This section includes instructions and definitions of the fields on SF 2809.
The following fields are available on the SF 2809, Employees Health Benefits Registration form:
Add/Edit Family Member Information
Select the checkbox if you are editing the family member information. This field defaults to a blank checkbox.
Address Line 2
Enter the second line of the enrollee's address, if applicable.
Address Line 2
Enter the second line of the family member's address, if applicable.
Are you covered by Insurance other than Medicare?
Select the applicable radio button to indicate whether the enrollee is covered by insurance other than Medicare. Valid values are:
- Yes
- No
Are you covered by Insurance other than Medicare? - Family Member
Select the applicable radio button if the family member iscovered by insurance other the Medicare. Valid values are:
- Yes
- No
Are You Married?
Select the enrollee's marital status. Valid values are:
- Yes
- No
Authorizing Official
Enter the authorizing official's name.
City- Enrollee
Enter the enrollee's city.
City - Family Member
Enter the city of the family member.
Date of Birth
Enter the enrollee's date of birth in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.
Date of Birth for the Family Member
Enter the family member's date of birth in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.
Date of Event
Enter the enrollee's event date in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.
Date Received
Enter the date received in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.
Effective Date of the Action
Enter effective dateof coverage in MM/DD/YYYY format.
OR
Use the calendar icon to select the date.
Email Address
Enter the enrollee's email address.
Email Address Family Member
Enter the email address of the family member.
Enrollee First Name
Enter the enrollee's first name.
Enrollment Code
Displays the enrollment code if the enrollee is currently enrolled in Federal Employees Health Benefits (FEHB).
Enrollment Code
Enter the enrollee's current enrollment code, if applicable.
Event Code
Enter the event code that permits the enrollee to enroll, change, or cancel FEHB coverage.
First Name - Enrollee
Enter the enrollee's first name.
First Name
Enter the family member's first name.
Home Mailing Address
Enter the enrollee's home mailing address.
Home Mailing Address
Enter thefamily member's mailing address.
I CANCEL My Enrollment
Select the checkbox if the enrollee is canceling their enrollment. This field defaults to a blank checkbox.
Indicate Other Types of Insurance
Select the enrollee's other types of insurance, if applicable. Valid values are:
- Tricare
- FEHB
- Other
Indicate Other Types of Insurance
Select the family member's other types of insurance, if applicable. Valid values are:
- Tricare
- FEHB
- Other
Information Only
Select this checkbox if the form is for information only. The default is a blank checkbox.
Last Name
Enter the enrollee's last name.
Last Name
Enter the family member's last name.
Medicare if you are covered by, Medicare, check all that apply - Family Member if applicable
Select if the family member is covered by Medicare. Valid values are:
- A
- B
- D
Medicare Claim Number
Enter the enrollee's Medicare claim number.
Medicare Claim Number
Enter the family member's Medicare claim number.
Medicare if you are covered by, Medicare, check all that apply - Enrollee if applicable
Select if the enrollee is covered by Medicare. Valid values are:
- A
- B
- D
Middle Name
Enter the enrollee's middle name, if applicable.
Middle Name
Enter the family member's middle name, if applicable.
Name and Address of the Tribal Employer
Enter the name and address of the tribal employer.
Name of Insurance - Enrollee
Enter the name of the enrollee's insurance if Other was selected on the Indicate other types of insurance field.
Name of Insurance - Family Member
Enter the name of the family member'sinsurance.
Part A - Enrollee Information Continued Member's Last Name
Enter the family member's last name.
Payroll Office Number
Displays the payroll office number.
Personnel Telephone Number
Enter the telephone number of the tribal office in (xxx) xxx-xxxx format.
Plan Name
Displays the plan name if the enrollee is currently enrolled in FEHB.
Plan Name - Currently Enrolled In
Displays the current plan name.
POI
Select the enrollee's POI.
Policy No.
Enter the enrollee's policy number if Other was selected on the Indicate other types of insurance field.
Policy No.
Enter the family member's policy number if Other was selected on the Indicate other types of insurance field.
Preferred Telephone Number- Enrollee
Enter the enrollee's preferred telephone number in (xxx)xxx-xxxx format.
Preferred Telephone Number
Enter the preferred telephone number for the enrollee's family memberin (xxx) xxx-xxxx format.
Premium Conversion
Select the checkbox if the enrollee is eligible for premium conversion. Premium conversion designates whether the user has pre-tax premiums. If this checkbox is not checked, there are tax consequences resulting in the FEHB premium being taxed.
Note: This field defaults to the checkbox being checked.
Relationship Type
Select the relationship type.
Remarks
Enter any tribal employer remarks, if applicable.
Service Provider Contact
Displays the name of the service provider (e.g., National Finance Center).
Sex
Select the sex of the enrollee. Valid values are:
- Male
- Female
Sex
Select thesex of the family member. Valid values are:
- Male
- Female
Social Security Number
Enter the enrollee's SSN.
Social Security Number
Enter the family member's SSN.
State
Select the enrollee's State.
State
Select the family member's State.
Submit Date
Displays the current date.
Submit ID
Displays the ID of the current user.
Telephone Number
Enter theenrollee's telephonenumber in (xxx) xxx-xxxx format.
Tribe
Select the name of the tribe.
ZIP
Enter the enrollee's ZIP code.
ZIP
Enter the family member's ZIP code.
