Fillable Printable SF 2810
Fillable Printable SF 2810
SF 2810
8. Date this action becomes
effective
Your enrollment has been changed from family coverage to self
only. Your plan will send you a new identification card.
Your new enrollment code number is shown below.
(Note: This item is completed by Retirement Systems only.)
Copy 1 - To Enrollee
( )
Notice of Change in Health Benefits Enrollment
Part A - Identifying Information
Part B - Termination
Part C - Transfer In
Part E - Change in Name of Enrollee
Part G - Remarks
Part H - Date of Notice
Part D - Reinstatement
Part F - Change In Enrollment-Survivor Annuitant
Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.
Keep this form for your records.
Note: Instructions for Employing Offices are on the back of Copy 4 of this form.
1. Name
(Last, first, middle initial)
2. Date of birth
3. Social security number
4. Home address
(including ZIP Code)
5. Payroll office number
6. Enrollment code number
7. SF 2811 Report number
Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.
Important Notice:
You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have
the right to temporarily continue your group coverage.
See
Part B - Termination
on the back of this form for information
about 31-day extension of coverage, conversion, and temporary continuation of coverage.
If termination is due to death of enrollee enter date of death
Date of death (mo, dy, yr)
The new Payroll Office (or Retirement System) shown in Part H
below has accepted transfer of this enrollment and will continue
it.
Your enrollment has been reinstated effective on the date
in Part A, item 8, above.
Name Date of Birth
Address (including ZIP Code) if different from Part A, item 4, above.
New Enrollment Code Number
Federal Employees
Health Benefits Program
Name and address of agency
(including ZIP Code)
Personnel contact and telephone number
( )
Payroll contact and telephone number
Signature of authorized agency official Date
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234
Previous edition is usable Standard Form 2810
2810-104 Revised June 1995
The name under which this enrollment is carried has been
changed to:
RESET
PRINT
SAVE
Instructions for Employing Offices
Disposition Instructions To Payroll Offices - Pg 5
31-Day Extension of Coverage
Your enrollment terminates on the date shown in Part A, item 8, on the
front of this form. Coverage under your enrollment continues temporarily
for 31 days from the date shown. If you, or any covered member of
your family, are a patient in a hospital on the 31st day of this temporary
extension, benefits of the plan may continue for the rest of that
confinement, but not beyond 60 more days.
Conversion to Nongroup Contract
You may convert your enrollment to a nongroup contract, without
evidence of good health. The nongroup contract to which you may
convert is one regularly offered by your plan. It may differ from your
group plan in benefits, or cost, or both, and you will have to pay the
entire cost of the nongroup contract directly to the plan. The nongroup
contract is effective on the day after your 31-day extension of coverage
ends.
If you are interested in converting to a nongroup contract, write for
information to the nearest office of the plan in which you have been
enrolled (see the plan’s brochure or ask your employing office for the
address of the plan’s nearest office). The plan will promptly send you an
application form and details concerning benefits and rates of the
nongroup contract to which you may convert.
Time Limit on Conversion
Normally, to be eligible for conversion, you must send your written
request for information to your plan within 31 days after the date shown
in Part H. However, if the date shown in Part H is more than 60 days
after the date your enrollment terminates (Part A, item 8), you must
forward it to your plan within 91 days after the date shown in Part A,
item 8.
If you are prevented by causes beyond your control from submitting a
timely request for information about conversion to a nongroup contract,
you should write to your plan as soon as possible asking approval of a
belated conversion opportunity. Explain fully the circumstances that
Part B - Termination
If Part B on the other side of this form is checked, read the following instructions carefully.
prevented earlier action and attach proof of the loss of group coverage
(e.g., Standard Form 50 terminating Federal employment). A plan may
consider requests filed within 6 months after group eligibility ends. If
your plan needs assistance in processing your request, it should contact
OPM.
Temporary Continuation of Coverage
If you are an employee whose enrollment is terminating because you are
separating from service (including separation for retirement), you may be
eligible to temporarily continue your benefits coverage under the Federal
Employees Health Benefits Program after separation. Within 61 days
after the date shown in Part A, item 8, on the front of this form, your
employing office will formally notify you of your rights regarding
temporary continuation of coverage and tell you where you may obtain
additional information. You will have 60 days after the later of (1) your
date of separation from service, or (2) the date you receive the notice
from your employing office in which to elect temporary continuation of
coverage.
When your temporary continuation of coverage expires, you will be
entitled to the 31-day extension of coverage and the opportunity to
convert to a nongroup contract.
Entry on Active Military Duty
If you elected to terminate your enrollment because you are entering
military service, you may convert to a nongroup contract even though
your family members are entitled to care under the Uniformed Services
Health Benefits Program. If you return to civilian duty in the exercise of
reemployment rights, your enrollment will be reinstated effective on the
day you return to active duty. If you return to civilian duty not in the
exercise of reemployment rights, you must, if eligible for coverage,
register again the same as a new employee. If you are an annuitant,
your enrollment will be reinstated on the day you are separated from
military service. You must notify your retirement system of this event
by furnishing a copy of your separation papers.
Part C - Transfer of Enrollment
If Part C on the other side of this form is checked, read carefully whichever of the following instructions applies:
Keep This Form For Your Records
Transfer of Employment
Your enrollment has been transferred from your previous agency or
payroll office to the agency or payroll office shown in Part H. If you are
in a prepaid comprehensive medical plan and you left the area served by
the plan, you may be able to change to another plan. For details about
your right to change plans, check with your employing office.
Retirement
Your enrollment has been transferred from your employing agency to the
retirement system shown in Part H. Your enrollment continues
automatically during retirement if you retire on an immediate annuity and
you have been enrolled under the Federal Employees Health Benefits
Program for the lesser of (1) all your service since your first opportunity
to enroll, or (2) the 5 years of service immediately preceding retirement.
Your share of the cost of your enrollment will be withheld from your
annuity.
Death
The enrollment of the deceased employee named in Part A has been
transferred to the retirement system shown in Part H. If the deceased
employee or annuitant was enrolled for self and family at the time of
death, and if at least one member of the family is entitled to a survivor
annuity (or the widow(er) is entitled to the Basic Employee Death
Benefits under FERS), coverage for each family member who was
covered by the employee’s enrollment continues automatically.
If there is only one eligible survivor, the enrollment will be changed from
family coverage to self only. The survivor’s share of the cost of the
enrollment will be deducted from the annuity. Application for Death
Benefits (Standard Form 2800 or the equivalent) should be filed
promptly to avoid any question about health benefits coverage. When
the survivor annuity is approved, another form like this one will be
issued to show that the enrollment is being continued in the survivor’s
name.
Employees' Compensation
Your enrollment has been transferred to the Office of Workers'
Compensation Programs. Your enrollment continues automatically while
you receive monthly compensation from the Office of Workers'
Compensation Programs if the Secretary of Labor has held that you are
unable to return to duty and if you have been enrolled under the Federal
Employees Health Benefits Program for the lesser of (1) all your service
since your first opportunity to enroll, or (2) the 5 years of service
immediately preceding the start of your compensation. Enrollment of
covered family members of a deceased employee or compensationer
also continues automatically while they receive monthly compensation,
if (1) the deceased employee or compensationer was enrolled for self
and family at the time of death, and (2) at least one of the covered
family members is entitled to compensation as a surviving beneficiary
under the Federal Employees’ Compensation Act. The compensationer’s
or survivor’s share of the cost of the enrollment will be deducted from
the compensation checks.
Back, Copy 1
Standard Form 2810
Revised June 1995
Return to Form
Your enrollment has been changed from family coverage to self
only. Your plan will send you a new identification card.
Your new enrollment code number is shown below.
(Note: This item is completed by Retirement Systems only.)
New Enrollment Code Number
Copy 2 - To Insurance Carrier
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234
( )
Notice of Change in Health Benefits Enrollment
Part A - Identifying Information
Part B - Termination
Part C - Transfer In
Part E - Change in Name of Enrollee
Part G - Remarks
Part H - Date of Notice
Part D - Reinstatement
Part F - Change In Enrollment-Survivor Annuitant
Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.
Keep this form for your records.
Note: Instructions for Employing Offices are on the back of Copy 4 of this form.
1. Name
(Last, first, middle initial)
2. Date of birth
3. Social security number
4. Home address
(including ZIP Code)
5. Payroll office number
6. Enrollment code number
7. SF 2811 Report number
8. Date this action becomes
Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.
Important Notice:
You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have
the right to temporarily continue your group coverage.
See
Part B - Termination
on the back of this form for information
about 31-day extension of coverage, conversion, and temporary continuation of coverage.
If termination is due to death of enrollee enter date of death
Date of death (mo, dy, yr)
effective
The new Payroll Office (or Retirement System) shown in Part H
below has accepted transfer of this enrollment and will continue
it.
Your enrollment has been reinstated effective on the date
in Part A, item 8, above.
Name Date of Birth
Address (including ZIP Code) if different from Part A, item 4, above.
Federal Employees
Health Benefits Program
Name and address of agency
(including ZIP Code)
Personnel contact and telephone number
( )
Payroll contact and telephone number
Signature of authorized agency official Date
The name under which this enrollment is carried has been
changed to:
Previous edition is usable Standard Form 2810
2810-104 Revised June 1995
Copy 3 - To Payroll Office
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234
( )
Notice of Change in Health Benefits Enrollment
Part A - Identifying Information
Part B - Termination
Part C - Transfer In
Part E - Change in Name of Enrollee
Part G - Remarks
Part H - Date of Notice
Part D - Reinstatement
Part F - Change In Enrollment-Survivor Annuitant
Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.
Keep this form for your records.
Note: Instructions for Employing Offices are on the back of Copy 4 of this form.
1. Name
(Last, first, middle initial)
2. Date of birth
3. Social security number
4. Home address
(including ZIP Code)
5. Payroll office number
6. Enrollment code number
7. SF 2811 Report number
8. Date this action becomes
Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.
Important Notice:
You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have
the right to temporarily continue your group coverage.
See
Part B - Termination
on the back of this form for information
about 31-day extension of coverage, conversion, and temporary continuation of coverage.
If termination is due to death of enrollee enter date of death
Date of death (mo, dy, yr)
effective
The new Payroll Office (or Retirement System) shown in Part H
below has accepted transfer of this enrollment and will continue
it.
Your enrollment has been reinstated effective on the date
in Part A, item 8, above.
Name Date of Birth
Address (including ZIP Code) if different from Part A, item 4, above.
Your enrollment has been changed from family coverage to self
only. Your plan will send you a new identification card.
Your new enrollment code number is shown below.
(Note: This item is completed by Retirement Systems only.)
New Enrollment Code Number
Federal Employees
Health Benefits Program
Name and address of agency
(including ZIP Code)
Personnel contact and telephone number
( )
Payroll contact and telephone number
Signature of authorized agency official Date
The name under which this enrollment is carried has been
changed to:
Previous edition is usable Standard Form 2810
2810-104 Revised June 1995
Disposition Instructions To Payroll Offices
Copy 2
Copy 3
Copy 4
Back, Copy 3
Standard Form 2810
Revised June 1995
-
-
-
Send to insurance carrier, attached to Transmittal Report to Carrier (SF 2811),
at the earliest possible date.
Under no
circumstances should SF 2810s be accumulated for longer than a week, nor should they be delayed to coincide with
applicable payroll deductions.
Use as payroll action document, if necessary.
In cases of death or retirement under the Civil Service Retirement System or the Federal Employees Retirement System,
send to the Office of Personnel Management together with the Official Personnel Folder copy of each Health Benefits
Registration Form (SF 2809) accepted from the employee including any Medical Certificates attached thereto, Individual
Retirement Record (SF 2806 [CSRS] or SF 3100 [FERS]) and any other applicable documents. For other retirement
systems (including Office of Workers' Compensation Programs, Department of Labor), send these documents (or the
equivalent) to the office administering the system.
Return to Form
Copy 4 - For Official Personnel Folder
U.S. Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices NSN 7540-01-232-1234
( )
Notice of Change in Health Benefits Enrollment
Part A - Identifying Information
Part B - Termination
Part C - Transfer In
Part E - Change in Name of Enrollee
Part G - Remarks
Part H - Date of Notice
Part D - Reinstatement
Part F - Change In Enrollment-Survivor Annuitant
Only the item that is checked below affects your enrollment. Read that item carefully and follow any pertinent instructions.
Keep this form for your records.
Note: Instructions for Employing Offices are on the back of Copy 4 of this form.
1. Name
(Last, first, middle initial)
2. Date of birth
3. Social security number
4. Home address
(including ZIP Code)
5. Payroll office number
6. Enrollment code number
7. SF 2811 Report number
8. Date this action becomes
Your enrollment terminates on the date in Part A, item 8, above. However, your coverage is extended for 31 days after that date.
Important Notice:
You have the right to convert to an individual (nongroup) contract with the carrier of your plan. You also may have
the right to temporarily continue your group coverage.
See
Part B - Termination
on the back of this form for information
about 31-day extension of coverage, conversion, and temporary continuation of coverage.
If termination is due to death of enrollee enter date of death
Date of death (mo, dy, yr)
effective
The new Payroll Office (or Retirement System) shown in Part H
below has accepted transfer of this enrollment and will continue
it.
Your enrollment has been reinstated effective on the date
in Part A, item 8, above.
Name Date of Birth
Address (including ZIP Code) if different from Part A, item 4, above.
Your enrollment has been changed from family coverage to self
only. Your plan will send you a new identification card.
Your new enrollment code number is shown below.
(Note: This item is completed by Retirement Systems only.)
New Enrollment Code Number
Federal Employees
Health Benefits Program
Name and address of agency
(including ZIP Code)
Personnel contact and telephone number
( )
Payroll contact and telephone number
Signature of authorized agency official Date
The name under which this enrollment is carried has been
changed to:
Previous edition is usable Standard Form 2810
2810-104 Revised June 1995
Instructions for Employing Offices
Purpose of Form
This form 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 (Standard Form 2809). When an action requires a change
in health benefits enrollment, prepare SF 2810
As Soon As the Effective Date Is Known
and give the appropriate copies to the enrollee
and payroll office
Immediately.
Preparation and distribution of copies should not be delayed pending SF 50 action in the case of
transfers to another payroll office.
Prompt Action Required for Conversion
Give this form to the enrollee within 60 days after the date shown in Part A, item 8. To be eligible to convert to a nongroup contract,
the enrollee must send a written request for information about conversion to a nongroup contract to his or her plan within 31 days
after the date shown in Part H, but not later than 91 days after the date shown in Part A, item 8.
Completion of Form
Disposition
Back, Copy 4
Standard Form 2810
Revised June 1995
Part A - Identifying Information
1. For items 1, 2, and 6, transcribe from the last SF 2809 or
SF 2810, whichever is the most recent.
2
. Item 4, use most recent known address.
3. Item 5, use payroll office number of office authorized to
process withholdings.
4. Item 8, date as follows for action reported in:
B.
Termination
- Last day of pay period in which separa-
tion (or other action terminating enrollment) occurs
except, when coverage terminates because of com-
pletion of 365 days in nonpay status, use the last
day of the pay period which includes the 365th day
of continuous nonpay status; and when coverage
terminates because of military duty not limited to 30
days or less, use date employee is
separated, was
furloughed or placed on leave of absence for military
duty.
C.
Transfer In
- Actual date (first day on gaining
employing office or retirement system rolls.)
D.
Reinstatement
- Actual date.
E.
Change In Name Of Enrollee
- Actual date.
F.
Change In Enrollment-Survivor Annuitant
- Effective
day of sole survivor's annuity.
Part B - Termination
These most frequently occuring actions terminate enrollment:
Separated.
Retired - not eligible to continue enrollment.
Died - no survivor eligible to continue enrollment.
Termination of title to annuity or compensation.
Changed to excluded position or category.
365 days nonpay status completed.
Temporary continuation of coverage expired.
Part C - Transfer In
Gaining office uses this box to report transfer actions such as:
Acceptance of transfer from another agency to payroll office
number.
Retired - Acceptance of transfer by retirement system because
employee is eligible to continue enrollment as an annuitant.
Death - Acceptance of transfer by retirement system because
survivor is eligible to continue enrollment as a survivor
annuitant.
Transfer accepted by Office of Workers' Compensation
Programs.
Note:
Retirement systems (including OWCP) accepting
transfer in, show also in "Remarks" whether enrollment is for
an
"Employee Annuitant"
or "Survivor Annuitant."
Part D - Reinstatement
State in "Remarks"reason for any action not applicable to active
military duty, such as "Reinstatement of erroneous separation."
Part E - Change in Name of Enrollee
Use this box only for reporting changes in name where change of
coverage within a plan by SF 2809 is not involved. Show date of
birth only where enrollment is changed from employee’s or
annuitant’s name to name of survivor annuitant.
Part F - Change in Enrollment - Survivor Annuitant
Only agencies administering retirement systems will make this
determination on the basis of documentary evidence that there is
only one survivor annuitant.
Part G - Remarks
Use this box to bring to the attention of the employee, annuitant,
or insurance carrier any pertinent information to clarify or support
the action being taken.
Part H - Date of Notice
Facsimile signature is acceptable. Date as of day of issuance.
Copy 1
Copies 2 and 3
Copy 4
-
-
-
Deliver (or mail) to employee, annuitant or survivor
at the earliest possible date,
but before 60 days from the date
shown in Part A, item 8.
Send to appropriate insurance carrier and payroll office.
File in Official Personnel Folder (or its equivalent).
Return to Form
