SF 2810 is the Standard Form 2810, Notice of Change in Health Benefits Enrollment, issued by the U.S. Office of Personnel Management (OPM) for the Federal Employees Health Benefits Program. An employing office, payroll office or retirement system completes it when an enrollment ends, moves, is reinstated, changes name or changes to a survivor annuitant. The enrollee, the insurance carrier, the payroll office and the personnel folder each receive a copy. On FillingPDF you can fill out the fillable SF 2810 online and download or print the completed PDF; the form and its instructions are published by OPM.
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What is SF 2810?
SF 2810, Notice of Change in Health Benefits Enrollment, is the Office of Personnel Management (OPM) form an employing office uses to report a change in a Federal Employees Health Benefits Program enrollment, such as termination, transfer or reinstatement.
The form is a four-copy set. Copy 1 goes to the enrollee, Copy 2 to the insurance carrier, Copy 3 to the payroll office and Copy 4 to the Official Personnel Folder. Each copy repeats the same content: Part A, Identifying Information (items 1 to 8), and then one action, shown by the item that is checked. Only the checked item affects the enrollment. The actions are Part B, Termination; Part C, Transfer In; Part D, Reinstatement; Part E, Change in Name of Enrollee; and Part F, Change in Enrollment-Survivor Annuitant. Part G holds remarks and Part H the date of notice and the agency's contacts and signature.
The form does not cover enrollments, changes from one plan to another, changes of coverage within a plan or cancellations. Those are processed on the Health Benefits Registration Form, Standard Form 2809. The printed form notes that the previous edition is usable.
Who needs to file SF 2810?
SF 2810 is completed by the agency, not by the enrollee. The groups involved are:
- Employing offices and payroll offices, which prepare the form when an action requires a change in health benefits enrollment and give the copies to the enrollee, the carrier and the payroll office.
- Retirement systems, including the Office of Workers' Compensation Programs, which use Part C when they accept a transfer in and which alone complete Part F for a sole survivor annuitant.
- Enrollees, annuitants and survivors, who receive Copy 1 and are told to keep it for their records. A termination notice carries their rights to the 31-day extension of coverage, to convert to a nongroup contract and, for employees who are separating, to temporary continuation of coverage.
Do not use SF 2810 for enrollments, changes from one plan to another, changes of coverage within a plan or cancellations; the instructions send those to Standard Form 2809. Part E is for name changes only where a change of coverage within a plan by SF 2809 is not involved.
When to file SF 2810
Prepare SF 2810 as soon as the effective date of the action is known, and give the appropriate copies to the enrollee and the payroll office immediately. Transfers to another payroll office should not wait for the SF 50 action.
Copy 1 must be delivered or mailed to the employee, annuitant or survivor at the earliest possible date, and before 60 days from the date in Part A, item 8. Copy 2 goes to the carrier at the earliest possible date. Do not accumulate SF 2810s for longer than a week, and do not hold them to match payroll deductions.
Timing matters for conversion. The enrollee must send a written request for information about a nongroup contract to the plan within 31 days after the date in Part H, but no later than 91 days after the date in Part A, item 8.
Documents you need
- Transmittal Report to Carrier (SF 2811): Copy 2 of SF 2810 is sent to the insurance carrier attached to this report.
- Health Benefits Registration Form (SF 2809) from the Official Personnel Folder, with any attached Medical Certificates: sent to OPM with Copy 4 in cases of death or retirement under CSRS or FERS.
- Individual Retirement Record (SF 2806 for CSRS or SF 3100 for FERS): sent to OPM with Copy 4 in cases of death or retirement under CSRS or FERS, together with any other applicable documents.
How to fill out SF 2810
Transcribe the enrollee's identifying data
In Part A, copy items 1 (name), 2 (date of birth) and 6 (enrollment code number) from the last SF 2809 or SF 2810, whichever is the most recent. Enter item 3, the Social Security number, and item 4, the home address, using the most recent known address.
Enter payroll office and report numbers
Item 5: the payroll office number of the office authorized to process withholdings. Item 7: the SF 2811 report number.
Enter the effective date
Item 8, Date this action becomes effective, depends on the action. For a termination use the last day of the pay period in which the separation occurs, with the exceptions for 365 days in nonpay status and military duty; for transfer in, reinstatement and name change use the actual date.
Check only the item that applies
Mark one action: Part B Termination, Part C Transfer In, Part D Reinstatement, Part E Change in Name of Enrollee or Part F Change in Enrollment-Survivor Annuitant. For a termination due to death, enter the date of death (mo, dy, yr).
Complete the Part C, D or E details
Part C is used by the gaining office or retirement system to report the accepted transfer. For Part E, enter the new name and, only where the enrollment moves to a survivor annuitant, the date of birth, plus an address if different from item 4.
Complete Part F if you are a retirement system
Only agencies administering retirement systems complete Part F, on documentary evidence of a sole survivor annuitant. Enter the new enrollment code number, with the effective day of the sole survivor's annuity in item 8.
Add remarks
In Part G, state any information that clarifies the action for the employee, annuitant or carrier. Give the reason for a reinstatement not tied to active military duty, and for a retirement system accepting a transfer show whether it is an Employee Annuitant or a Survivor Annuitant.
Complete Part H, Date of Notice
Enter the agency name and address with ZIP Code, the personnel contact and telephone number and the payroll contact and telephone number. The authorized agency official signs and dates it as of the day of issuance; a facsimile signature is acceptable.
Review and download the completed PDF
Check that only one action is marked and that item 8 matches it. Download or print the completed PDF from FillingPDF, then distribute Copies 1 to 4 as described under How to submit.
How to submit SF 2810
SF 2810 is not filed by the enrollee. The employing office distributes the four copies:
- Copy 1: deliver or mail it to the employee, annuitant or survivor.
- Copy 2: send it to the insurance carrier, attached to the Transmittal Report to Carrier (SF 2811).
- Copy 3: send it to the payroll office, where it is used as the payroll action document if necessary.
- Copy 4: file it in the Official Personnel Folder or its equivalent. In cases of death or retirement under the Civil Service Retirement System or the Federal Employees Retirement System, send Copy 4 to OPM with the other documents the form lists, including the Health Benefits Registration Form (SF 2809) and the Individual Retirement Record (SF 2806 or SF 3100). For other retirement systems, including the Office of Workers' Compensation Programs, send them to the office that administers the system.
A facsimile signature is acceptable in Part H. The form prints no mailing address or portal. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Using SF 2810 for an enrollment, a change from one plan to another, a change of coverage within a plan or a cancellation; those go on Standard Form 2809.
- Accumulating SF 2810s for more than a week before sending Copy 2 to the carrier, or holding them to match payroll deductions.
- Giving Copy 1 to the enrollee after 60 days from the date in Part A, item 8, which leaves too little time for the conversion deadlines.
- Delaying preparation of a transfer to another payroll office until the SF 50 action is done.
- Entering the wrong date in item 8 for a termination; the instructions call for the last day of the pay period in which the separation or other terminating action occurs.
- Completing Part F when you are not an agency administering a retirement system; only those agencies make the sole-survivor determination.
- Leaving Part G empty for a reinstatement that is not for active military duty; the reason, such as "Reinstatement of erroneous separation," must be stated.
- Omitting whether an accepted transfer to a retirement system is for an "Employee Annuitant" or a "Survivor Annuitant" in Remarks.
Frequently asked questions
What is SF 2810 used for?
SF 2810 is the OPM notice an employing office issues to report a change in a Federal Employees Health Benefits Program enrollment. It covers termination, transfer in, reinstatement, a change of enrollee name and a change to a survivor annuitant enrollment.
Who completes SF 2810, the employee or the agency?
The agency does. The instructions for employing offices tell the payroll or personnel office to prepare it when an action changes the enrollment. The enrollee receives Copy 1 and keeps it. Retirement systems complete Part F and report transfers in Part C.
What is the difference between SF 2810 and SF 2809?
SF 2810 reports actions such as termination, transfer, reinstatement and name change. Standard Form 2809, the Health Benefits Registration Form, handles enrollments, changes from one plan to another, changes of coverage within a plan and cancellations.
When must the enrollee receive Copy 1 of SF 2810?
At the earliest possible date, and before 60 days from the date in Part A, item 8. The employing office delivers or mails it. Late delivery shortens the time the enrollee has to ask the plan about converting to a nongroup contract.
How long do I have to ask about converting to a nongroup contract?
Normally within 31 days after the date in Part H, but not later than 91 days after the Part A, item 8 date. Send a written request for information to your plan. If causes beyond your control prevented it, write to the plan promptly and explain.
Does coverage continue after a termination on SF 2810?
Yes, for 31 days after the date in Part A, item 8. If you or a covered family member is a hospital patient on the 31st day, plan benefits may continue for that confinement, but not beyond 60 more days.
Where do the copies of SF 2810 go?
Copy 1 goes to the enrollee, Copy 2 to the insurance carrier with the SF 2811 transmittal report, Copy 3 to the payroll office and Copy 4 to the Official Personnel Folder. In CSRS or FERS death or retirement cases, Copy 4 goes to OPM with other listed documents.
Can I fill out SF 2810 online?
You can fill out the fillable SF 2810 online on FillingPDF and download or print it. FillingPDF is an independent service and does not send the form to anyone; the employing office distributes the copies as the form instructs.
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