of good health. The enrollee pays the entire cost directly to the plan, and it is effective the day after the 31-day extension ends.

When does the enrollee get Copy 1?

The disposition instructions say Copy 1 is delivered or mailed to the employee, annuitant or survivor at the earliest possible date, but before 60 days from the date in Part A, item 8.