SF 2809 is the Health Benefits Election Form that the Office of Personnel Management (OPM) uses for the Federal Employees Health Benefits (FEHB) Program. You use it to enroll or reenroll, change or cancel an enrollment, suspend it (annuitants and former spouses only), or, if you are an employee, to elect not to enroll. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the form and its instructions are published by the government at gsa.gov, and the completed form goes to your employing office.
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What is SF 2809?
SF 2809, Health Benefits Election Form is the Standard Form that records an election under the Federal Employees Health Benefits (FEHB) Program: to enroll or reenroll, switch plans or the designated family member, cancel, suspend, or, for employees only, decline to enroll.
The Office of Personnel Management (OPM) issues the form under Chapter 89 of Title 5, U.S. Code, and it carries OMB No. 3206-0160. The edition printed is Revised November 2019, and the form states that the previous edition is not usable.
The form has nine parts:
- Part A: enrollee and family member information.
- Part B: the plan you are currently enrolled in.
- Part C: the plan you are enrolling in or changing to.
- Part D: the event that permits you to enroll, change or cancel.
- Part E: election not to enroll (employees only).
- Part F: cancellation of FEHB.
- Part G: suspension of FEHB (annuitants and former spouses only).
- Part H: signature.
- Part I: agency or retirement system use only.
The instructions also include the Table of Permissible Changes in FEHB Enrollment, which lists each Qualifying Life Event (QLE) code and the time limit for filing, plus notes on dual enrollment, effective dates and survivor benefits.
SF 2809 is not the form for annuitants under the Civil Service Retirement System (CSRS) or the Federal Employees Retirement System (FERS). They use form OPM 2809, and CSRS and FERS annuitants who cancel or suspend use form RI 79-9, Health Benefits Cancellation/Suspension Confirmation.
Who needs to file SF 2809?
Employees who are eligible to enroll in, or are currently enrolled in, the FEHB Program use SF 2809. So do the other groups the instructions list:
- Annuitants in retirement systems other than CSRS or FERS, including people who receive monthly compensation from the Office of Workers' Compensation Programs (OWCP).
- Former spouses eligible to enroll in or already enrolled in FEHB under the Spouse Equity law or similar statutes.
- Individuals eligible for Temporary Continuation of Coverage (TCC): former employees who separated from service, children who lose FEHB coverage, and former spouses who are not eligible under the Spouse Equity provisions.
Do not use SF 2809 if you are a CSRS or FERS annuitant, or a former spouse or child of a CSRS/FERS annuitant. Use form OPM 2809 (www.opm.gov/forms/OPM-forms) or call the Retirement Information Office at 1-888-767-6738. To cancel or suspend as a CSRS or FERS annuitant, use form RI 79-9.
Election not to enroll (Part E) is for employees only. Suspension (Part G) is for annuitants and former spouses only.
Someone may sign for the enrollee. If you register for another person under their written authorization, sign in Part H and attach it. If you register for a former spouse or a TCC-eligible individual as court-appointed guardian, sign in Part H and attach evidence of the guardianship.
When to file SF 2809
File SF 2809 when an event lets you enroll or change: your first opportunity to enroll, open season, or a Qualifying Life Event (QLE). The time limit depends on your enrollee group and the event code you enter in Part D.
- Open season: as announced by OPM.
- Employees, initial opportunity to enroll (event 1A): within 60 days after becoming eligible.
- Employees, change in family status (event 1C): within 60 days after the change; enrolling or changing may begin 31 days before the event.
- Annuitants and former spouses: most events run from 31 days before through 60 days after the event.
- TCC: within 60 days after the QLE or receiving notice of eligibility, whichever is later.
- Former spouses, initial opportunity (event 3A): generally within 60 days after the marriage is dissolved.
Employees in premium conversion may cancel only during open season or after a QLE. Employees who waived premium conversion, annuitants, former spouses and TCC enrollees may cancel at any time.
Except for open season, most changes take effect on the first day of the pay period after the employing office receives the form and that follows a pay period in which the employee was in pay status. Ask your employing office for the exact date.
Documents you need
- Written authorization from the person you are registering for, when you sign Part H on behalf of someone else; attach it to the form.
- Evidence of court-appointed guardianship, when you register for a former spouse eligible under Spouse Equity or for an individual eligible for TCC as guardian.
- A separate sheet listing additional family members, when your enrollment covers more family members than the form has space for.
- Adequate medical certification of a mental or physical disability that began before the child's 26th birthday, when you cover a disabled child age 26 or older; your employing office can tell you what is required.
- Documentation of eligibility for the non-FEHB program, when you suspend under Part G; submit it to the office that maintains your enrollment.
How to fill out SF 2809
Enter enrollee details in Part A
Type or print. Complete items 1 to 6: name (last, first, middle initial), Social Security Number, date of birth (mm/dd/yyyy), sex, and whether you are married. If you are separated but not divorced, you are still married.
Add Medicare and other insurance
Items 7 and 8: if you have Medicare, check Part A, B or D as applicable and enter your Medicare Beneficiary Identifier. Item 9: check Yes if other insurance covers you, then give the type, name and policy number in item 10.
Give contact information
Item 11: your email address. Item 12: your preferred telephone number. Item 6 takes your home mailing address including ZIP Code.
List eligible family members
Items 13 to 24 cover the first family member, and the form repeats the block for more. Complete these only for Self Plus One or Self and Family; for Self Plus One, the designated family member's information is required.
Enter relationship code and details
Item 17: use 01 spouse, 19 child, 09 adopted child, 17 stepchild, 10 foster child, or 99 disabled child age 26 or older. Item 14: Social Security Number if the person has one, otherwise leave blank; item 18: address only if different from yours.
Complete Part B for changes
If you are changing, cancelling or suspending, enter your current plan name (item 1) from the plan brochure cover and your enrollment code (item 2) from your plan ID card. Skip it for a first enrollment.
Complete Part C for the new plan
Enter the name and enrollment code of the plan you are enrolling in or changing to, both from the brochure's front cover. The code shows the option and whether it is Self Only, Self Plus One or Self and Family.
Enter the event code and date
Part D, item 1: the event code from the Table of Permissible Changes in Enrollment that applies to you. Item 2: the date of the QLE as mm/dd/yyyy, the date you became eligible, or the date open season begins.
Mark Part E, F or G if it applies
Place an X in Part E only if you are an employee electing not to enroll, in Part F only to cancel, or in Part G only to suspend (annuitants and former spouses). For F and G also fill in Part B.
Sign and date in Part H
Sign your name (do not print) in item 1 and enter the date as mm/dd/yyyy in item 2. If you sign for someone else, attach their written authorization or the guardianship evidence.
Leave Part I blank
The agency or retirement system fills in Part I, including remarks and the effective date of action. Do not enter anything there.
Review, download and deliver
Check every part you completed against the instructions and the plan brochure. Download or print the completed PDF from FillingPDF and give it to your employing office as described under How to submit.
How to submit SF 2809
The form is given to your employing office, meaning the agency, retirement system or office that maintains your enrollment, or it is replaced by an electronic enrollment where one is offered.
- Employing office: Give the signed SF 2809 to the office responsible for your health benefits actions. The form prints no mailing address or portal for this purpose. It states that the agency, retirement system or office cannot process your request unless Part H is completed.
- Electronic enrollment: Many agencies use automated systems, such as Employee Express, that let employees make changes by touch-tone telephone or computer instead of using a form. If you are not sure it is available to you, ask your employing office.
- Suspension documents: If you suspend under Part G, submit documentation of eligibility for the non-FEHB program to the office that maintains your enrollment.
Leave Part I blank; the agency or retirement system completes it and distributes copies to the Official Personnel Folder, new carrier, old carrier, payroll office and enrollee, as appropriate. The instructions say a fee is not part of this form and give no processing time; ask your employing office about your effective date. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Using SF 2809 as a CSRS or FERS annuitant, or as a former spouse or child of one; those groups use form OPM 2809, and RI 79-9 to cancel or suspend.
- Choosing Self Plus One without completing the family member information for the designated family member; the election cannot be processed without it.
- Checking the FEHB box under other insurance (items 10 or 22) and continuing: that is a dual coverage situation, and the instructions say to contact your Human Resources office or retirement system immediately.
- Leaving Part B blank when changing, cancelling or suspending; it must be completed in those cases, with your current plan name and enrollment code.
- Entering a plan name or enrollment code from memory instead of from the front cover of the plan brochure (Part C) or your plan ID card (Part B).
- Omitting the event code or date of event in Part D, or using the date you filled in the form instead of the date of the QLE.
- Printing your name in Part H instead of signing; the form says not to print the signature, and the request cannot be processed without it.
- Entering a Social Security Number for a family member who has none; leave item 14 blank.
- Writing anything in Part I, which is for agency or retirement system use only.
- Cancelling without checking the consequences: cancelled enrollees and covered family members get no 31-day temporary extension of coverage, and family members who lose coverage are not eligible for TCC.
Frequently asked questions
What is SF 2809 used for?
SF 2809, the Health Benefits Election Form, is used under the FEHB Program to enroll or reenroll, change or cancel an enrollment, switch the designated family member, or suspend coverage. Employees can also use it to elect not to enroll.
Who should not use SF 2809?
CSRS and FERS annuitants, and former spouses and children of CSRS/FERS annuitants, should not use it. They use form OPM 2809, available at www.opm.gov/forms/OPM-forms, or can call 1-888-767-6738. To cancel or suspend, they use form RI 79-9.
Where do I send SF 2809 after filling it out?
Give it to your employing office, the agency, retirement system or office that maintains your enrollment. The form prints no mailing address. Many agencies offer electronic enrollment, such as Employee Express, instead of the form, so ask whether it is available to you.
How long do I have to file SF 2809 after a life event?
It depends on your group and event code. Employees generally have 60 days after the event, and annuitants and former spouses usually from 31 days before through 60 days after. Open season dates are announced by OPM. Check your event code in the Table of Permissible Changes.
What is the event code in Part D?
It is the code of the Qualifying Life Event or enrollment opportunity from the Table of Permissible Changes in Enrollment, such as 1A for an employee's initial opportunity or 1B for open season. Enter it in Part D, item 1, with the event date in item 2.
Can I cancel my FEHB enrollment with SF 2809?
Yes, by marking Part F and entering your current plan and code in Part B. Employees in premium conversion may cancel only in open season or after a QLE. Cancelling can mean no 31-day extension of coverage, so read the cancellation information first.
Can I fill out SF 2809 online?
Yes. You can fill out the fillable PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit the form; you give it to your employing office or use an electronic enrollment system your agency offers.
Who can sign SF 2809 for someone else?
A person holding the enrollee's written authorization can sign in Part H and attach that authorization. A court-appointed guardian for a Spouse Equity former spouse or a TCC-eligible individual signs in Part H and attaches evidence of the guardianship.
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