**Federal Employees Health Benefits (FEHB) Program**

HIPAA Transaction

Standard Companion Guide

**Refers to the X12N Implementation Guide 004010X095A1: 834 -- Benefit
Enrollment and Maintenance**

**Companion Guide Version Number 1.0**

**Table of Contents**

**General
lnformation............................................................3**

**Background..................................................................3**

**Communications............................................................3**

**Definitions and
Notes......................................................4**

**Contact
Information.......................................................4**

**Control Segments /
Envelopes........................................5**

**ISA-IEA.......................................................................5**

**GS-GE.........................................................................5**

**ST-SE..........................................................................5**

**Mapping Detail
Table................................................\...6**

**FEHB Program Business Rules and Limitations.................27**

**Dependent
Information................................................\...27**

> **Temporary Continuation of Coverage (TCC) and Spouse**
>
> **Equity.................................................................28**

**Children Incapable of
Self-support.....................................28**

**Information currently provided on paper forms through**

> **"Remarks"...........................................................28**

**Data Sample**

**Appendix**

> **EEX/Data-Hub HIPAA 2809 File Layout (Current file format to 834
> mapping)................................................................30**
>
> **Mapping of current EEX/Data-Hub Nature of Transaction Field to the
> 834.....................................................................62**

**General Information**

This Companion Guide to the ASC X12N 834 Implementation Guide adopted
under HIPAA clarifies and specifies the data content transmitted
electronically from OPM-Macon to plans participating in the FEHB Program
to process enrollment and disenrollment actions. Transmissions based on
this companion guide, used in tandem with the X12N 834 Implementation
Guide, are compliant with both X12 syntax and the Guide. The Companion
Guide is not intended to replace the X12N 834 Implementation Guide;
rather it is intended to convey information that is within the framework
and structure of the X12N Implementation Guide and not to contradict or
exceed them in any way.

This Companion Guide only relates to the mapping of FEHB Program
electronic enrollment information to the ASC X12N 834 standard for
HIPAA. This Companion Guide does not modify or affect FEHB law,
regulations or policies nor the contracts between the Office of
Personnel Management and carriers participating in the FEHB Program.

**Background**

Beginning with FEHB Open Season of 1996, OPM-Macon has accepted
electronic input of FEHB actions from Employee Express and agencies
using the Data-HUB. By establishing communications with insurance plans,
OPM has transmitted these actions to each of the plans electronically.
To further reduce unnecessary paperwork, this concept was expanded to
require that all electronic transfers of the enrollment data to the
plans be routed through OPM-Macon. The FEHB actions were transmitted in
OPM-Macon's propriety file format.

The final HIPAA Standards for Electronic Transactions regulation defines
the FEHB Program as a Group Health Plan. Since both the FEHB Program
(administered by OPM) and our plans are defined as covered entities, we
determined that OPM-Macon transmissions must be in the HIPAA standard
format. In accordance with the HIPAA regulation and the Administrative
Simplification Compliance Act, FEHB actions transmitted from OPM-Macon
to FEHB carriers after October 15, 2003 will be in the ASC X12N 834
format.

**Communications**

Communications between the OPM-Macon and the FEHB plans will continue to
be through your FTP connection with OPM-Macon.

For the \"pull\" technique, OPM-Macon will send FEHB plans an email
notification that they have posted new enrollment data in their account
for pick up. OPM-Macon will send this email to the FEHB plan's official
plan contact and enrollment contact, as well as the plan's OPM contract
specialist. Although the FEHB plans should check the FTP server every
week for enrollment changes, these e-mails will remind them to pick up
enrollment changes.

OPM-Macon will post enrollment change reports for Employee Express to
the FTP server every Sunday from the beginning of November through the
end of January. After that, OPM-Macon will provide the FEHB plans a file
only when there is data to transmit.

**Definitions and Notes**

All dates are CCYYMMDD in format

All mapping created using the addenda version (004010X095A1) of the ASC
X12N 834. We will not use delimiters in any of the fields.

**Enrollee** refers to a current Federal employee, annuitant, survivor
annuitant, former employee, overage child, or former spouse of a Federal
employee, enrolled in a FEHB Program plan.

**Agency** refers to the office, site, or Federal organization providing
FEHB data or information

**OPM-Macon** will provide the connectivity from Employee Express and
the Data-HUB agencies to the FEHB plans

**OPM-Insurance Services Programs** **(ISP)** will provide the policy
and guidance on this process

**FEHB plans** are the insurance companies that have entered into an
agreement with OPM-Washington to provide, pay for, or reimburse the cost
of health services for Federal employees, annuitants and eligible family
members.

**Contact Information**

For additional FEHB Program information, contact Eric Figg, OPM-ISP at
202-606-4083.

For information on HIPAA X12N 834 formatting, contact Jay Fritz, OPM-ISP
at 202-606-0004.

For information on transmissions from OPM-Macon to the FEHB plans,
contact Chris Selle, OPM-Macon at 478-744-2115.

**Control Segments / Envelopes**

**ISA-IEA**

This section describes OPM-Macon's use of the interchange control
segments. It includes expected sender and receiver codes.

**ISA Interchange Control Header**

ISA01, I01, Pg. B.3 = \'00\'

ISA02, I02, Pg. B.3 = spaces (10)

ISA03, I03, Pg. B.4 = \'00\'

ISA04, I04, Pg. B.4 = spaces (10)

ISA05, I05, Pg. B.4 = \'ZZ\'

ISA06, I06, Pg. B.4 = \'OPM DATAHUB\'

ISA07, I05, Pg. B.4 = \'ZZ\'

ISA08, I07, Pg. B.4 = Carrier\'s 2-character FEHB CODE

ISA09, I08, Pg. B.5 = File Creation Date (YYMMDD)

ISA10, I09, Pg. B.5 = File Creation Time (HHMM)

ISA11, I10, Pg. B.5 = \'U\'

ISA12, I11, Pg. B.5 = \'00401\'

ISA13, I12, Pg. B.5 = taken out of Macon\'s SEQ_NUM database - padded
left with zeroes

ISA14, I13, Pg. B.6 = \"0\" - No acknowledgement requested

ISA15, I14, Pg. B.6 = \"P\" for Production, \"T\" for Testing

ISA16, I15, Pg. B.6 = \':\'

**IEA Interchange Control Trailer**

IEA01, I16, Pg. B.7 = \'1\'

IEA02, I12, Pg. B.7 = taken out of Macon\'s SEQ_NUM database - padded
left with zeroes

**GS-GE**

This section describes OPM-Macon's use of the functional group control
segments. It includes expected application sender and receiver codes.

**GS Functional Group Header**

GS01, 479, Pg. B.8 = \'BE\'

GS02, 142, Pg. B.8 = OPM DATAHUB\'

GS03, 124, Pg. B.8 = Carrier\'s 2-character FEHB CODE

GS04, 373, Pg. B.8 = File Creation Date (CCYYMMDD)

GS05, 337, Pg. B.8 = File Creation Time (HHMM)

GS06, 28, Pg. B.9 = taken out of Macon\'s SEQ_NUM database - NO leading
zeroes

GS07, 455, Pg. B.9 = \'X\'

GS08, 480, Pg. B.9 = \'004010X095A1\'

**Functional Group Trailer**

GE01, 97, Pg. B.10 = number of transaction sets included

GE02, 28, Pg. B.10 = taken out of Macon\'s SEQ_NUM database - NO leading
zeroes

**ST-SE**

This section describes OPM-Macon's use of transaction set control
numbers.

**Transaction Set Header**

ST01, 143, Pg. 27 = \'834\'

ST02, 329, Pg. 27 = taken out of Macon\'s SEQ_NUM database - padded left
with zeroes

**Transaction Set Trailer**

SE01, 96, Pg. 158 = number of segments sent in file

SE02, 329, Pg. 158 = ST02 (Transaction Set Header)

**Mapping Detail Table**

This section contains a table describing where FEHB Program enrollment
information will be placed in the 834 format and the values that will be
used for each segment. It also describes where OPM has something
additional, over and above, the information in the Implementation Guide.

**OPM EEX/DATA-HUB 2809**

**834 TRANSACTION SET-BENEFIT ENROLLMENT AND MAINTENANCE**

  ---------- ------- ---------- ---------------- --------- -------- -------------- --------- --------- -------------- ----------------
  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**     **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                      in OPM\'s      
                     Number**                                                                          EEX/Data-Hub   
                                                                                                       2809 File      
                                                                                                       Layout**       

  ** **      ** **   ** **      ** **            ** **     ** **    ** **          ** **                              ** **

                                **TRANSACTION                                                                          
                                SET HEADER                                                                            
                                REQUIRED**                                                                            

             ST01    143        Transaction Set  R         ID       834            3         3                         
                                Identifier Code                                                                       

             ST02    329        Transaction Set  R         AN       Taken from     4         9                        Padded left with
                                Control Number                      OPM-Macon\'s                                      zeros
                                                                    SEQ_NUM                                           
                                                                    database                                          

                                                                                                                       

                                **BEGINNING                                                                            
                                SEGMENT**                                                                             

             BGN01   353        Transaction Set  R         ID       00 = Original  2         2                        We will not
                                Purpose Code                                                                          resubmit
                                                                                                                      transactions.
                                                                                                                      Each transaction
                                                                                                                      will be
                                                                                                                      considered an
                                                                                                                      original, will
                                                                                                                      contain all data
                                                                                                                      and is to be
                                                                                                                      processed (1)

             BGN02   127        Transaction Set  R         AN       \"EEX2809\"    1         30                       This identifies
                                Identifier Code                                                                       the type of data
                                                                                                                      being
                                                                                                                      transmitted. (2)

             BGN03   373        Transaction Set  R         DT       File Creation  8         8                        CCYYMMDD
                                Creation Date                       Date                                              

             BGN04   337        Transaction Set  R         TM       File Creation  4         8                        HHMM
                                Creation Time                       Time                                              

             BGN05   623        Time Zone Code   S         ID       ET = Eastern   2         2                         
                                                                    Time                                              

             BGN06   127        Transaction Set  S         AN                      1         30                       Will not be sent
                                Identifier Code                                                                       

             BGN08   306        Action Code      R         ID       2 = change     1         2                        \"2\" will be
                                                                                                                      used for all
                                                                                                                      transactions

                                                                                                                       

                                **TRANSACTION                                                                         **Will not be
                                SET POLICY                                                                            sent**
                                NUMBER                                                                                
                                SITUATIONAL**                                                                         

             REF01   128        Reference        R         ID                      2         3                         
                                Identification                                                                        
                                Qualifier                                                                             

             **Ref   **Data     **Segment**      **Req. by **Data   **Values**     **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                      in OPM\'s      
                     Number**                                                                          EEX/Data-Hub   
                                                                                                       2809 File      
                                                                                                       Layout**       

             REF02   127        Reference        R         AN                      1         30                        
                                Identification                                                                        

                                                                                                                      

                                **FILE EFFECTIVE                                                                      **Will not be
                                DATE**                                                                                sent**

             DTP01   374        Date Time        R         ID                      3         3                         
                                Qualifier file                                                                        
                                effective date                                                                        
                                at header level                                                                       

             DTP02   1250       Date Time Period R         ID                      2         3                         
                                Format Qualifier                                                                      

             DTP03   1251       Date Time Period R         AN                      1         35                        
                                file date at                                                                          
                                header level                                                                          

                                **LOOP 1000A                                                                           
                                SPONSOR NAME                                                                          
                                REQUIRED**                                                                            

  1000A      N101    98         Entity           R         ID       P5 = Plan      2         3                         
                                Identifier Code                     Sponsor                                           

  1000A      N102    93         Plan Sponsor     S         AN                      1         60                       Will not be sent
                                Name                                                                                  

  1000A      N103    66         Identification   R         AN       ZZ = mutually  1         2                         
                                Code Qualifier                      defined                                           

  1000A      N104    67         Sponsor          R         AN       \"Agency\"     2         80                       OPM is unable to
                                Identifier                                                                            locate the
                                                                                                                      Federal
                                                                                                                      Taxpayer\'s
                                                                                                                      Identification
                                                                                                                      Number for every
                                                                                                                      agency/payroll
                                                                                                                      office that
                                                                                                                      processes
                                                                                                                      electronic FEHB
                                                                                                                      enrollments.
                                                                                                                      \"Agency\" will
                                                                                                                      be used for all
                                                                                                                      transactions

                                **LOOP 1000B                                                                           
                                PAYER REQUIRED**                                                                      

  1000B      N101    98         Entity           R         ID       IN = Insurer   2         3                         
                                Identifier Code                                                                       

  1000B      N102    93         Insurer Name     S         AN                      1         60                       Will not be sent

  1000B      N103    93         Identification   R         ID       FI = Fed Tax   1         2                         
                                Code Qualifier                      ID                                                

  1000B      N104    167        Insurer          R         AN                      2         80                       Carrier\'s
                                Identification                                                                        Federal Tax ID
                                Code                                                                                  

                                **LOOP 1000C                                                                          **Will not be
                                TPA/BROKER NAME                                                                       sent**
                                SITUATIONAL**                                                                         

  1000C      N101    98         Entity           R         ID                      2         3                         
                                Identifier Code                                                                       

  1000C      N102    93         TPA/Broker Name  R         AN                      1         60                        

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**     **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                      in OPM\'s      
                     Number**                                                                          EEX/Data-Hub   
                                                                                                       2809 File      
                                                                                                       Layout**       

  1000C      N103    66         TPA or Broker    R         ID                      1         2                         
                                Identification                                                                        
                                qualifier                                                                             

  1000C      N104    67         TPA/Broker ID    R         AN                      2         80                        

                                                                                                                       

                                **LOOP 1100C                                                                          **Will not be
                                TPA/BROKER ACCT.                                                                      sent**
                                INFO**                                                                                

  1100C      ACT01   508        TPA or Broker    R         AN                      1         35                        
                                Account Number                                                                        

  1100C      ACT06   508        Account Number   S         AN                      1         35                        

                                **TRANSACTION                                                                          
                                SET DETAIL**                                                                          

                                **LOOP 2000                                                                            
                                MEMBER LEVEL                                                                          
                                DETAIL                                                                                
                                REQUIRED**                                                                            

  2000       INS01   1073       Insured          R         ID       Y=insured is   1         1                         
                                Indicator                           subscriber.                                       
                                                                    N=insured is                                      
                                                                    dependent.                                        

  2000       INS02   1069       Individual       R         ID       01 =Spouse 03  2         2         30, 51, 72,    Siblings (14)
                                Relationship                        = Father or                        93, 114, 135,  and parents (03)
                                Code                                Mother 09 =                        156, 177, 198, may be covered
                                                                    Adopted Child                      219            when enrollee is
                                                                    10 = Foster                                       a child survivor
                                                                    Child 14 =                                        annuitant If
                                                                    Brother or                                        INS01 = Y, this
                                                                    Sister 17 =                                       element will be
                                                                    Stepson or                                        processed as 18
                                                                    Stepdaughter                                      (Self) If INS02
                                                                    18 = Self 19 =                                    = 19 (Child) and
                                                                    Child                                             INS10 = Y
                                                                                                                      (Handicapped),
                                                                                                                      individual is an
                                                                                                                      unmarried
                                                                                                                      disabled child
                                                                                                                      age 22 or over
                                                                                                                      who is incapable
                                                                                                                      of self-support
  ---------- ------- ---------- ---------------- --------- -------- -------------- --------- --------- -------------- ----------------

  ---------- ------- ---------- ---------------- --------- -------- --------------- --------- --------- -------------- --------------------------
  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**      **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                       in OPM\'s      
                     Number**                                                                           EEX/Data-Hub   
                                                                                                        2809 File      
                                                                                                        Layout**       

  2000       INS03   875        Maintenance Type R         ID       001 = change    3         3         2              001 - Change will be used
                                Code                                021 = addition                                     when enrollee makes a
                                                                    024 =                                              change in option (high vs.
                                                                    cancellation/                                      standard) or enrollment
                                                                    termination                                        type (self vs. self and
                                                                                                                       family) within the same
                                                                                                                       plan 021 - Addition will
                                                                                                                       be used when the enrollee
                                                                                                                       is new to your plan 024 -
                                                                                                                       Cancellation/Termination
                                                                                                                       will be used when enrollee
                                                                                                                       cancels coverage or
                                                                                                                       changes to another plan

  2000       INS04   1203       Maintenance      S         ID       14 = Voluntary  2         3         2              14 - Voluntary Withdrawl
                                Reason Code                         Withdrawal 22 =                                    will be used when enrollee
                                                                    Plan Change 28                                     cancels their coverage
                                                                    = Initial                                          22 - Plan Change will be
                                                                    Enrollment 29 =                                    used when enrollee changes
                                                                    Benefit                                            amongst plans in the FEHB
                                                                    Selection                                          Program 28 - Initial
                                                                                                                       Enrollment will be used
                                                                                                                       when an individual enrolls
                                                                                                                       in the FEHB Program for
                                                                                                                       the first time 29 -
                                                                                                                       Benefit Selection will be
                                                                                                                       used when enrollee makes a
                                                                                                                       change in option (high
                                                                                                                       vs., standard) or
                                                                                                                       enrollment type (self vs.,
                                                                                                                       self and family) within
                                                                                                                       the same plan

  2000       INS05   1216       Benefit Status   R         ID       A = Active      1         1         NA             \"A\" will be used for all
                                Code                                                                                   transactions

  2000       INS06   1218       Medicare Plan    S         ID       A = Part A B =  1         1                        Will be blank if no
                                Code                                Part B C = Part                                    Medicare enrollment
                                                                    A and B                                            reported

  2000       INS07   1219       COBRA Qualifying S         ID                       1         2                        Will not be sent
                                Event Code                                                                             

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**      **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                       in OPM\'s      
                     Number**                                                                           EEX/Data-Hub   
                                                                                                        2809 File      
                                                                                                        Layout**       

                                                                                                                       

  2000       INS08   584        Employment       S         ID       FT = Full-time  2         2         NA             \"RT\" will be used for
                                Status code                         RT = Retired                                       annuitants (Payroll Office
                                                                                                                       ID = 24900002 or 24900003)
                                                                                                                       (Report number =OEOPM)
                                                                                                                       \"FT\" will be used for
                                                                                                                       all others

  2000       INS09   1220       Student Status   S         ID                       1         1                        Will not be sent
                                Code                                                                                   

  2000       INS10   1073       Handicap         S         ID       Y = Yes N = No  1         1                        Value \"Y\" will only be
                                Indicator                                                                              used to indicate a child
                                                                                                                       age 22 or over but
                                                                                                                       incapable of self-support

  2000       INS11   1250       Date Time Period S         ID                       2         3                        Will not be sent
                                Format Qualifier                                                                       

  2000       INS12   1251       Insured          S         AN                       1         35                       Will not be sent
                                Individual Death                                                                       
                                Date                                                                                   

  2000       INS17   1470       Birth Sequence   S         N0                       1         9                        Will not be sent
                                Number                                                                                 

                                **SUBSCRIBER                                                                            
                                NUMBER                                                                                 
                                REQUIRED**                                                                             

  2000       REF01   128        Reference        R         ID       0F = Subscriber 2         3                         
                                Identification                      Number                                             
                                Qualifier                                                                              

  2000       REF02   127        Ref. ID -        R         AN                       1         30        6              Enrollee\'s Social
                                Subscriber \#                                                                          Security Number (No
                                                                                                                       dashes) (4) We will only
                                                                                                                       validate that SSN is nine
                                                                                                                       digits.

                                **MEMBER POLICY                                                         NA              
                                NUMBER                                                                                 
                                SITUATIONAL**                                                                          

  2000       REF01   128        Reference        R         ID       1L = Group or   2         3                         
                                Identification                      Policy Number                                      
                                Qualifier                                                                              

  2000       REF02   127        Ref. ID -        R         AN       \"FEHB\"        1         30                       \"FEHB\" will be used for
                                Insured Group or                                                                       all members since FEHB
                                Policy Number                                                                          Program does not use group
                                                                                                                       or policy numbers
  ---------- ------- ---------- ---------------- --------- -------- --------------- --------- --------- -------------- --------------------------

  ---------- ------- ---------- ---------------- --------- -------- ---------------- --------- --------- -------------- -------------------
  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**       **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                        in OPM\'s      
                     Number**                                                                            EEX/Data-Hub   
                                                                                                         2809 File      
                                                                                                         Layout**       

                                                                                                                        

  2000                          **MEMBER                                                                                 
                                IDENTIFICATION                                                                          
                                NUMBER                                                                                  
                                SITUATIONAL**                                                                           

  2000       REF01   128        Reference        R         ID       17 = Client      2         3                        Code \"17\"
                                Identification                      Reporting 23 =                                      indicates Personnel
                                Qualifier                           Client Number DX                                    Office ID (sent
                                                                    = Dept/Agency                                       only in subscriber
                                                                    Number 60 =                                         loop). Code \"23\"
                                                                    Cross Reference                                     indicates Annuity
                                                                    Number ZZ =                                         Claim Number (sent
                                                                    Mutually Defined                                    only in subscriber
                                                                                                                        loop) Code \"DX\"
                                                                                                                        indicates Payroll
                                                                                                                        Office Number (sent
                                                                                                                        in subscriber and
                                                                                                                        dependent loops)
                                                                                                                        Code \"60\"
                                                                                                                        indicates HB
                                                                                                                        Identification
                                                                                                                        Number (sent only
                                                                                                                        in subscriber loop)
                                                                                                                        Code \"ZZ\"
                                                                                                                        indicates Report
                                                                                                                        Number (sent only
                                                                                                                        in subscriber loop)

  2000       REF02   127        Subscriber       R         AN       Personnel Office 1         30        242 244 243    Personnel Office
                                Supplemental                        ID Payroll                           245 247        ID - 8 position
                                Identifier                          Office Number                                       valid Federal
                                                                    Annuity Claim                                       Personnel Office ID
                                                                    Number HB                                           Payroll Office
                                                                    Identification                                      Number - 8 position
                                                                    Number Report                                       valid Federal
                                                                    Number                                              Payroll Office
                                                                                                                        Number Annuity
                                                                                                                        Claim Number - 9
                                                                                                                        position valid
                                                                                                                        annuity claim
                                                                                                                        number (Annuitants
                                                                                                                        only) HB
                                                                                                                        Identification
                                                                                                                        Number - The SSN of
                                                                                                                        the retiree or in
                                                                                                                        the case of a
                                                                                                                        survivor annuitant,
                                                                                                                        the SSN of the
                                                                                                                        deceased
                                                                                                                        retiree/employee.
                                                                                                                        This number will be
                                                                                                                        the SSN of the
                                                                                                                        person to whom the
                                                                                                                        coverage was
                                                                                                                        originally issued
                                                                                                                        and it will not
                                                                                                                        change (Annuitants
                                                                                                                        only) Report
                                                                                                                        Number - Generated
                                                                                                                        by OPM-Macon

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**       **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                        in OPM\'s      
                     Number**                                                                            EEX/Data-Hub   
                                                                                                         2809 File      
                                                                                                         Layout**       

                                **PRIOR COVERAGE                                                                        Will not be sent
                                MONTHS                                                                                  
                                SITUATIONAL**                                                                           

  2000       REF01   128        Reference        R         ID                        2         3                         
                                Identification                                                                          
                                Qualifier                                                                               

  2000       REF02   127        Prior Coverage   R         AN                        1         30                        
                                Month Count                                                                             

                                **MEMBER LEVEL                                                                           
                                DATES                                                                                   
                                SITUATIONAL**                                                                           

  2000       DTP01   374        Date Time        R         ID       300 = Enrollment 3         3         239 252        Code \"300\"
                                Qualifier loop                      Signature Date                                      indicates the date
                                2000 member                         357 =                                               of enrollee\'s
                                level dates                         Eligibility End                                     election Code
                                                                                                                        \"357\" indicates
                                                                                                                        enrollment is under
                                                                                                                        Temporary
                                                                                                                        Continuation of
                                                                                                                        Coverage provision
                                                                                                                        or Spouse Equity
                                                                                                                        provision

  2000       DTP02   1250       Date Time Period R         ID       D8               2         3                         
                                Format Qualifier                                                                        

  2000       DTP03   1251       Status           R         AN       CCYYMMDD         1         35                       With Code \"357\",
                                Information                         \"99991231\"                                        CCYYMMDD indicates
                                Effective Date                                                                          that enrollment is
                                                                                                                        under Temporary
                                                                                                                        Continuation of
                                                                                                                        Coverage (TCC)
                                                                                                                        provision and has a
                                                                                                                        set expiration date
                                                                                                                        which applies to
                                                                                                                        enrollee and all
                                                                                                                        dependents. With
                                                                                                                        Code \"357\",
                                                                                                                        \"99991231\"
                                                                                                                        indicates that
                                                                                                                        enrollment is under
                                                                                                                        Spouse Equity
                                                                                                                        provision and there
                                                                                                                        is no set
                                                                                                                        expiration date (3)

                                **LOOP 2100A                                                                             
                                MEMBER NAME                                                                             
                                REQUIRED**                                                                              

  2100A      NM101   98         Entity           R         ID       IL = Insured or  2         3                        We will not be
                                Identifier Code                     Subsc.                                              sending any
                                                                                                                        correction
                                                                                                                        transmissions

  2100A      NM102   1065       Entity Type      R         ID       1 = person       1         1                         
                                Qualifier                                                                               

  2100A      NM103   1035       Insured          R         AN                        1         35        3              ** **
                                /Subscriber Last                                                                        
                                Name                                                                                    

  2100A      NM104   1036       Insured          R         AN                        1         25        4               
                                /Subscriber                                                                             
                                First Name                                                                              

  2100A      NM105   1037       Insured          S         AN                        1         25        5              Middle initial will
                                /Subscriber                                                                             be sent
                                Middle Name                                                                             

  2100A      NM106   1038       Insured          S         AN                        1         10                       Will not be sent
                                /Subscriber Name                                                                        
                                Prefix                                                                                  
  ---------- ------- ---------- ---------------- --------- -------- ---------------- --------- --------- -------------- -------------------

  ---------- ------- ---------- ----------------- --------- -------- ------------ --------- --------- -------------- --------------
  **Loop**   **Ref   **Data     **Segment**       **Req. by **Data   **Values**   **Min**   **Max**   **Field Number **Comments**
             Des**   Element                      HIPAA**   Type**                                    in OPM\'s      
                     Number**                                                                         EEX/Data-Hub   
                                                                                                      2809 File      
                                                                                                      Layout**       

                                                                                                                     

  2100A      NM107   1039       Insured           S         AN                    1         10                       Will be
                                /Subscriber Name                                                                     included in
                                Suffix                                                                               last name
                                                                                                                     field

  2100A      NM108   66         Identification    S         AN       34 = Social  1         2                         
                                Code Qualifier                       Security                                        
                                                                     Number                                          

  2100A      NM109   67         Subscriber        S         AN                    2         80        6, 31, 52, 73, Enrollee\'s or
                                Identifier                                                            94, 115, 136,  dependent\'s
                                                                                                      157, 178, 199, Social
                                                                                                      220            Security
                                                                                                                     Number (No
                                                                                                                     dashes) (4) We
                                                                                                                     will only
                                                                                                                     validate that
                                                                                                                     SSN is nine
                                                                                                                     digits.

  2100A      PER01   366        Contact Function  R         ID       IP = Insured 2         2                         
                                Code                                 Party                                           

  2100A      PER03   365        Communication     R         ID       TE =         2         2                         
                                Number Qualifier                     telephone                                       

                                **SITUATIONAL**                                                                       

  2100A      PER04   364        Communication     R         AN                    1         80        23             Daytime
                                Number                                                                               telephone
                                                                                                                     number

  2100A      PER05   365        Communication     S         ID       EX =         2         2                         
                                Number Qualifier                     Extension                                       

  2100A      PER06   364        Communication     S         AN                    1         80        23             Daytime
                                Number                                                                               telephone
                                                                                                                     extension

  2100A      PER07   365        Communication     S         ID                    2         2                        Will not be
                                Number Qualifier                                                                     sent

  2100A      PER08   364        Communication     S         AN                    1         80                       Will not be
                                Number                                                                               sent
  ---------- ------- ---------- ----------------- --------- -------- ------------ --------- --------- -------------- --------------

  ---------- ------- ---------- ------------- --------- -------- ------------- --------- --------- -------------- ---------------
  **Loop**   **Ref   **Data     **Segment**   **Req. by **Data   **Values**    **Min**   **Max**   **Field Number **Comments**
             Des**   Element                  HIPAA**   Type**                                     in OPM\'s      
                     Number**                                                                      EEX/Data-Hub   
                                                                                                   2809 File      
                                                                                                   Layout**       

  2100A      N301    166        Subscriber    R         AN       \"Not passed  1         55        8              N301 and N302
                                Address Line                     for security                                     will not be
                                                                 reasons\"                                        sent if no
                                                                                                                  street address
                                                                                                                  is provided for
                                                                                                                  enrollee.
                                                                                                                  Dependent
                                                                                                                  addresses will
                                                                                                                  default to
                                                                                                                  enrollee\'s
                                                                                                                  address if
                                                                                                                  dependent
                                                                                                                  addresses are
                                                                                                                  not provided
                                                                                                                  \"Not passed
                                                                                                                  for security
                                                                                                                  reasons\" will
                                                                                                                  appear when
                                                                                                                  address is not
                                                                                                                  provided and
                                                                                                                  Report Number =
                                                                                                                  EESTA

  2100A      N302    166        Subscriber    R         AN                     1         55        9, 10          Will include
                                Address Line                                                                      any information
                                                                                                                  contained on a
                                                                                                                  third line of
                                                                                                                  the
                                                                                                                  individual\'s
                                                                                                                  address (5)

  2100A      N401    19         Subscriber    R         AN                     2         30        11              
                                City Name                                                                         

  2100A      N402    156        Subscriber    R         ID                     2         2         12             Field will be
                                State Code                                                                        populated with
                                                                                                                  \'DC\' if
                                                                                                                  address is
                                                                                                                  foreign. (6)

  2100A      N403    116        Subscriber    R         ID       Valid Postal  3         15        13             \"00000\" will
                                Postal Zone                      Codes                                            be used for
                                or ZIP Code                      \"00000\" -                                      foreign
                                                                 if not                                           addresses where
                                                                 provided                                         a postal code
                                                                                                                  is unavailable

  2100A      N404    26         Subscriber    S         ID       ISO = 3166    2         3         12             Will be
                                Country Code                     codes (2                                         provided when
                                                                 character                                        address is
                                                                 alpha) \"XX\"                                    foreign \"XX\"
                                                                 \"ZZ\"                                           is propriety
                                                                                                                  code for
                                                                                                                  Paracel Islands
                                                                                                                  \"ZZ\" is
                                                                                                                  propriety code
                                                                                                                  for Spratley
                                                                                                                  Islands

  2100A      N405    309        Subscriber    S         ID                     1         2                        Will not be
                                Location                                                                          sent
                                Qualifier                                                                         

  2100A      N406    310        Subscriber    S         AN                     1         30                       Will not be
                                Location                                                                          sent
                                Identifier                                                                        

  2100A      DMG01   1250       Date Time     R         ID       D8            2         3                         
                                Period Format                                                                     
                                Qualifier                                                                         

  2100A      DMG02   1251       Date Time     R         AN                     1         35        7, 28, 49, 70, CCYYMMDD
                                Period Member                                                      91, 112, 133,  
                                Birth Date                                                         154, 175, 196, 
                                                                                                   217            
  ---------- ------- ---------- ------------- --------- -------- ------------- --------- --------- -------------- ---------------

  ---------- ------- ---------- ---------------- --------- -------- ------------- --------- --------- -------------- --------------
  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**    **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                     in OPM\'s      
                     Number**                                                                         EEX/Data-Hub   
                                                                                                      2809 File      
                                                                                                      Layout**       

  2100A      DMG03   1068       Gender Code      R         ID       F = Female M  1         1         14, 29, 71,    Code \"U\"
                                                                    = Male U =                        92, 113, 134,  will be sent
                                                                    Unknown                           155, 176, 197, if Gender is
                                                                                                      218            not provided
                                                                                                                     by enrollee

  2100A      DMG04   1067       Marital Status   S         ID       I = single, M 1         1         15             Code \"R\"
                                Code                                = married, R                                     will be sent
                                                                    = unreported,                                    if Marital
                                                                                                                     Status is not
                                                                                                                     reported by
                                                                                                                     enrollee

  2100A      DMG05   1109       Race or          S         ID                     1         1                        Will not be
                                Ethnicity Code                                                                       sent

  2100A      DMG06   1066       Citizenship      S         ID                     1         2                        Will not be
                                Status Code                                                                          sent

  2100A      ICM01   594        Frequency code   R         ID                     1         1                        Will not be
                                                                                                                     sent

  2100A      ICM02   782        Wage Amount      R         R                      1         18                       Will not be
                                                                                                                     sent

  2100A      ICM03   380        Work Hours Count S         R                      1         15                       Will not be
                                                                                                                     sent

  2100A      ICM04   310        Location         S         AN                     1         30                       Will not be
                                Identifier                                                                           sent

  2100A      ICM05   1214       Salary Grade     S         AN                     1         5                        Will not be
                                                                                                                     sent

  2100A      AMT01   522        Amount Qualifier R         ID                                                        Will not be
                                Code                                                                                 sent

  2100A      AMT02   782        Contract         R         R                      1         18                       Will not be
                                Amount -                                                                             sent
                                coinsurance                                                                          
                                Contract                                                                             
                                Amount - copay                                                                       
                                Contract                                                                             
                                Amount -                                                                             
                                deductible                                                                           

  2100A      AMT02   782        Contract         R         R                      1         18                       Will not be
                                Amount - premium                                                                     sent
                                amt                                                                                  

  2100A      HLH01   1212       Health Related   S         ID                     1         1                        Will not be
                                Code                                                                                 sent

  2100A      HLH02   65         Height           S         R                      1         8                        Will not be
                                                                                                                     sent

  2100A      HLH03   81         Weight           S         R                      1         10                       Will not be
                                                                                                                     sent

  2100A      LU101   66         Identification   S         ID                     1         2                        Will not be
                                Code Qualifier                                                                       sent

  2100A      LU102   67         Language Code    S         AN                     2         80                       Will not be
                                                                                                                     sent

  2100A      LU103   352        Language         S         AN                     1         80                       Will not be
                                Description                                                                          sent

  2100A      LU104   1303       Language Use     S         ID                     1         2                        Will not be
                                Indicator                                                                            sent

  ** **      ** **   ** **      **LOOP 2100B     ** **     ** **    ** **         ** **                              **Will not be
                                INCORRECT MEMBER                                                                     sent**
                                NAME                                                                                 
                                SITUATIONAL**                                                                        

  2100B      NM101   98         Entity           R         ID                     2         3                         
                                Identifier Code                                                                      

  2100B      NM102   1065       Entity Type      R         ID                     1         1                         
                                Qualifier                                                                            

  2100B      NM103   1035       Prior Incorrect  R         AN                     1         35                        
                                Last Name                                                                            

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**    **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                     in OPM\'s      
                     Number**                                                                         EEX/Data-Hub   
                                                                                                      2809 File      
                                                                                                      Layout**       

  2100B      NM104   1036       Prior Incorrect  R         AN                     2         3                         
                                First Name                                                                           

  2100B      NM105   1037       Prior Incorrect  S         AN                     1         25                        
                                Middle Name                                                                          

  2100B      NM106   1038       Prior Incorrect  S         AN                     1         10                        
                                Name Prefix                                                                          

  2100B      NM107   1039       Prior Incorrect  S         AN                     1         10                        
                                Name Suffix                                                                          

  2100B      NM108   66         Identification   S         AN                     1         2                         
                                Code Qualifier                                                                       

  2100B      NM109   67         Identification   S         AN                     2         80                        
                                Code Qualifier                                                                       

  2100B      DMG01   1250       Date Time Period R         ID                     2         3                         
                                Format Qualifier                                                                     

  2100B      DMG02   1251       Prior Incorrect  R         AN                     1         35                        
                                DOB                                                                                  

  2100B      DMG03   1068       Prior Incorrect  R         ID                     1         1                         
                                Gender Code                                                                          

                                                                                                                      

                                **LOOP 2100C -                                                                       **Will not be
                                MEMBER MAILING                                                                       sent**
                                ADDRESS                                                                              
                                SITUATIONAL**                                                                        

  2100C      NM101   98         Entity           R         ID                     2         3                         
                                Identifier Code                                                                      

  2100C      NM102   1065       Entity Type      R         ID                     1         1                         
                                Qualifier                                                                            

  2100C      N301    166        Subscriber       S         AN                     1         55                        
                                Address Line                                                                         

  2100C      N302    166        Subscriber       S         AN                     1         55                        
                                Address Line                                                                         

  2100C      N401    19         Subscriber City  R         AN                     2         30                        
                                Name                                                                                 

  2100C      N402    156        Subscriber State R         ID                     2         2                         
                                or Province Code                                                                     

  2100C      N403    116        Subscriber       R         ID                     3         15                        
                                Postal Code                                                                          

  2100C      N404    26         Subscriber       S         ID                     2         3                         
                                Country Code                                                                         

                                **LOOP 2100D -   \`                                                                  **Will not be
                                MEMBER                                                                               sent**
                                EMPLOYER**                                                                           

  2100D      N301    166        Insured Employer R         AN                     1         55                        
                                Address line                                                                         

  2100D      N302    166        Insured Employer S         AN                     1         55                        
                                Address line                                                                         

  2100D      N401    19         Insured Employer R         AN                     2         30                        
                                City Name                                                                            

  2100D      N402    156        Insured Employer R         ID                     2         2                         
                                State Code                                                                           

  2100D      N403    116        Insured Employer R         ID                     3         15                        
                                ZIP Code                                                                             

  2100D      N404    26         Insured Employer S         ID                     2         3                         
                                Country Code                                                                         

                                **LOOP 2100E -                                                                       **Will not be
                                MEMBER SCHOOL                                                                        sent**
                                SITUATIONAL**                                                                        

  2100E      NM101   98         Entity           R         ID                     2         3                         
                                Identifier Code                                                                      

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**    **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                     in OPM\'s      
                     Number**                                                                         EEX/Data-Hub   
                                                                                                      2809 File      
                                                                                                      Layout**       

                                                                                                                     

  2100E      NM102   1065       Entity Type      R         ID                     1         1                         
                                Qualifier                                                                            

  2100E      NM103   1035       School Name      R         AN                     1         35                        

  2100E      PER01   366        Contact Function R         ID                     2         2                         
                                Code                                                                                 

  2100E      PER03   365        Communication    R         ID                     2         2                         
                                Number Qualifier                                                                     

  2100E      PER04   364        Communication    R         AN                     1         80                        
                                Number                                                                               

  2100E      PER05   365        Communication    S         ID                     2         2                         
                                Number Qualifier                                                                     

  2100E      PER06   364        Communication    S         AN                     1         80                        
                                Number                                                                               

  2100E      PER07   365        Communication    S         ID                     2         2                         
                                Number Qualifier                                                                     

  2100E      PER08   364        Communication    S         AN                     1         80                        
                                Number                                                                               

  2100E      N301    166        School Address   R         AN                     1         55                        
                                Line                                                                                 

  2100E      N302    166        School Address   S         AN                     1         55                        
                                Line                                                                                 

  2100E      N401    19         School City Name R         AN                     2         30                        

  2100E      N402    156        School State     R         ID                     2         2                         
                                Code                                                                                 

  2100E      N403    116        School Postal    R         ID                     3         15                        
                                Zone or ZIP code                                                                     

                                **LOOP 2100F -                                                                       **Will not be
                                CUSTODIAL PARENT                                                                     sent**
                                SITUATIONAL**                                                                        

  2100F      NM101   98         Entity           R         ID                     2         3                         
                                Identifier Code                                                                      

  2100F      NM102   1065       Entity Type      R         ID                     1         1                         
                                Qualifier                                                                            

  2100F      NM103   1035       Custodial Parent R         AN                     1         35                        
                                Last Name                                                                            

  2100F      NM104   1036       Custodial Parent R         AN                     1         25                        
                                First Name                                                                           

  2100F      NM105   1037       Custodial Parent S         AN                     1         25                        
                                Middle Name                                                                          

  2100F      NM106   1038       Custodial Parent S         AN                     1         10                        
                                Name Prefix                                                                          

  2100F      NM107   1039       Custodial Parent S         AN                     1         10                        
                                Name Suffix                                                                          

  2100F      NM108   66         Identification   s         AN                     1         2                         
                                Code Qualifier                                                                       

  2100F      NM109   67         Custodial Parent S         AN                     2         80                        
                                Identifier                                                                           

  2100F      PER01   366        Contact Function R         ID                     2         2                         
                                Code                                                                                 

  2100F      PER03   365        Communication    R         ID                     2         2                         
                                Number Qualifier                                                                     

  2100F      PER04   364        Communication    R         AN                     1         80                        
                                Number                                                                               
  ---------- ------- ---------- ---------------- --------- -------- ------------- --------- --------- -------------- --------------

  ---------- ------- ---------- ---------------- --------- -------- --------------- --------- --------- -------------- --------------------------
  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**      **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                       in OPM\'s      
                     Number**                                                                           EEX/Data-Hub   
                                                                                                        2809 File      
                                                                                                        Layout**       

  2100F      PER05   365        Communication    S         ID                       2         2                         
                                Number Qualifier                                                                       

  2100F      PER07   365        Communication    S         ID                       2         2                         
                                Number Qualifier                                                                       

  2100F      PER08   364        Communication    S         AN                       1         80                        
                                Number                                                                                 

  2100F      N301    166        Custodial Parent R         AN                       1         55                        
                                Address Line                                                                           

  2100F      N302    166        Custodial Parent S         AN                       1         55                        
                                Address Line                                                                           

  2100F      N401    19         Custodial Parent R         AN                       2         30                        
                                City Name                                                                              

  2100F      N402    156        Custodial Parent R         ID                       2         2                         
                                State Code                                                                             

  2100F      N403    116        Custodial Parent R         ID                       3         15                        
                                Postal Zone or                                                                         
                                ZIP Code                                                                               

  2100F      N404    26         Custodial Parent S         ID                       2         3                         
                                Country Code                                                                           

                                                                                                                        

                                **LOOP 2100G -                                                                         Used in Temporary
                                RESPONSIBLE                                                                            Continuation of Coverage
                                PERSON                                                                                 (TCC) and Spouse Equity
                                SITUATIONAL**                                                                          enrollments (7)

  2100G      NM101   98         Entity           R         ID       QD =            2         3                         
                                Identifier Code                     responsible                                        
                                                                    party                                              

  2100G      NM102   1065       Entity Type      R         ID       1 = Person      1         1                         
                                Qualifier                                                                              

  2100G      NM103   1035       Responsible      R         AN                       1         35        248             
                                Party Last or                                                                          
                                Organization                                                                           
                                Name                                                                                   

  2100G      NM104   1036       Responsible      R         AN                       1         25        249             
                                Party First Name                                                                       

  2100G      NM105   1037       Responsible      S         AN                       1         25        250             
                                Party Middle                                                                           
                                Name                                                                                   

  2100G      NM106   1038       Responsible      S         AN                       1         10                       Will not be sent
                                Party Name                                                                             
                                Prefix                                                                                 

  2100G      NM107   1039       Responsible      S         AN                       1         10                       Will be included in last
                                Party Name                                                                             name field
                                Suffix                                                                                 

  2100G      NM108   66         Identification   S         AN       34 = Social     1         2                         
                                Code Qualifier                      Security Number                                    

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**      **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                       in OPM\'s      
                     Number**                                                                           EEX/Data-Hub   
                                                                                                        2809 File      
                                                                                                        Layout**       

  2100G      NM109   67         Responsible      S         AN                       2         80        251            Social Security Number of
                                Party Identifier                                                                       employee or annuitant (No
                                                                                                                       dashes) We will only
                                                                                                                       validate that SSN is nine
                                                                                                                       digits long

  2100G      PER01   366        Contact Function R         ID                       2         2                        Will not be sent
                                Code                                                                                   

  2100G      PER03   365        Communication    R         ID                       2         2                        Will not be sent
                                Number Qualifier                                                                       

  2100G      PER04   364        Communication    R         AN                       1         80                       Will not be sent
                                Number                                                                                 

  2100G      PER05   365        Communication    S         ID                       2         2                        Will not be sent
                                Number Qualifier                                                                       

  2100G      PER06   364        Communication    R         AN                       1         80                       Will not be sent
                                Number                                                                                 

  2100G      PER07   365        Communication    S         ID                       2         2                        Will not be sent
                                Number Qualifier                                                                       

  2100G      PER08   364        Communication    S         AN                       1         80                       Will not be sent
                                Number                                                                                 

  2100G      N301    166        Responsible      R         AN                       1         55                       Will not be sent
                                Party Address                                                                          
                                Line                                                                                   

  2100G      N302    166        Responsible      S         AN                       1         55                       Will not be sent
                                Party Address                                                                          
                                Line                                                                                   

  2100G      N401    19         Responsible      R         AN                       2         30                       Will not be sent
                                Party City Name                                                                        

  2100G      N402    156        Responsible      R         ID                       2         2                        Will not be sent
                                Party State Code                                                                       

  2100G      N403    116        Responsible      R         ID                       3         15                       Will not be sent
                                Party Postal                                                                           
                                Zone or ZIP Code                                                                       

  2100G      N404    26         Responsible      S         ID                       2         3                        Will not be sent
                                Country Code                                                                           

  **Loop**   **Ref   **Data     **Segment**      **Req. by **Data   **Values**      **Min**   **Max**   **Field Number **Comments**
             Des**   Element                     HIPAA**   Type**                                       in OPM\'s      
                     Number**                                                                           EEX/Data-Hub   
                                                                                                        2809 File      
                                                                                                        Layout**       

                                                                                                                        

                                **LOOP 2200                                                                            **Will not be sent**
                                DISABILITY                                                                             
                                INFORMATION                                                                            
                                SITUATIONAL**                                                                          

  2200       DSB01   1146       Disability Type  R         ID                       1         1                         
                                code                                                                                   

  2200       DSB07   235        Product or       S         ID                       2         2                         
                                Service Id                                                                             
                                Qualifier                                                                              

  2200       DSB08   1137       Diagnosis Code   S         AN                       1         15                        

  2200       DTP01   374        Date Time        R         ID                       3         3                         
                                Qualifier                                                                              

  2200       DTP02   1250       Date Time Period R         ID                       2         3                         
                                Format Qualifier                                                                       

  2200       DTP03   1251       Disability       R         AN                       1         35                        
                                Eligibility Date                                                                       

                                **LOOP 2300                                                                             
                                HEALTH COVERAGE                                                                        
                                SITUATIONAL**                                                                          

  2300       HD01    875        Maintenance Type R         ID       001 = change    3         3         2              001 - Change will be used
                                Code                                021 = addition                                     when enrollee makes a
                                                                    024 =                                              change in option (high vs.
                                                                    cancellation/                                      standard) or enrollment
                                                                    termination                                        type (self vs. self and
                                                                                                                       family) within the same
                                                                                                                       plan 021 - Addition will
                                                                                                                       be used when the enrollee
                                                                                                                       is new to your plan 024 -
                                                                                                                       Cancellation/Termination
                                                                                                                       will be used when enrollee
                                                                                                                       cancels coverage or
                                                                                                                       changes to another plan

  2300       HD03    1205       Insurance Line   R         ID       HLT = Health    2         3                        \"HLT\" will be used for
                                Code                                                                                   all transmissions
  ---------- ------- ---------- ---------------- --------- -------- --------------- --------- --------- -------------- --------------------------

<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 19%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 10%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 20%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Loop</strong></td>
<td><strong>Ref Des</strong></td>
<td><strong>Data Element Number</strong></td>
<td><strong>Segment</strong></td>
<td><strong>Req. by HIPAA</strong></td>
<td><strong>Data Type</strong></td>
<td><strong>Values</strong></td>
<td><strong>Min</strong></td>
<td><strong>Max</strong></td>
<td><strong>Field Number in OPM's EEX/Data-Hub 2809 File
Layout</strong></td>
<td><strong>Comments</strong></td>
</tr>
<tr class="even">
<td>2300</td>
<td>HD04</td>
<td>1204</td>
<td>Plan Coverage Description</td>
<td>S</td>
<td>AN</td>
<td>OPM assigned plan Enrollment Codes OPM designated Event Codes</td>
<td>1</td>
<td>50</td>
<td>24 - enrollment code of plan enrolling in or changing to 235 -
enrollment code currently enrolled in</td>
<td>Positions 1 - 10 is <em>gaining plan's Enrollment Code</em>
Positions 11 - 20 is <em>losing plan's enrollment code</em> Position 21
- 22 is <em>Event code</em> Our current three place enrollment codes
will be preceded by leading zeros</td>
</tr>
<tr class="odd">
<td>2300</td>
<td>HD05</td>
<td>1207</td>
<td>Coverage Level Code</td>
<td>S</td>
<td>ID</td>
<td> </td>
<td>3</td>
<td>3</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td><strong>HEALTH COVERAGE DATES - REQUIRED</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2300</td>
<td>DTP01</td>
<td>374</td>
<td>Date Time Qualifier</td>
<td>R</td>
<td>ID</td>
<td>303 = Maintenance Effective 348 = Benefit Begin 349 = Benefit
End</td>
<td>3</td>
<td>3</td>
<td>238</td>
<td>Date enrollee's election takes effect. 303 - Maintenance Effective
will be used when enrollee makes a change in option (high vs. standard)
or enrollment type (self vs. self and family) within the same plan 348 -
Benefit Begin will be used when the enrollee is new to your plan 349 -
Benefit End will be used when enrollee cancels coverage or changes to
another plan</td>
</tr>
<tr class="even">
<td>2300</td>
<td>DTP02</td>
<td>1250</td>
<td>Date Time Period Format Qualifier</td>
<td>R</td>
<td>ID</td>
<td>D8</td>
<td>2</td>
<td>3</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2300</td>
<td>DTP03</td>
<td>1251</td>
<td>Coverage Period</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>35</td>
<td> </td>
<td>CCYYMMDD</td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td><strong>SITUATIONAL</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2300</td>
<td>AMT01</td>
<td>522</td>
<td>Amount Qualifier Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td>2300</td>
<td>AMT02</td>
<td>782</td>
<td>Contract Amount - coinsurance Contract Amount - copay Contract
Amount - deductible</td>
<td>R</td>
<td>R</td>
<td> </td>
<td>1</td>
<td>18</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td><strong>Loop</strong></td>
<td><strong>Ref Des</strong></td>
<td><strong>Data Element Number</strong></td>
<td><strong>Segment</strong></td>
<td><strong>Req. by HIPAA</strong></td>
<td><strong>Data Type</strong></td>
<td><strong>Values</strong></td>
<td><strong>Min</strong></td>
<td><strong>Max</strong></td>
<td><strong>Field Number in OPM's EEX/Data-Hub 2809 File
Layout</strong></td>
<td><strong>Comments</strong></td>
</tr>
<tr class="even">
<td>2300</td>
<td>AMT02</td>
<td>782</td>
<td>Contract Amount - premium amt</td>
<td>R</td>
<td>R</td>
<td></td>
<td>1</td>
<td>18</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td>2300</td>
<td>AMT02</td>
<td>782</td>
<td>Contract Amount - deductible</td>
<td>R</td>
<td>R</td>
<td> </td>
<td>1</td>
<td>18</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td>2300</td>
<td>AMT02</td>
<td>782</td>
<td>Contract Amount - premium amt</td>
<td>R</td>
<td>R</td>
<td> </td>
<td>1</td>
<td>18</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td>2300</td>
<td>REF01</td>
<td>128</td>
<td>Reference Identification Qualifier</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>3</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td>2300</td>
<td>REF02</td>
<td>127</td>
<td>Ref. ID - Insured Group or Policy Number</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>30</td>
<td> </td>
<td>Will not be sent Already identified in LOOP 2000 REF02</td>
</tr>
<tr class="odd">
<td>2300</td>
<td>IDC01</td>
<td>1204</td>
<td>Plan Coverage Description</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>50</td>
<td> </td>
<td>Will not be sent You must provide enrollment cards to new enrollees.
Enrollees will contact you directly for replacement enrollment
cards</td>
</tr>
<tr class="even">
<td>2300</td>
<td>IDC02</td>
<td>1215</td>
<td>Identification Card Type Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td> </td>
<td>1</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td>2300</td>
<td>IDC03</td>
<td>380</td>
<td>Identification Card Count</td>
<td>S</td>
<td>R</td>
<td> </td>
<td>1</td>
<td>15</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td>2300</td>
<td>IDC04</td>
<td>306</td>
<td>Action Code</td>
<td>S</td>
<td>ID</td>
<td> </td>
<td>1</td>
<td>2</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td><strong>LOOP 2310 PROVIDER INFORMATION SITUATIONAL</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td><strong>Will not be sent</strong></td>
</tr>
<tr class="even">
<td>2310</td>
<td>LX01</td>
<td>554</td>
<td>Assigned Number</td>
<td>R</td>
<td>N0</td>
<td> </td>
<td>1</td>
<td>6</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td><strong>LOOP 2310 PROVIDER NAME REQUIRED</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td><strong>Will not be sent</strong></td>
</tr>
<tr class="even">
<td>2310</td>
<td>NM101</td>
<td>98</td>
<td>Entity Identifier Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>3</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>NM102</td>
<td>1065</td>
<td>Entity Type Qualifier</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>1</td>
<td>1</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>NM103</td>
<td>1035</td>
<td>Provider Last Name</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>25</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>NM104</td>
<td>1036</td>
<td>Provider First Name</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>25</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>NM105</td>
<td>1037</td>
<td>Provider Middle Name</td>
<td>S</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>25</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>NM106</td>
<td>1038</td>
<td>Provider Name Prefix</td>
<td>S</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>10</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>NM107</td>
<td>1039</td>
<td>Provider Suffix Name</td>
<td>S</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>10</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>NM108</td>
<td>66</td>
<td>Identification Code Qualifier</td>
<td>s</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>NM109</td>
<td>67</td>
<td>Provider Identifier</td>
<td>S</td>
<td>AN</td>
<td> </td>
<td>2</td>
<td>80</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>NM110</td>
<td>706</td>
<td>Entity Relationship Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td><strong>Loop</strong></td>
<td><strong>Ref Des</strong></td>
<td><strong>Data Element Number</strong></td>
<td><strong>Segment</strong></td>
<td><strong>Req. by HIPAA</strong></td>
<td><strong>Data Type</strong></td>
<td><strong>Values</strong></td>
<td><strong>Min</strong></td>
<td><strong>Max</strong></td>
<td><strong>Field Number in OPM's EEX/Data-Hub 2809 File
Layout</strong></td>
<td><strong>Comments</strong></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td><strong>SITUATIONAL</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td><strong>Will not be sent</strong></td>
</tr>
<tr class="odd">
<td>2310</td>
<td>N401</td>
<td>19</td>
<td>Member City Name</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>2</td>
<td>30</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>N402</td>
<td>156</td>
<td>Member State or Province Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>N403</td>
<td>116</td>
<td>Member Postal Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>3</td>
<td>15</td>
<td> </td>
<td><strong> </strong></td>
</tr>
<tr class="even">
<td>2310</td>
<td>N404</td>
<td>26</td>
<td>Member Country Code</td>
<td>S</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>3</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>N405</td>
<td>309</td>
<td>Location Qualifier</td>
<td>S</td>
<td>ID</td>
<td> </td>
<td>1</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>N406</td>
<td>310</td>
<td>Location Identification Code</td>
<td>S</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>PER01</td>
<td>366</td>
<td>Contact Function Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>PER03</td>
<td>365</td>
<td>Communication Number Qualifier</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>PER04</td>
<td>364</td>
<td>Communication Number</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>80</td>
<td> </td>
<td><strong> </strong></td>
</tr>
<tr class="even">
<td>2310</td>
<td>PLA01</td>
<td>306</td>
<td>Action Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>1</td>
<td>2</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>PLA02</td>
<td>98</td>
<td>Entity Identifier Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>3</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td>2310</td>
<td>PLA03</td>
<td>373</td>
<td>Provider Effective Date</td>
<td>R</td>
<td>DT</td>
<td> </td>
<td>8</td>
<td>8</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2310</td>
<td>PLA05</td>
<td>1203</td>
<td>Maintenance Reason Code</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>3</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td><strong>LOOP 2320 COORDINATION OF BENEFITS SITUATIONAL</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td>2320</td>
<td>COB01</td>
<td>1138</td>
<td>Payer Responsibility Sequence Number Code</td>
<td>R</td>
<td>ID</td>
<td>U = Unknown</td>
<td>1</td>
<td>1</td>
<td> </td>
<td>Will be populated if individual has TRICARE and/or other group
health insurance. OPM and the Federal agencies are in no position to
make payer responsibility determinations, therefore field will always be
populated with "U" .</td>
</tr>
<tr class="even">
<td>2320</td>
<td>COB02</td>
<td>127</td>
<td>Insured Group/Policy Number</td>
<td>S</td>
<td>AN</td>
<td>"TRICARE"</td>
<td>1</td>
<td>30</td>
<td>20, 36, 57, 78, 99, 120, 141, 162, 183, 204, 225</td>
<td>"TRICARE" will appear if person is covered under TRICARE or
CHAMPUS</td>
</tr>
<tr class="odd">
<td><strong>Loop</strong></td>
<td><strong>Ref Des</strong></td>
<td><strong>Data Element Number</strong></td>
<td><strong>Segment</strong></td>
<td><strong>Req. by HIPAA</strong></td>
<td><strong>Data Type</strong></td>
<td><strong>Values</strong></td>
<td><strong>Min</strong></td>
<td><strong>Max</strong></td>
<td><strong>Field Number in OPM's EEX/Data-Hub 2809 File
Layout</strong></td>
<td><strong>Comments</strong></td>
</tr>
<tr class="even">
<td>2320</td>
<td>COB03</td>
<td>1143</td>
<td>Coordination of Benefits Code</td>
<td>R</td>
<td>ID</td>
<td>1 = Coordination of Benefits 5 = Unknown</td>
<td>1</td>
<td>1</td>
<td> </td>
<td>"1" will appear when other coverage is TRICARE/CHAMPUS since we know
COB exists. "5" will be used when other insurance company names or
group/policy numbers are provided since we don't know for certain that
COB exists</td>
</tr>
<tr class="odd">
<td>2320</td>
<td>REF01</td>
<td>128</td>
<td>Reference Identification Qualifier</td>
<td>R</td>
<td>ID</td>
<td>ZZ = mutually defined</td>
<td>2</td>
<td>3</td>
<td> </td>
<td>Field will be populated if individual indicates he/she has group
health insurance coverage other than FEHB or TRICARE and provides
Group/Policy Number</td>
</tr>
<tr class="even">
<td>2320</td>
<td>REF02</td>
<td>127</td>
<td>Insured Group/Policy Number</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>30</td>
<td>22, 38, 59, 80, 101, 122, 143, 164, 185, 206, 227</td>
<td> </td>
</tr>
<tr class="odd">
<td>2320</td>
<td>N101</td>
<td>98</td>
<td>Entity Identifier Code</td>
<td>R</td>
<td>ID</td>
<td>IN = Insurer</td>
<td>2</td>
<td>3</td>
<td> </td>
<td>Field will be populated if individual indicates he/she has group
health insurance coverage other than FEHB or TRICARE</td>
</tr>
<tr class="even">
<td>2320</td>
<td>N102</td>
<td>93</td>
<td>Insurer Name</td>
<td>S</td>
<td>AN</td>
<td></td>
<td>1</td>
<td>60</td>
<td>21, 37, 58, 79, 100, 121, 142, 163, 184, 205, 226</td>
<td> </td>
</tr>
<tr class="odd">
<td>2320</td>
<td>N103</td>
<td>66</td>
<td>Identification Code Qualifier</td>
<td>S</td>
<td>ID</td>
<td> </td>
<td>1</td>
<td>2</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td>2320</td>
<td>N104</td>
<td>67</td>
<td>Insured Group or Policy Number</td>
<td>S</td>
<td>AN</td>
<td></td>
<td>2</td>
<td>80</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td>2320</td>
<td>DTP01</td>
<td>374</td>
<td>Date Time Qualifier</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>3</td>
<td>3</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td>2320</td>
<td>DTP02</td>
<td>1250</td>
<td>Date Time Period Format Qualifier</td>
<td>R</td>
<td>ID</td>
<td> </td>
<td>2</td>
<td>3</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="odd">
<td>2320</td>
<td>DTP03</td>
<td>1251</td>
<td>Coordination of Benefits Date</td>
<td>R</td>
<td>AN</td>
<td> </td>
<td>1</td>
<td>35</td>
<td> </td>
<td>Will not be sent</td>
</tr>
<tr class="even">
<td><strong>Loop</strong></td>
<td><strong>Ref Des</strong></td>
<td><strong>Data Element Number</strong></td>
<td><strong>Segment</strong></td>
<td><strong>Req. by HIPAA</strong></td>
<td><strong>Data Type</strong></td>
<td><strong>Values</strong></td>
<td><strong>Min</strong></td>
<td><strong>Max</strong></td>
<td><strong>Field Number in OPM's EEX/Data-Hub 2809 File
Layout</strong></td>
<td><strong>Comments</strong></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td><strong>TRANSACTION SET TRAILER REQUIRED</strong></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td>SE01</td>
<td>96</td>
<td>Number of Included Segments</td>
<td>R</td>
<td>NO</td>
<td> </td>
<td>1</td>
<td>10</td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td>SE02</td>
<td>329</td>
<td>Transaction Set Control Number</td>
<td>R</td>
<td>AN</td>
<td>Taken from OPM-Macon's SEQ_NUM database</td>
<td>4</td>
<td>9</td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td><table>
<colgroup>
<col style="width: 100%" />
</colgroup>
<tbody>
<tr class="odd">
<td> </td>
</tr>
</tbody>
</table></td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="even">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr class="odd">
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</tbody>
</table>

**FEHB Program Business Rules and Limitations**

**Dependent Information**

Dependent records will not be created when Nature of Transaction is
'Stop' (Maintenance Reason Code in LOOP 2000 MEMBER LEVEL DETAIL {INS04,
1203} = '14' -- Voluntary Withdrawal). Dependent records will be created
for all other transactions, when dependent data is provided. Not all
Federal agencies provide dependent information even though enrollee
selects self and family coverage.

Some transactions will have dependent information, but not provide
"Other Insurance" information for each dependent. Some transactions will
have dependent information, but not provide an address for the dependent
when the dependent's address is different from that of the enrollee. You
must process these transactions as you receive them. You may send the
enrollee a Post Enrollment Questionnaire to gather any missing data.

**Temporary Continuation of Coverage (TCC) and Spouse Equity**

Temporary Continuation of Coverage (TCC) and Spouse Equity enrollments
will be identified in LOOP 2000 MEMBER LEVEL DETAIL (DTP01, 374 = '357';
DTP03, 1251 = 'ccyymmdd' or '99991231'. An expiration date of 'ccyymmdd'
indicates that the enrollment is under the TCC provisions and has a set
expiration date. An expiration date of '99991231' indicates that
enrollment is under Spouse Equity provision and there is no set
expiration date.

If an individual enrolled in TCC obtains eligibility for Spouse Equity
coverage, you will receive a 'Change-Within a Plan' transaction
(Maintenance Reason Code in LOOP 2000 MEMBER LEVEL DETAIL {INS04, 1203}
= '29' -- Benefit Selection). The individual is not changing plan,
option, or enrollment type. The gaining plan and losing plan enrollment
codes in LOOP 2300 HEALTH COVERAGE (HD04, 1204) will be the same. This
transaction notifies you that the enrollment no longer has an expiration
date since Spouse Equity coverage can continue for life. The coverage
expiration date in LOOP 2000 MEMBER LEVEL DETAIL (DTP03, 1251) =
'99991231'.

If an individual enrolled under Spouse Equity coverage loses entitlement
to coverage (for example they remarry before reaching age 55) during the
36 months following their divorce from the Federal employee, they are no
longer eligible for Spouse Equity coverage but are now eligible for TCC
that will expire 36 months after the date of the divorce or annulment
from the Federal employee. In these cases, you will receive a
'Change-Within a Plan' transaction (Maintenance Reason Code in LOOP 2000
MEMBER LEVEL DETAIL {INS04, 1203} = '29' -- Benefit Selection). The
individual is not changing plan, option, or enrollment type. The gaining
plan and losing plan enrollment codes in LOOP 2300 HEALTH COVERAGE
(HD04, 1204) will be the same. This transaction notifies you that the
enrollment now has an expiration date. The coverage expiration date in
LOOP 2000 MEMBER LEVEL DETAIL (DTP03, 1251) = 'ccyymmdd'.

Certain information on the Federal employee or annuitant whose coverage
entitles Spouse Equity coverage or former spouses and children to enroll
in TCC, will be provided in LOOP 2100G RESPONSIBLE PERSON. The
relationship of this individual to the TCC enrollee will not be
provided.

We will not populate LOOP 2000 MEMBER LEVEL DETAIL (INSO7, 1219) because
there isn't a mechanism for the National Finance Center to indicate the
event that allows TCC enrollment.

**Children Incapable of Self-support**

When you get a new enrollment that includes a Child Incapable of
Self-support, you need to know if the child has been determined to be
incapable of self support, and the length of time before a new
determination is needed. Go ahead and enroll the child and contact the
enrollee for a copy of the determination which can come from the
following sources:

a.  from the enrollee's personal records;

b.  from the child's healthcare provider, if the diagnosis is included
    in Carrier Letter 97-32;

c.  from the losing carrier;

d.  from the employing agency.

If no documentation is provided, you may terminate the enrollment.

**Information currently sent by agencies through "Remarks"**

The paper SF and OPM 2809 forms contain space for remarks where agencies
can provide pertinent information to support the enrollment action in
addition to that gathered on the form. The 834 transaction does not
contain any free form fields for providing this information. Several
items commonly addressed in remarks have been mapped to the 834 and will
be included in the electronic transactions. The following items
addressed in remarks will not be provided in the electronic
transactions.

Temporary employees who enroll will not be identified. The premiums paid
for temporary employees is the same as that paid for other employees and
there is no expiration date on the enrollment.

The reason for a change in enrollment code will not be provided.

Public Law information relating to an enrollment will not be provided.

Individuals covered under Spouse Equity enrolling as employees will not
be identified. The National Finance Center will terminate the Spouse
Equity enrollment and the individual's new agency will enroll them.

Belated enrollments or enrollments by proxy will not be identified.
Enrollment actions will be based on the effective date provided in the
transaction.

**Appendix**

***[EEX/Data-Hub 2809 HIPAA File Layout]{.underline}***

***Updated:*** 7/30/2003 9:24 AM

Individual Records (EEX/HUB 2809)

+---+---------+----------------+---+---+---+-------------+---------------+
| 2 | Nature  | Values:        | Y | 6 | 4 | **Start:**  | In HD04:      |
|   | of      | STA            |   |   | - |             |               |
|   | Tran    | RT/CHANGE/STOP |   |   | 9 | **INS03,    | Positions     |
|   | saction |                |   |   |   | 875, Pg.45  | 1-10 are      |
|   |         | Justification: |   |   |   | = \'021\'** | *Gaining      |
|   |         | Left           |   |   |   |             | Carrier Code* |
|   |         |                |   |   |   | **INS04,    |               |
|   |         |                |   |   |   | 1203, Pg.46 | Positions     |
|   |         |                |   |   |   | = \'28\'**  | 11-20 are     |
|   |         |                |   |   |   |             | *Losing       |
|   |         |                |   |   |   | **HD01,     | Carrier Code* |
|   |         |                |   |   |   | 875, Pg.128 |               |
|   |         |                |   |   |   | = \'021\'** | Positions     |
|   |         |                |   |   |   |             | 21-22 are     |
|   |         |                |   |   |   | **HD03,     | *Event Code*  |
|   |         |                |   |   |   | 1205,       |               |
|   |         |                |   |   |   | Pg.129 =    | If any other  |
|   |         |                |   |   |   | \'HLT\'**   | value other   |
|   |         |                |   |   |   |             | than START,   |
|   |         |                |   |   |   | **HD04,     | CHANGE, or    |
|   |         |                |   |   |   | 1204, Pg.   | STOP, REJECT  |
|   |         |                |   |   |   | 130 =       | the           |
|   |         |                |   |   |   | \'0000      | transaction.  |
|   |         |                |   |   |   | 000XX100000 |               |
|   |         |                |   |   |   | 000001B\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **Cha       |               |
|   |         |                |   |   |   | nge-Gaining |               |
|   |         |                |   |   |   | Carrier:**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS03,    |               |
|   |         |                |   |   |   | 875, Pg.45  |               |
|   |         |                |   |   |   | = \'021\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS04,    |               |
|   |         |                |   |   |   | 1203, Pg.46 |               |
|   |         |                |   |   |   | = \'22\'**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD01,     |               |
|   |         |                |   |   |   | 875, Pg.128 |               |
|   |         |                |   |   |   | = \'021\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD03,     |               |
|   |         |                |   |   |   | 1205,       |               |
|   |         |                |   |   |   | Pg.129 =    |               |
|   |         |                |   |   |   | \'HLT\'**   |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD04,     |               |
|   |         |                |   |   |   | 1204, Pg.   |               |
|   |         |                |   |   |   | 130 =       |               |
|   |         |                |   |   |   | \'0000      |               |
|   |         |                |   |   |   | 000XX100000 |               |
|   |         |                |   |   |   | 00ZZ21B\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **Ch        |               |
|   |         |                |   |   |   | ange-Losing |               |
|   |         |                |   |   |   | Carrier:**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS03,    |               |
|   |         |                |   |   |   | 875, Pg.45  |               |
|   |         |                |   |   |   | = \'024\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS04,    |               |
|   |         |                |   |   |   | 1203, Pg.46 |               |
|   |         |                |   |   |   | = \'22\'**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD01,     |               |
|   |         |                |   |   |   | 875, Pg.128 |               |
|   |         |                |   |   |   | = \'024\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD03,     |               |
|   |         |                |   |   |   | 1205,       |               |
|   |         |                |   |   |   | Pg.129 =    |               |
|   |         |                |   |   |   | \'HLT\'**   |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD04,     |               |
|   |         |                |   |   |   | 1204, Pg.   |               |
|   |         |                |   |   |   | 130 =       |               |
|   |         |                |   |   |   | \'0000      |               |
|   |         |                |   |   |   | 000ZZ100000 |               |
|   |         |                |   |   |   | 00XX21B\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **Ch        |               |
|   |         |                |   |   |   | ange-Within |               |
|   |         |                |   |   |   | a Plan:**   |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS03,    |               |
|   |         |                |   |   |   | 875, Pg.45  |               |
|   |         |                |   |   |   | = \'001\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS04,    |               |
|   |         |                |   |   |   | 1203, Pg.46 |               |
|   |         |                |   |   |   | = \'29\'**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD01,     |               |
|   |         |                |   |   |   | 875, Pg.128 |               |
|   |         |                |   |   |   | = \'001\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD03,     |               |
|   |         |                |   |   |   | 1205,       |               |
|   |         |                |   |   |   | Pg.129 =    |               |
|   |         |                |   |   |   | \'HLT\'**   |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD04,     |               |
|   |         |                |   |   |   | 1204, Pg.   |               |
|   |         |                |   |   |   | 130 =       |               |
|   |         |                |   |   |   | \'0000      |               |
|   |         |                |   |   |   | 000XX100000 |               |
|   |         |                |   |   |   | 00XX21F\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **Stop:**   |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS03,    |               |
|   |         |                |   |   |   | 875, Pg.45  |               |
|   |         |                |   |   |   | = \'024\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **INS04,    |               |
|   |         |                |   |   |   | 1203, Pg.46 |               |
|   |         |                |   |   |   | = \'14\'**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD01,     |               |
|   |         |                |   |   |   | 875, Pg.128 |               |
|   |         |                |   |   |   | = \'024\'** |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD03,     |               |
|   |         |                |   |   |   | 1205,       |               |
|   |         |                |   |   |   | Pg.129 =    |               |
|   |         |                |   |   |   | \'HLT\'**   |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **HD04,     |               |
|   |         |                |   |   |   | 1204, Pg.   |               |
|   |         |                |   |   |   | 130 =       |               |
|   |         |                |   |   |   | \'0000      |               |
|   |         |                |   |   |   | 00000000000 |               |
|   |         |                |   |   |   | 00XX21C\'** |               |
+---+---------+----------------+---+---+---+-------------+---------------+
| * | **\*E   | **Edits: No    | * | * | * | **NM101,    | REJECT if not |
| * | mployee | punctuation**  | * | * | * | 98, Pg.62 = | present       |
| 3 | Last    |                | Y | 2 | 1 | \'IL\'**    |               |
| * | Name**  | **Example:     | * | 9 | 0 |             |               |
| * |         | JOHNSON**      | * | * | - | **NM102,    |               |
|   |         |                |   | * | 3 | 1065, Pg.62 |               |
|   |         | **             |   |   | 8 | = \'1\'**   |               |
|   |         | Justification: |   |   | * |             |               |
|   |         | Left**         |   |   | * | **NM103,    |               |
|   |         |                |   |   |   | 1035, Pg.   |               |
|   |         |                |   |   |   | 62**        |               |
+---+---------+----------------+---+---+---+-------------+---------------+
| * | **\*E   | **Edits: No    | * | * | * | **NM104,    | REJECT if not |
| * | mployee | punctuation**  | * | * | * | 1036, Pg.   | present       |
| 4 | First   |                | Y | 2 | 3 | 62**        |               |
| * | Name**  | **Example:     | * | 0 | 9 |             |               |
| * |         | DERRICK**      | * | * | - |             |               |
|   |         |                |   | * | 5 |             |               |
|   |         | **             |   |   | 8 |             |               |
|   |         | Justification: |   |   | * |             |               |
|   |         | Left**         |   |   | * |             |               |
+---+---------+----------------+---+---+---+-------------+---------------+
| * | **\*E   | **Edits: No    | * | * | * | **NM105,    |               |
| * | mployee | punctuation**  | * | * | * | 1037, Pg.   |               |
| 5 | Middle  |                | N | 1 | 5 | 62**        |               |
| * | In      | **Example: M** | * | * | 9 |             |               |
| * | itial** |                | * | * | - |             |               |
|   |         |                |   |   | 5 |             |               |
|   |         |                |   |   | 9 |             |               |
|   |         |                |   |   | * |             |               |
|   |         |                |   |   | * |             |               |
+---+---------+----------------+---+---+---+-------------+---------------+
| 6 | Social  | Edits: No      | Y | 9 | 6 | **REF01,    | REJECT if not |
|   | S       | dashes         |   |   | 0 | 128, Pg.51  | present or    |
|   | ecurity |                |   |   | - | = \'0F\'**  | less than     |
|   | Number  | Example:       |   |   | 6 |             | nine digits   |
|   |         | 123456789      |   |   | 8 | **REF02,    |               |
|   |         |                |   |   |   | 127, Pg.    |               |
|   |         |                |   |   |   | 52**        |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **NM108,    |               |
|   |         |                |   |   |   | 66, Pg. 63  |               |
|   |         |                |   |   |   | = \'34\'**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **NM109,    |               |
|   |         |                |   |   |   | 67, Pg.     |               |
|   |         |                |   |   |   | 63**        |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **Repeats   |               |
|   |         |                |   |   |   | in the      |               |
|   |         |                |   |   |   | Dependent   |               |
|   |         |                |   |   |   | record as   |               |
|   |         |                |   |   |   | well.**     |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **NM108,    |               |
|   |         |                |   |   |   | 66, Pg. 63  |               |
|   |         |                |   |   |   | = \'34\'**  |               |
|   |         |                |   |   |   |             |               |
|   |         |                |   |   |   | **NM109,    |               |
|   |         |                |   |   |   | 67, Pg.     |               |
|   |         |                |   |   |   | 63**        |               |
+---+---------+----------------+---+---+---+-------------+---------------+
| 7 | Date of | Edits:         | Y | 8 | 6 | **DMG01,    | REJECT if not |
|   | Birth   | MMDDYYYY       |   |   | 9 | 1250, Pg.   | present OR    |
|   |         |                |   |   | - | 70 =        | invalid date  |
|   |         | Example:       |   |   | 7 | \'D8\'**    |               |
|   |         | 01011969       |   |   | 6 |             | Macon will    |
|   |         |                |   |   |   | **DMG02,    | reformat the  |
|   |         |                |   |   |   | 1251, Pg.   | date to the   |
|   |         |                |   |   |   | 71**        | proper HIPAA  |
|   |         |                |   |   |   |             | format        |
+---+---------+----------------+---+---+---+-------------+---------------+

Note: The flat file layout does not have a Relationship Code field for
the Employee. The 834 transaction will contain the following for the
Individual Relationship Code

**INS01, 1073, Pg. 44 = \'Y\'**

**INS02, 1069, Pg. 44 = \'18\'**

Address Layout (EEX/Data-Hub 2809)

+---+---------+----------------+---+---+---+---------+------------------+
| * | **Field | **Values:      | * | * | * | **834   | **Explanations   |
| * | Descri  | Edits:         | * | * | * | Trans.  | or Validation**  |
| F | ption** | Examples:      | R | L | P | Set**   |                  |
| i |         | J              | e | e | o |         |                  |
| e |         | ustification** | q | n | s | **(Ref, |                  |
| l |         |                | - | g | i | Data    |                  |
| d |         |                | u | t | - | E.,     |                  |
| * |         |                | i | h | * | Page)** |                  |
| * |         |                | r | * | * |         |                  |
|   |         |                | e | * |   |         |                  |
| * |         |                | d |   | * |         |                  |
| * |         |                | * |   | * |         |                  |
| \ |         |                | * |   | t |         |                  |
| # |         |                |   |   | i |         |                  |
| * |         |                |   |   | o |         |                  |
| * |         |                |   |   | n |         |                  |
|   |         |                |   |   | * |         |                  |
|   |         |                |   |   | * |         |                  |
+===+=========+================+===+===+===+=========+==================+
| 8 | Home    | Edits: No      | Y | 3 | 7 | ## N30  | If not present,  |
|   | Street  | punctuation,   |   | 5 | 7 | 1, 166, | do not send      |
|   | 1       | A - Z, 0 - 9,  |   |   | - |  Pg. 67 | Street Address   |
|   |         | \#             |   |   | 1 |         | information in   |
|   |         |                |   |   | 1 |         | 2100A loop. Just |
|   |         | Example: ROUTE |   |   | 1 |         | send City,       |
|   |         | 1 BOX 618B     |   |   |   |         | State, and Zip.  |
|   |         |                |   |   |   |         |                  |
|   |         | Justification: |   |   |   |         |                  |
|   |         | Left           |   |   |   |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 9 | Home    | Edits: Same as | N | 3 | 1 | **N302, |                  |
|   | Street  | Home Street 1  |   | 5 | 1 | 166,    |                  |
|   | 2       |                |   |   | 2 | Pg.     |                  |
|   |         |                |   |   | - | 67**    |                  |
|   |         |                |   |   | 1 |         |                  |
|   |         |                |   |   | 4 |         |                  |
|   |         |                |   |   | 6 |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | Edits: Same as | N | 3 | 1 | *       |                  |
| 0 | Street  | Home Street 1  |   | 5 | 4 | *Append |                  |
|   | 3       |                |   |   | 7 | into    |                  |
|   |         |                |   |   | - | Street  |                  |
|   |         |                |   |   | 1 | 2**     |                  |
|   |         |                |   |   | 8 |         |                  |
|   |         |                |   |   | 1 | **N302, |                  |
|   |         |                |   |   |   | 166,    |                  |
|   |         |                |   |   |   | Pg. 67  |                  |
|   |         |                |   |   |   | above** |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | -Edits: Valid  | Y | 2 | 1 | ## N4   | REJECT if not    |
| 1 | City    | city name      |   | 3 | 8 | 01, 19, | present          |
|   |         |                |   |   | 2 |  Pg. 68 |                  |
|   |         | Example: MACON |   |   | - |         |                  |
|   |         |                |   |   | 2 |         |                  |
|   |         | Justification: |   |   | 0 |         |                  |
|   |         | Left           |   |   | 4 |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | Values: Valid  | Y | 2 | 2 | **N402, | REJECT if not    |
| 2 | State   | State          |   |   | 0 | 156,    | present          |
|   | Abbre   | Abbreviation   |   |   | 5 | Pg.     |                  |
|   | viation |                |   |   | - | 68**    |                  |
|   |         | Example: GA    |   |   | 2 |         |                  |
|   |         |                |   |   | 0 |         |                  |
|   |         |                |   |   | 6 |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | Edits: 5       | Y | 1 | 2 | **N403, | REJECT if not    |
| 3 | Zip     | REQUIRED, 4    |   | 1 | 0 | 116,    | present          |
|   |         | Optional       |   |   | 7 | Pg.     |                  |
|   |         |                |   |   | - | 69**    |                  |
|   |         | Values: Valid  |   |   | 2 |         |                  |
|   |         | Zip Code or    |   |   | 1 |         |                  |
|   |         | Zip+4 code     |   |   | 7 |         |                  |
|   |         |                |   |   |   |         |                  |
|   |         | Examples:      |   |   |   |         |                  |
|   |         | 31206,         |   |   |   |         |                  |
|   |         | 312064204      |   |   |   |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+

**Foreign Address Layout** - Used by Agency Generated (AG) and Open
Season Express (OEOPM)-Annuitants only

+---+---------+----------------+---+---+---+---------+------------------+
| * | **Field | **Values:      | * | * | * | **834   | **Explanations   |
| * | Descri  | Edits:         | * | * | * | Trans.  | or Validation**  |
| F | ption** | Examples:      | R | L | P | Set**   |                  |
| i |         | J              | e | e | o |         |                  |
| e |         | ustification** | q | n | s | **(Ref, |                  |
| l |         |                | - | g | i | Data    |                  |
| d |         |                | u | t | - | E.,     |                  |
| * |         |                | i | h | * | Page)** |                  |
| * |         |                | r | * | * |         |                  |
|   |         |                | e | * |   |         |                  |
| * |         |                | d |   | * |         |                  |
| * |         |                | * |   | * |         |                  |
| \ |         |                | * |   | t |         |                  |
| # |         |                |   |   | i |         |                  |
| * |         |                |   |   | o |         |                  |
| * |         |                |   |   | n |         |                  |
|   |         |                |   |   | * |         |                  |
|   |         |                |   |   | * |         |                  |
+===+=========+================+===+===+===+=========+==================+
| 8 | Home    | Edits:         | Y | 3 | 7 | # N30   | If not present,  |
|   | Street  |                |   | 5 | 7 | 1, 166, | do not send      |
|   | 1 =     | Example: 60    |   |   | - |  Pg. 67 | Street Address   |
|   |         | DULUTH WEST    |   |   | 1 |         | information in   |
|   | Foreign |                |   |   | 1 |         | 2100A loop. Just |
|   | Street  | Justification: |   |   | 1 |         | send Foreign     |
|   | 1       | Left           |   |   |   |         | City, State Code |
|   |         |                |   |   |   |         | of \'DC\',       |
|   |         |                |   |   |   |         | Postal Code and  |
|   |         |                |   |   |   |         | Country Code.    |
+---+---------+----------------+---+---+---+---------+------------------+
| 9 | Home    | Edits: Same as | N | 3 | 1 | **N302, |                  |
|   | Street  | Home Street 1  |   | 5 | 1 | 166,    |                  |
|   | 2 =     |                |   |   | 2 | Pg.     |                  |
|   |         |                |   |   | - | 67**    |                  |
|   | Foreign |                |   |   | 1 |         |                  |
|   | Street  |                |   |   | 4 |         |                  |
|   | 2       |                |   |   | 6 |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | Edits: Same as | N | 3 | 1 | **N401, | REJECT if not    |
| 0 | Street  | Home Street 1  |   | 5 | 4 | 19, Pg. | present          |
|   | 3 =     |                |   |   | 7 | 68**    |                  |
|   |         |                |   |   | - |         |                  |
|   | Foreign |                |   |   | 1 |         |                  |
|   | City    |                |   |   | 8 |         |                  |
|   | Name    |                |   |   | 1 |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | Edits: Valid   | Y | 2 | 1 | **Not   |                  |
| 1 | City =  | City Name      |   | 3 | 8 | in the  |                  |
|   |         |                |   |   | 2 | 834**   |                  |
|   | Foreign | Example:       |   |   | - |         |                  |
|   | Country | MONTREAL       |   |   | 2 |         |                  |
|   | Name    |                |   |   | 0 |         |                  |
|   |         | Justification: |   |   | 4 |         |                  |
|   |         | Left           |   |   |   |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| * | *       | **Values: GM   | * | * | * | **N402, | REJECT if not    |
| * | *\*Home | (Germany)**    | * | * | * | 156,    | present OR       |
| 1 | State = |                | Y | 2 | 2 | Pg. 68  | invalid          |
| 2 | Foreign | **Country Code | * | * | 0 | =       |                  |
| * | Country | tables from    | * | * | 5 | \       | Macon will       |
| * | Code**  | FIPS table**   |   |   | - | 'DC\'** | crosswalk FIPS   |
|   |         |                |   |   | 2 |         | code to ISO-3166 |
|   |         |                |   |   | 0 | **N404, | code             |
|   |         |                |   |   | 6 | 26, Pg. |                  |
|   |         |                |   |   | * | 69**    |                  |
|   |         |                |   |   | * |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+
| 1 | Home    | Value: Valid   | N | 1 | 2 | **N403, | If blanks, set   |
| 3 | Zip=    | Postal Code if |   | 1 | 0 | 116,    | to \"00000\"     |
|   |         | country has a  |   |   | 7 | Pg. 69  |                  |
|   | Foreign | Postal Code    |   |   | - | =       |                  |
|   | Postal  |                |   |   | 2 | \'00    |                  |
|   | Code    | Example: H2W   |   |   | 1 | 000\'** |                  |
|   |         | 1J5            |   |   | 7 |         |                  |
+---+---------+----------------+---+---+---+---------+------------------+

**Foreign Address Layout** - Used by \"EEDOI\", \"EEEDU\", \"EESSA\"

+---+---------+----------------+---+---+---+--------+-------------------+
| * | **Field | **Values:      | * | * | * | **834  | **Explanations or |
| * | Descri  | Edits:         | * | * | * | Trans. | Validation**      |
| F | ption** | Examples:      | R | L | P | Set**  |                   |
| i |         | J              | e | e | o |        |                   |
| e |         | ustification** | q | n | s | *      |                   |
| l |         |                | - | g | i | *(Ref, |                   |
| d |         |                | u | t | - | Data   |                   |
| * |         |                | i | h | * | E.,    |                   |
| * |         |                | r | * | * | P      |                   |
|   |         |                | e | * |   | age)** |                   |
| * |         |                | d |   | * |        |                   |
| * |         |                | * |   | * |        |                   |
| \ |         |                | * |   | t |        |                   |
| # |         |                |   |   | i |        |                   |
| * |         |                |   |   | o |        |                   |
| * |         |                |   |   | n |        |                   |
|   |         |                |   |   | * |        |                   |
|   |         |                |   |   | * |        |                   |
+===+=========+================+===+===+===+========+===================+
| 8 | Home    | Edits:         | Y | 3 | 7 | #      | If not present,   |
|   | Street  |                |   | 5 | 7 |  N301, | do not send       |
|   | 1 =     | Example: 60    |   |   | - |  166,  | Street Address    |
|   |         | DULUTH WEST    |   |   | 1 | Pg. 67 | information in    |
|   | Foreign |                |   |   | 1 |        | 2100A loop. Just  |
|   | Street  | Justification: |   |   | 1 |        | send Foreign      |
|   | 1       | Left           |   |   |   |        | City, State Code  |
|   |         |                |   |   |   |        | of \'DC\', Postal |
|   |         |                |   |   |   |        | Code and Country  |
|   |         |                |   |   |   |        | Code              |
+---+---------+----------------+---+---+---+--------+-------------------+
| 9 | Home    | Edits: Same as | N | 3 | 1 | *      |                   |
|   | Street  | Home Street 1  |   | 5 | 1 | *N302, |                   |
|   | 2 =     |                |   |   | 2 | 166,   |                   |
|   |         |                |   |   | - | Pg.    |                   |
|   | Foreign |                |   |   | 1 | 67**   |                   |
|   | Street  |                |   |   | 4 |        |                   |
|   | 2       |                |   |   | 6 |        |                   |
+---+---------+----------------+---+---+---+--------+-------------------+
| 1 | Home    | Value: BLANKS  | N | 3 | 1 |        |                   |
| 0 | Street  |                |   | 5 | 4 |        |                   |
|   | 3 =     | DOI does not   |   |   | 7 |        |                   |
|   |         | allow a third  |   |   | - |        |                   |
|   |         | street         |   |   | 1 |        |                   |
|   |         |                |   |   | 8 |        |                   |
|   |         |                |   |   | 1 |        |                   |
+---+---------+----------------+---+---+---+--------+-------------------+
| 1 | Home    | Edits:         | Y | 2 | 1 | *      | REJECT if not     |
| 1 | City =  |                |   | 3 | 8 | *N401, | present           |
|   |         | Example:       |   |   | 2 | 19,    |                   |
|   | Foreign | TENGAH AIR     |   |   | - | Pg.    |                   |
|   | City    | BASE           |   |   | 2 | 68**   |                   |
|   | Name    |                |   |   | 0 |        |                   |
|   |         |                |   |   | 4 |        |                   |
+---+---------+----------------+---+---+---+--------+-------------------+
| 1 | Home    | Values: GM     | Y | 2 | 2 | *      | REJECT if not     |
| 2 | State = | (Germany)      |   |   | 0 | *N402, | present OR        |
|   | Foreign |                |   |   | 5 | 156,   | invalid           |
|   | Country | Country Code   |   |   | - | Pg. 68 |                   |
|   | Code    | tables from    |   |   | 2 | =      | Macon will        |
|   |         | FIPS table     |   |   | 0 | \'     | crosswalk FIPS    |
|   |         |                |   |   | 6 | DC\'** | code to ISO-3166  |
|   |         |                |   |   |   |        | code              |
|   |         |                |   |   |   | *      |                   |
|   |         |                |   |   |   | *N404, |                   |
|   |         |                |   |   |   | 26,    |                   |
|   |         |                |   |   |   | Pg.    |                   |
|   |         |                |   |   |   | 69**   |                   |
+---+---------+----------------+---+---+---+--------+-------------------+
| 1 | Home    | Value: Valid   | N | 1 | 2 | #      | If blanks, set to |
| 3 | Zip=    | Postal Code if |   | 1 | 0 |  N403, | \"00000\"         |
|   |         | country has a  |   |   | 7 |  116,  |                   |
|   | Foreign | Postal Code    |   |   | - | Pg. 69 |                   |
|   | Postal  |                |   |   | 2 |  = \'0 |                   |
|   | Code    | Example: H2W   |   |   | 1 | 0000\' |                   |
|   |         | 1J5            |   |   | 7 |        |                   |
+---+---------+----------------+---+---+---+--------+-------------------+

Note: This Foreign Address layout will only be used when Field #235
(Position 3040) - Foreign/Overseas Address Indicator is set to \"Y\" and
the record is an EEDOI, EEEDU or EESSA record.

**Foreign Address Layout** - Used by (DOT Agency Only) \"EEDOT"

+---+---------+----------------+---+---+---+------------+---------------+
| * | **Field | **Values:      | * | * | * | **834      | *             |
| * | Descri  | Edits:         | * | * | * | Trans.     | *Explanations |
| F | ption** | Examples:      | R | L | P | Set**      | or            |
| i |         | J              | e | e | o |            | Validation**  |
| e |         | ustification** | q | n | s | **(Ref,    |               |
| l |         |                | - | g | i | Data E.,   |               |
| d |         |                | u | t | - | Page)**    |               |
| * |         |                | i | h | * |            |               |
| * |         |                | r | * | * |            |               |
|   |         |                | e | * |   |            |               |
| * |         |                | d |   | * |            |               |
| * |         |                | * |   | * |            |               |
| \ |         |                | * |   | t |            |               |
| # |         |                |   |   | i |            |               |
| * |         |                |   |   | o |            |               |
| * |         |                |   |   | n |            |               |
|   |         |                |   |   | * |            |               |
|   |         |                |   |   | * |            |               |
+===+=========+================+===+===+===+============+===============+
| 8 | Home    | Edits:         | Y | 3 | 7 | # N301, 1  | If not        |
|   | Street  |                |   | 5 | 7 | 66, Pg. 67 | present, do   |
|   | 1 =     | Example: 60    |   |   | - |            | not send      |
|   |         | DULUTH WEST    |   |   | 1 |            | Street        |
|   | Foreign |                |   |   | 1 |            | Address       |
|   | Street  | Justification: |   |   | 1 |            | information   |
|   | 1       | Left           |   |   |   |            | in 2100A      |
|   |         |                |   |   |   |            | loop. Just    |
|   |         |                |   |   |   |            | send Foreign  |
|   |         |                |   |   |   |            | City, State   |
|   |         |                |   |   |   |            | Code of       |
|   |         |                |   |   |   |            | \'DC\',       |
|   |         |                |   |   |   |            | Postal Code   |
|   |         |                |   |   |   |            | and Country   |
|   |         |                |   |   |   |            | Code          |
+---+---------+----------------+---+---+---+------------+---------------+
| 9 | Home    | Edits:         | N | 3 | 1 | **N401,    | REJECT if not |
|   | Street  |                |   | 5 | 1 | 19, Pg.    | present       |
|   | 2 =     | Example:       |   |   | 2 | 68**       |               |
|   |         | TENGAH AIR     |   |   | - |            |               |
|   | Foreign | BASE           |   |   | 1 |            |               |
|   | City    |                |   |   | 4 |            |               |
|   | Name    |                |   |   | 6 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| 1 | Home    | Value: BLANKS  | N | 3 | 1 |            |               |
| 0 | Street  |                |   | 5 | 4 |            |               |
|   | 3 =     | DOT does not   |   |   | 7 |            |               |
|   |         | allow a third  |   |   | - |            |               |
|   |         | street         |   |   | 1 |            |               |
|   |         |                |   |   | 8 |            |               |
|   |         |                |   |   | 1 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| 1 | Home    | Edits:         | Y | 2 | 1 | **Not in   |               |
| 1 | City =  |                |   | 3 | 8 | the 834**  |               |
|   |         | Example:       |   |   | 2 |            |               |
|   | Foreign | SINGAPORE      |   |   | - |            |               |
|   | Country |                |   |   | 2 |            |               |
|   | Name    |                |   |   | 0 |            |               |
|   |         |                |   |   | 4 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| * | *       | **Values: GM   | * | * | * | **N402,    | REJECT if not |
| * | *\*Home | (Germany)**    | * | * | * | 156, Pg.   | present OR    |
| 1 | State = |                | Y | 2 | 2 | 68 =       | invalid       |
| 2 | Foreign | **Country Code | * | * | 0 | \'DC\'**   |               |
| * | Country | tables from    | * | * | 5 |            | Macon will    |
| * | Code**  | FIPS table**   |   |   | - | **N404,    | crosswalk     |
|   |         |                |   |   | 2 | 26, Pg.    | FIPS code to  |
|   |         |                |   |   | 0 | 69**       | ISO-3166 code |
|   |         |                |   |   | 6 |            |               |
|   |         |                |   |   | * |            |               |
|   |         |                |   |   | * |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| 1 | Home    | Value:         | N | 1 | 2 | #          | Set to        |
| 3 | Zip     | 00000000000    |   | 1 | 0 |  N403, 116 | \"00000\"     |
|   |         |                |   |   | 7 | , Pg. 69 = |               |
|   | Foreign | DOT does not   |   |   | - |  \'00000\' |               |
|   | Postal  | allow entry of |   |   | 2 |            |               |
|   | Code    | a FOREIGN      |   |   | 1 |            |               |
|   |         | POSTAL CODE    |   |   | 7 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+

Note: This Foreign Address layout will only be used when Field #235
(Position 3040) - Foreign/Overseas Address Indicator is set to \"Y\" and
the record is an EEDOT record.

**Foreign Address Layout** - Used by (STA Agency Only) \"EESTA"

+---+---------+----------------+---+---+---+------------+---------------+
| * | **Field | **Values:      | * | * | * | **834      | *             |
| * | Descri  | Edits:         | * | * | * | Trans.     | *Explanations |
| F | ption** | Examples:      | R | L | P | Set**      | or            |
| i |         | J              | e | e | o |            | Validation**  |
| e |         | ustification** | q | n | s | **(Ref,    |               |
| l |         |                | - | g | i | Data E.,   |               |
| d |         |                | u | t | - | Page)**    |               |
| * |         |                | i | h | * |            |               |
| * |         |                | r | * | * |            |               |
|   |         |                | e | * |   |            |               |
| * |         |                | d |   | * |            |               |
| * |         |                | * |   | * |            |               |
| \ |         |                | * |   | t |            |               |
| # |         |                |   |   | i |            |               |
| * |         |                |   |   | o |            |               |
| * |         |                |   |   | n |            |               |
|   |         |                |   |   | * |            |               |
|   |         |                |   |   | * |            |               |
+===+=========+================+===+===+===+============+===============+
| 8 | Home    | Edits:         | Y | 3 | 7 | # N301,    | Must be       |
|   | Street  |                |   | 5 | 7 |  166, Pg.  | PRESENT WHEN  |
|   | 1=      | Example:       |   |   | - | 67 = \"Not | For           |
|   | Foreign | BRUSSELS       |   |   | 1 |  passed fo | eign/OverSeas |
|   | City    |                |   |   | 1 | r security | Address       |
|   | Name    | Justification: |   |   | 1 |  reasons\" | Indicator =   |
|   |         | Left           |   |   |   |            | \"Y\" and     |
|   |         |                |   |   |   | # N401,    | report# =     |
|   |         |                |   |   |   | 19, Pg. 68 | EESTA         |
|   |         |                |   |   |   |            | (contains     |
|   |         |                |   |   |   |            | city which is |
|   |         |                |   |   |   |            | required)     |
+---+---------+----------------+---+---+---+------------+---------------+
| 9 | Home    | Edits:         | N | 3 | 1 | **Not in   |               |
|   | Street  |                |   | 5 | 1 | 834**      |               |
|   | 2 =     | Example:       |   |   | 2 |            |               |
|   | Foreign | BELGIUM        |   |   | - |            |               |
|   | Country |                |   |   | 1 |            |               |
|   | Name    |                |   |   | 4 |            |               |
|   |         |                |   |   | 6 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| 1 | Home    | Value: BLANKS  | N | 3 | 1 |            |               |
| 0 | Street  |                |   | 5 | 4 |            |               |
|   | 3 =     |                |   |   | 7 |            |               |
|   |         |                |   |   | - |            |               |
|   |         |                |   |   | 1 |            |               |
|   |         |                |   |   | 8 |            |               |
|   |         |                |   |   | 1 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| 1 | Home    | Value: BLANKS  | Y | 2 | 1 |            |               |
| 1 | City =  |                |   | 3 | 8 |            |               |
|   |         |                |   |   | 2 |            |               |
|   |         |                |   |   | - |            |               |
|   |         |                |   |   | 2 |            |               |
|   |         |                |   |   | 0 |            |               |
|   |         |                |   |   | 4 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| * | *       | **Values: GM   | * | * | * | **N402,    | REJECT if not |
| * | *\*Home | (Germany)**    | * | * | * | 156, Pg.   | present OR    |
| 1 | State = |                | Y | 2 | 2 | 68 =       | invalid       |
| 2 | Foreign | **Country Code | * | * | 0 | \'DC\'**   |               |
| * | Country | tables from    | * | * | 5 |            | Macon will    |
| * | Code**  | FIPS table**   |   |   | - | **N404,    | crosswalk     |
|   |         |                |   |   | 2 | 26, Pg.    | FIPS code to  |
|   |         |                |   |   | 0 | 69**       | ISO-3166 code |
|   |         |                |   |   | 6 |            |               |
|   |         |                |   |   | * |            |               |
|   |         |                |   |   | * |            |               |
+---+---------+----------------+---+---+---+------------+---------------+
| 1 | Home    | Value: BLANKS  | N | 1 | 2 | #          | Set to        |
| 3 | Zip     |                |   | 1 | 0 |  N403, 116 | \"00000\"     |
|   |         |                |   |   | 7 | , Pg. 69 = |               |
|   |         |                |   |   | - |  \'00000\' |               |
|   |         |                |   |   | 2 |            |               |
|   |         |                |   |   | 1 |            |               |
|   |         |                |   |   | 7 |            |               |
+---+---------+----------------+---+---+---+------------+---------------+

Note: This Foreign Address layout will only be used when Field #235
(Position 3040) - Foreign/Overseas Address Indicator is set to \"Y\" and
the record is an EESTA record.

FEHB Carrier File Layout (EEX/Data-Hub 2809) cont.

+---+---------+----------------+---+---+----+-----------+---------------+
| * | **Field | **Values:      | * | * | *  | **834     | *             |
| * | Descri  | Edits:         | * | * | *P | Trans.    | *Explanations |
| F | ption** | Examples:      | R | L | os | Set**     | or            |
| i |         | J              | e | e | i- |           | Validation**  |
| e |         | ustification** | q | n | ** | **(Ref,   |               |
| l |         |                | - | g |    | Data E.,  |               |
| d |         |                | u | t | ** | Page)**   |               |
| * |         |                | i | h | ti |           |               |
| * |         |                | r | * | on |           |               |
|   |         |                | e | * | ** |           |               |
| * |         |                | d |   |    |           |               |
| * |         |                | * |   |    |           |               |
| \ |         |                | * |   |    |           |               |
| # |         |                |   |   |    |           |               |
| * |         |                |   |   |    |           |               |
| * |         |                |   |   |    |           |               |
+===+=========+================+===+===+====+===========+===============+
| 1 | Sex     | Values: M/F    | Y | 1 | 2  | **DMG03,  | If agency     |
| 4 |         |                |   |   | 18 | 1068,     | passes a      |
|   |         |                |   |   | -2 | Pg.71 =   | blank or      |
|   |         |                |   |   | 18 | \'F\',    | anything      |
|   |         |                |   |   |    | \'M\' or  | other than    |
|   |         |                |   |   |    | \'U\'**   | \'F\' or      |
|   |         |                |   |   |    |           | \'M\', then   |
|   |         |                |   |   |    |           | Macon will    |
|   |         |                |   |   |    |           | default to    |
|   |         |                |   |   |    |           | \'U\'         |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Values: Y/N    | Y | 1 | 2  | **DMG04,  | I = Single    |
| 5 | M       |                |   |   | 19 | 1067,     |               |
|   | arriage |                |   |   | -2 | Pg.71 =   | M = Married   |
|   | In      |                |   |   | 19 | \'I,      |               |
|   | dicator |                |   |   |    | \'M\',    | If agency     |
|   |         |                |   |   |    | \'R\'**   | passes blanks |
|   |         |                |   |   |    |           | or anything   |
|   |         |                |   |   |    |           | other than    |
|   |         |                |   |   |    |           | \'Y\', or     |
|   |         |                |   |   |    |           | \'N\', then   |
|   |         |                |   |   |    |           | Macon will    |
|   |         |                |   |   |    |           | default to    |
|   |         |                |   |   |    |           | \"R\" =       |
|   |         |                |   |   |    |           | Unreported    |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | Will not  |               |
| * | *\*FEHB | Y/N**          | * | * | *2 | map.      |               |
| 1 | Other   |                | Y | 1 | 20 |           |               |
| 6 | In      | **Edits:       | * | * | -2 |           |               |
| * | surance | Indicates if   | * | * | 20 |           |               |
| * | In      | the employee   |   |   | ** |           |               |
|   | dicator | has non-FEHB   |   |   |    |           |               |
|   | E       | coverage       |   |   |    |           |               |
|   | mployee | outside of the |   |   |    |           |               |
|   | (i.e.   | FEHB Program** |   |   |    |           |               |
|   | Main    |                |   |   |    |           |               |
|   | Subscr  |                |   |   |    |           |               |
|   | iber)** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **See     |               |
| * | *\*FEHB | Y/N**          | * | * | *2 | field     |               |
| 1 | M       |                | Y | 1 | 21 | #19**     |               |
| 7 | edicare | **Edits:       | * | * | -2 |           |               |
| * | Indi    | Indicates if   | * | * | 21 |           |               |
| * | cator** | the employee   |   |   | ** |           |               |
|   |         | has Medicare   |   |   |    |           |               |
|   | **E     | coverage**     |   |   |    |           |               |
|   | mployee |                |   |   |    |           |               |
|   | (i.e.   | **Edits:       |   |   |    |           |               |
|   | Main    | REQUIRED if    |   |   |    |           |               |
|   | Subscr  | FEHB Other     |   |   |    |           |               |
|   | iber)** | Insurance      |   |   |    |           |               |
|   |         | Indicator is   |   |   |    |           |               |
|   |         | Y**            |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR is   |   |   |    |           |               |
|   |         | \"N\", then    |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **See     |               |
| * | *\*FEHB | Y/N**          | * | * | *2 | field     |               |
| 1 | Medic   |                | Y | 1 | 22 | #19**     |               |
| 8 | are-A** | **Edits:       | * | * | -2 |           |               |
| * |         | Indicates if   | * | * | 22 |           |               |
| * | **E     | the employee   |   |   | ** |           |               |
|   | mployee | has Medicare   |   |   |    |           |               |
|   | (i.e.   | Part-A**       |   |   |    |           |               |
|   | Main    |                |   |   |    |           |               |
|   | Subscr  | **Edits:       |   |   |    |           |               |
|   | iber)** | REQUIRED if    |   |   |    |           |               |
|   |         | FEHB Other     |   |   |    |           |               |
|   |         | Insurance      |   |   |    |           |               |
|   |         | Indicator is   |   |   |    |           |               |
|   |         | Y**            |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR is   |   |   |    |           |               |
|   |         | \"N\", then    |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **INS06,  |               |
| * | *\*FEHB | Y/N**          | * | * | *2 | 1218,     |               |
| 1 | Medic   |                | Y | 1 | 23 | Pg.48**   |               |
| 9 | are-B** | **Edits:       | * | * | -2 |           |               |
| * |         | Indicates if   | * | * | 23 | **\'A\' = |               |
| * | **E     | the employee   |   |   | ** | Medicare  |               |
|   | mployee | has Medicare   |   |   |    | Part A**  |               |
|   | (i.e.   | Part-B**       |   |   |    |           |               |
|   | Main    |                |   |   |    | **\'B\' = |               |
|   | Subscr  | **Edits:       |   |   |    | Medicare  |               |
|   | iber)** | REQUIRED if    |   |   |    | Part B**  |               |
|   |         | FEHB Other     |   |   |    |           |               |
|   |         | Insurance      |   |   |    | **\'C\' = |               |
|   |         | Indicator is   |   |   |    | Medicare  |               |
|   |         | Y**            |   |   |    | Part A &  |               |
|   |         |                |   |   |    | B**       |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR is   |   |   |    |           |               |
|   |         | \"N\", then    |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | # | * | *  | **COB01,  |               |
| * | *\*FEHB | Y/N**          | # | * | *2 | 1138, Pg. |               |
| 2 | TRICARE |                | # | 1 | 24 | 150 =     |               |
| 0 | (in     | **Edits:       | # | * | -2 | \'U\'**   |               |
| * | cluding | Indicates if   | # | * | 24 |           |               |
| * | C       | the employee   | # |   | ** | **COB02,  |               |
|   | HAMPUS) | has TriCare    |   |   |    | 127, Pg.  |               |
|   | Indi    | coverage**     | * |   |    | 151 =     |               |
|   | cator** |                | * |   |    | \"TR      |               |
|   |         | **Edits:       | Y |   |    | ICARE\"** |               |
|   | **E     | REQUIRED if    | * |   |    |           |               |
|   | mployee | FEHB Other     | * |   |    | **COB03,  |               |
|   | (i.e.   | Insurance      |   |   |    | 1143, Pg. |               |
|   | Main    | Indicator is   |   |   |    | 151 =     |               |
|   | Subscr  | Y**            |   |   |    | \'1\'**   |               |
|   | iber)** |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR is   |   |   |    |           |               |
|   |         | \"N\", then    |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values: Name | * | * | *  | **N101,   | If either     |
| * | *\*FEHB | of any group   | * | * | *2 | 98, Pg.   | Other         |
| 2 | Other   | health         | Y | 3 | 25 | 154 =     | Insurance     |
| 1 | In      | insurance      | / | 5 | -2 | \'IN\'**  | Name and/or   |
| * | surance | coverage the   | N | * | 59 |           | Other         |
| * | Name**  | employee has   | * | * | ** | **N102,   | Insurance     |
|   |         | other than the | * |   |    | 93, Pg.   | Policy Number |
|   | **E     | FEHB plan in   |   |   |    | 154**     | have data,    |
|   | mployee | which the      |   |   |    |           | then this     |
|   | (i.e.   | employee is    |   |   |    |           | will be sent  |
|   | Main    | enrolling in   |   |   |    |           | as well:      |
|   | Subscr  | or changing    |   |   |    |           |               |
|   | iber)** | to.**          |   |   |    |           | **COB01,      |
|   |         |                |   |   |    |           | 1138, Pg. 150 |
|   |         | **Edits:       |   |   |    |           | = \'U\'**     |
|   |         | REQUIRED if    |   |   |    |           |               |
|   |         | FEHB Other     |   |   |    |           | **COB03,      |
|   |         | Insurance      |   |   |    |           | 1143, Pg. 151 |
|   |         | Indicator is Y |   |   |    |           | = \'5\'**     |
|   |         | and all other  |   |   |    |           |               |
|   |         | types of       |   |   |    |           |               |
|   |         | insurance are  |   |   |    |           |               |
|   |         | N**            |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Example:     |   |   |    |           |               |
|   |         | STATE FARM     |   |   |    |           |               |
|   |         | HEALTH**       |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **REF01,  |               |
| * | *\*FEHB | Provide if     | * | * | *2 | 128, Pg.  |               |
| 2 | Other   | known**        | N | 3 | 60 | 153 =     |               |
| 2 | In      |                | * | 0 | -2 | \'ZZ\'**  |               |
| * | surance | **Example:     | * | * | 89 |           |               |
| * | Policy  | 1234123 or     |   | * | ** | **REF02,  |               |
|   | N       | A4232DB232**   |   |   |    | 127, Pg.  |               |
|   | umber** |                |   |   |    | 153**     |               |
|   |         |                |   |   |    |           |               |
|   | **E     |                |   |   |    |           |               |
|   | mployee |                |   |   |    |           |               |
|   | (i.e.   |                |   |   |    |           |               |
|   | Main    |                |   |   |    |           |               |
|   | Subscr  |                |   |   |    |           |               |
|   | iber)** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Edits: Empty   | N | 1 | 2  | **First   |               |
| 3 | Daytime | or 17 digits   |   | 7 | 90 | ten       |               |
|   | Phone   |                |   |   | -3 | bytes:**  |               |
|   |         | Edits:         |   |   | 06 |           |               |
|   |         | Employee's     |   |   |    | **PER01,  |               |
|   |         | daytime phone  |   |   |    | 366, Pg.  |               |
|   |         | number         |   |   |    | 65 =      |               |
|   |         |                |   |   |    | \'IP\'**  |               |
|   |         | Values: 0 -- 9 |   |   |    |           |               |
|   |         |                |   |   |    | **PER03,  |               |
|   |         | Example:       |   |   |    | 365, Pg.  |               |
|   |         | 4787442286(Pad |   |   |    | 65 =      |               |
|   |         | Right with     |   |   |    | \'TE\'**  |               |
|   |         | Spaces)        |   |   |    |           |               |
|   |         |                |   |   |    | **PER04,  |               |
|   |         |                |   |   |    | 364, Pg.  |               |
|   |         |                |   |   |    | 65**      |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **Bytes   |               |
|   |         |                |   |   |    | 11-17     |               |
|   |         |                |   |   |    | will be   |               |
|   |         |                |   |   |    | mapped    |               |
|   |         |                |   |   |    | to:**     |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **PER05,  |               |
|   |         |                |   |   |    | 365, Pg.  |               |
|   |         |                |   |   |    | 65 =      |               |
|   |         |                |   |   |    | \'EX\'**  |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **PER06,  |               |
|   |         |                |   |   |    | 364, Pg.  |               |
|   |         |                |   |   |    | 66**      |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Values: Valid  | Y | 3 | 3  | **HD04,   | Must be       |
| 4 | Enr     | FEHB           | / |   | 07 | 1204, Pg. | PRESENT when  |
|   | ollment | enrollment     | N |   | -3 | 130**     | (Nature of    |
|   | Code    | code of the    |   |   | 09 |           | Transaction = |
|   |         | carrier the    |   |   |    | **First   | \"START\")    |
|   |         | employee or    |   |   |    | 10 bytes. |               |
|   |         | annuitant is   |   |   |    | Pad left  | **OR**        |
|   |         | enrolling in   |   |   |    | with      |               |
|   |         | or changing to |   |   |    | zeroes.   | (Nature of    |
|   |         |                |   |   |    | Will be   | Transaction = |
|   |         | Edits:         |   |   |    | the first | \"CHANGE\")   |
|   |         | REQUIRED for   |   |   |    | element   |               |
|   |         | Starts,        |   |   |    | in the    |               |
|   |         | Changes        |   |   |    | free form |               |
|   |         |                |   |   |    | field.**  |               |
|   |         | Edits: Blank   |   |   |    |           |               |
|   |         | for Stops      |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Example: 104   |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: NO    | * | * | *  | **NM101,  | REJECT if not |
| * | *\*FEHB | PUNCTUATION**  | * | * | *3 | 98, Pg.   | present       |
| 2 | Family  |                | Y | 2 | 10 | 62 =      |               |
| 5 | Member  | ***Edits: If   | / | 0 | -3 | \'IL\'**  |               |
| * | Last    | family member  | N | * | 29 |           |               |
| * | Name    | 1 is used,     | * | * | ** | **NM102,  |               |
|   | (1)**   | LAST NAME is   | * |   |    | 1065, Pg. |               |
|   |         | REQUIRED for   |   |   |    | 62 =      |               |
|   |         | family         |   |   |    | \'1\'**   |               |
|   |         | coverage***    |   |   |    |           |               |
|   |         |                |   |   |    | **NM103,  |               |
|   |         | **Example:     |   |   |    | 1035, Pg. |               |
|   |         | JOHNSON**      |   |   |    | 62**      |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: NO    | * | * | *  | **NM104,  | REJECT if not |
| * | *\*FEHB | PUNCTUATION**  | * | * | *3 | 1036, Pg. | present       |
| 2 | Family  |                | Y | 1 | 30 | 62**      |               |
| 6 | Member  | ***Edits: If   | / | 4 | -3 |           |               |
| * | First   | family member  | N | * | 43 |           |               |
| * | Name    | 1 is used,     | * | * | ** |           |               |
|   | (1)**   | FIRST NAME is  | * |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Example:     |   |   |    |           |               |
|   |         | SUSAN**        |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | ***Edits: If   | * | * | *  | **NM105,  |               |
| * | *\*FEHB | family member  | * | * | *3 | 1037, Pg. |               |
| 2 | Family  | 1 is used,     | Y | 1 | 44 | 62**      |               |
| 7 | Member  | MIDDLE INITIAL | / | * | -3 |           |               |
| * | Middle  | is REQUIRED    | N | * | 44 |           |               |
| * | Initial | for family     | * |   | ** |           |               |
|   | (1)**   | coverage***    | * |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Example: L** |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Edits:         | # | 8 | 3  | **DMG01,  | REJECT if not |
| 8 | Family  | MMDDYYYY       | # |   | 45 | 1250, Pg. | present OR    |
|   | DOB (1) |                | # |   | -3 | 70 =      | invalid date  |
|   |         | Edits: If      | # |   | 52 | \'D8\'**  |               |
|   |         | family member  | # |   |    |           | Macon will    |
|   |         | 1 is used, is  | # |   |    | **DMG02,  | reformat the  |
|   |         | REQUIRED for   |   |   |    | 1251, Pg. | date to the   |
|   |         | family         | Y |   |    | 71        | proper HIPAA  |
|   |         | coverage       | / |   |    | C         | format        |
|   |         |                | N |   |    | CYYMMDD** |               |
|   |         | Example:       |   |   |    |           |               |
|   |         | 01011996       |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Values: M/F    | Y | 1 | 3  | **DMG03,  | If agency     |
| 9 | Family  |                | / |   | 53 | 1068, Pg. | passes a      |
|   | Sex     | Edits: F =     | N |   | -3 | 71 =      | blank or      |
|   | Code    | Female, M =    |   |   | 53 | \'F\',    | anything      |
|   | (1)     | Male           |   |   |    | \'M\',    | other than    |
|   |         |                |   |   |    | \'U\'**   | \'F\' or      |
|   |         | Edits: If      |   |   |    |           | \'M\', then   |
|   |         | family member  |   |   |    |           | Macon will    |
|   |         | 1 is used, is  |   |   |    |           | default to    |
|   |         | REQUIRED for   |   |   |    |           | \'U\'         |
|   |         | family         |   |   |    |           |               |
|   |         | coverage       |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:**    | * | * | *  | **INS01,  | REJECT if not |
| * | *\*FEHB |                | * | * | *3 | 1073, Pg. | present or    |
| 3 | Family  | **01 =         | Y | 2 | 54 | 44 =      | invalid value |
| 0 | Relat   | Spouse**       | / | * | -3 | \'N\'**   |               |
| * | ionship |                | N | * | 55 |           |               |
| * | (1)**   | **19 = Child** | * |   | ** | **INS02,  |               |
|   |         |                | * |   |    | 1069, Pg. |               |
|   |         | **09 = Adopted |   |   |    | 44**      |               |
|   |         | Child**        |   |   |    |           |               |
|   |         |                |   |   |    | **If      |               |
|   |         | **10 = Foster  |   |   |    | \'99\'    |               |
|   |         | Child**        |   |   |    | (         |               |
|   |         |                |   |   |    | incapable |               |
|   |         | **17 = Stepson |   |   |    | of self   |               |
|   |         | or             |   |   |    | support   |               |
|   |         | Stepdaughter** |   |   |    | ):**      |               |
|   |         |                |   |   |    |           |               |
|   |         | **99 =         |   |   |    | **INS02,  |               |
|   |         | Unmarried      |   |   |    | 1069, Pg. |               |
|   |         | disabled child |   |   |    | 44 =      |               |
|   |         | over age 22    |   |   |    | \'19\'**  |               |
|   |         | incapable of   |   |   |    |           |               |
|   |         | self-support** |   |   |    | **INS10,  |               |
|   |         |                |   |   |    | 1073, Pg. |               |
|   |         | **14 = Brother |   |   |    | 49 =      |               |
|   |         | or Sister**    |   |   |    | \'Y\'**   |               |
|   |         |                |   |   |    |           |               |
|   |         | **03 = Father  |   |   |    |           |               |
|   |         | or Mother**    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: See   |   |   |    |           |               |
|   |         | field          |   |   |    |           |               |
|   |         | description**  |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 3 | FEHB    | SSN is         | N | 9 | 3  | **NM108,  |               |
| 1 | Family  | optional but   |   |   | 56 | 66, Pg.   |               |
|   | SSN (1) | recommended    |   |   | -3 | 63 =      |               |
|   |         |                |   |   | 64 | \'34\'**  |               |
|   |         | Edits: No      |   |   |    |           |               |
|   |         | dashes         |   |   |    | **NM109,  |               |
|   |         |                |   |   |    | 67, Pg.   |               |
|   |         | Example:       |   |   |    | 63**      |               |
|   |         | 123456789      |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | Will not  |               |
| * | *\*FEHB | Y/N**          | * | * | *3 | map       |               |
| 3 | Family  |                | Y | 1 | 65 |           |               |
| 2 | Other   | **Edits:       | / | * | -3 |           |               |
| * | In      | Indicates if   | N | * | 65 |           |               |
| * | surance | the specific   | * |   | ** |           |               |
|   | In      | dependent has  | * |   |    |           |               |
|   | dicator | non-FEHB       |   |   |    |           |               |
|   | (1)**   | coverage       |   |   |    |           |               |
|   |         | outside of the |   |   |    |           |               |
|   |         | FEHB Program** |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **See     |               |
| * | *\*FEHB | Y/N**          | * | * | *3 | field     |               |
| 3 | Family  |                | Y | 1 | 66 | #35**     |               |
| 3 | M       | **Edits:       | / | * | -3 |           |               |
| * | edicare | Indicates if   | N | * | 66 |           |               |
| * | In      | Dependent #1   | * |   | ** |           |               |
|   | dicator | has Medicare   | * |   |    |           |               |
|   | (1)**   | coverage**     |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits:       |   |   |    |           |               |
|   |         | REQUIRED if    |   |   |    |           |               |
|   |         | FEHB Family    |   |   |    |           |               |
|   |         | Other          |   |   |    |           |               |
|   |         | Insurance      |   |   |    |           |               |
|   |         | Indicator (1)  |   |   |    |           |               |
|   |         | is Y**         |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | FEHB FAMILY    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR (1)  |   |   |    |           |               |
|   |         | is \"N\", then |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **See     |               |
| * | *\*FEHB | Y/N**          | * | * | *3 | field     |               |
| 3 | Family  |                | Y | 1 | 67 | #35**     |               |
| 4 | Medi    | **Edits:       | / | * | -3 |           |               |
| * | care--A | Indicates if   | N | * | 67 |           |               |
| * | (1)**   | Dependent #1   | * |   | ** |           |               |
|   |         | has Medicare   | * |   |    |           |               |
|   |         | Part-A**       |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits:       |   |   |    |           |               |
|   |         | REQUIRED if    |   |   |    |           |               |
|   |         | FEHB Family    |   |   |    |           |               |
|   |         | Other          |   |   |    |           |               |
|   |         | Insurance      |   |   |    |           |               |
|   |         | Indicator (1)  |   |   |    |           |               |
|   |         | is Y**         |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | FEHB FAMILY    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR (1)  |   |   |    |           |               |
|   |         | is \"N\", then |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **INS06,  |               |
| * | *\*FEHB | Y/N**          | * | * | *3 | 1218,     |               |
| 3 | Family  |                | Y | 1 | 68 | Pg.48**   |               |
| 5 | Medi    | **Edits:       | / | * | -3 |           |               |
| * | care--B | Indicates if   | N | * | 68 | **\'A\' = |               |
| * | (1)**   | Dependent #1   | * |   | ** | Medicare  |               |
|   |         | has Medicare   | * |   |    | Part A**  |               |
|   |         | Part-B**       |   |   |    |           |               |
|   |         |                |   |   |    | **\'B\' = |               |
|   |         | **Edits:       |   |   |    | Medicare  |               |
|   |         | REQUIRED if    |   |   |    | Part B**  |               |
|   |         | FEHB Family    |   |   |    |           |               |
|   |         | Other          |   |   |    | **\'C\' = |               |
|   |         | Insurance      |   |   |    | Medicare  |               |
|   |         | Indicator (1)  |   |   |    | Part A &  |               |
|   |         | is Y**         |   |   |    | B**       |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | FEHB FAMILY    |   |   |    |           |               |
|   |         | OTHER          |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR (1)  |   |   |    |           |               |
|   |         | is \"N\", then |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **COB01,  |               |
| * | *\*FEHB | Y/N**          | * | * | *3 | 1138, Pg. |               |
| 3 | Family  |                | Y | 1 | 69 | 150 =     |               |
| 6 | TRICARE | **Edits:       | / | * | -3 | \'U\'**   |               |
| * | (in     | Indicates if   | N | * | 69 |           |               |
| * | cluding | Dependent #1   | * |   | ** | **COB02,  |               |
|   | C       | has TriCare    | * |   |    | 127, Pg.  |               |
|   | HAMPUS) | coverage**     |   |   |    | 151 =     |               |
|   | In      |                |   |   |    | \"TR      |               |
|   | dicator | **Edits:       |   |   |    | ICARE\"** |               |
|   | (1)**   | REQUIRED if    |   |   |    |           |               |
|   |         | FEHB Family    |   |   |    | **COB03,  |               |
|   |         | Other          |   |   |    | 1143, Pg. |               |
|   |         | Insurance      |   |   |    | 151 =     |               |
|   |         | Indicator (1)  |   |   |    | \'1\'**   |               |
|   |         | is Y**         |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: If    |   |   |    |           |               |
|   |         | FEHB OTHER     |   |   |    |           |               |
|   |         | INSURANCE      |   |   |    |           |               |
|   |         | INDICATOR (1)  |   |   |    |           |               |
|   |         | is \"N\", then |   |   |    |           |               |
|   |         | populate with  |   |   |    |           |               |
|   |         | \"N\"**        |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values: Name | * | * | *  | #         | If either     |
| * | *\*FEHB | of any group   | * | * | *3 |  N101, 98 | Other         |
| 3 | Family  | health         | Y | 3 | 70 | , Pg. 154 | Insurance     |
| 7 | Other   | insurance      | / | 5 | -4 |  = \'IN\' | Name and/or   |
| * | In      | coverage       | N | * | 04 |           | Other         |
| * | surance | Dependent #1   | * | * | ** | **N102,   | Insurance     |
|   | Name    | may have or be | * |   |    | 93, Pg.   | Policy Number |
|   | (1)**   | covered under  |   |   |    | 154**     | have data,    |
|   |         | other than the |   |   |    |           | then this     |
|   |         | FEHB plan in   |   |   |    |           | will be sent  |
|   |         | which the main |   |   |    |           | as well:      |
|   |         | subscriber is  |   |   |    |           |               |
|   |         | enrolling in   |   |   |    |           | **COB01,      |
|   |         | or changing    |   |   |    |           | 1138, Pg. 150 |
|   |         | to.**          |   |   |    |           | = \'U\'**     |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits:      |   |   |    |           | **COB03,      |
|   |         | REQUIRED if    |   |   |    |           | 1143, Pg. 151 |
|   |         | FEHB Family    |   |   |    |           | = \'5\'**     |
|   |         | Other          |   |   |    |           |               |
|   |         | Insurance      |   |   |    |           |               |
|   |         | Indicator (1)  |   |   |    |           |               |
|   |         | is Y and all   |   |   |    |           |               |
|   |         | other types of |   |   |    |           |               |
|   |         | insurance are  |   |   |    |           |               |
|   |         | N***           |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Example:     |   |   |    |           |               |
|   |         | STATE FARM     |   |   |    |           |               |
|   |         | HEALTH**       |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **REF01,  |               |
| * | *\*FEHB | Provide if     | * | * | *4 | 128, Pg.  |               |
| 3 | Family  | known**        | N | 3 | 05 | 153 =     |               |
| 8 | Other   |                | * | 0 | -4 | \'ZZ\'**  |               |
| * | In      | **Example:     | * | * | 34 |           |               |
| * | surance | 1234123 or     |   | * | ** | **REF02,  |               |
|   | Policy  | A4232DB232**   |   |   |    | 127, Pg.  |               |
|   | Number  |                |   |   |    | 153**     |               |
|   | (1)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: No    | * | * | *  | **N301,   | IF Report# =  |
| * | *\*FEHB | punctuation,   | * | * | *4 | 166, Pg.  | EESTA and     |
| 3 | Family  | A - Z, 0 - 9,  | Y | 3 | 35 | 67**      | Home Street 1 |
| 9 | Home    | \#**           | / | 5 | -4 |           | = blank, pass |
| * | Street  |                | N | * | 69 |           |               |
| * | 1 (1)** | **Example:     | * | * | ** |           | **N301, 166,  |
|   |         | ROUTE 1 BOX    | * |   |    |           | Pg. 67 =      |
|   | ***If   | 618B**         |   |   |    |           | \"Not passed  |
|   | F       |                |   |   |    |           | for security  |
|   | oreign, | **             |   |   |    |           | reasons\"**   |
|   | Foreign | Justification: |   |   |    |           |               |
|   | Street  | Left**         |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
|   |         | ***Edits:      |   |   |    |           |               |
|   |         | Occurrence 1   |   |   |    |           |               |
|   |         | is REQUIRED    |   |   |    |           |               |
|   |         | for family     |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: Same  | * | * | *  | **N302,   |               |
| * | *\*FEHB | as Home Street | * | * | *4 | 166, Pg.  |               |
| 4 | Family  | 1**            | Y | 3 | 70 | 67**      |               |
| 0 | Home    |                | / | 5 | -5 |           |               |
| * | Street  | ***Edits:      | N | * | 04 |           |               |
| * | 2 (1)** | Occurrence 1   | * | * | ** |           |               |
|   |         | is REQUIRED    | * |   |    |           |               |
|   | ***If   | for family     |   |   |    |           |               |
|   | F       | coverage***    |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign | ***Edits: If   |   |   |    |           |               |
|   | Street  | family member  |   |   |    |           |               |
|   | 2***    | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: Same  | * | * | *  | **Append  |               |
| * | *\*FEHB | as Home Street | * | * | *5 | into      |               |
| 4 | Family  | 1**            | Y | 3 | 05 | Street    |               |
| 1 | Home    |                | / | 5 | -5 | 2**       |               |
| * | Street  | ***Edits:      | N | * | 39 |           |               |
| * | 3 (1)** | Occurrence 1   | * | * | ** | **N302,   |               |
|   |         | is REQUIRED    | * |   |    | 166, Pg.  |               |
|   | ***If   | for family     |   |   |    | 67        |               |
|   | F       | coverage***    |   |   |    | above**   |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign | ***Edits: If   |   |   |    |           |               |
|   | City    | family member  |   |   |    |           |               |
|   | Name*** | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: Valid | * | * | *  | **N401,   |               |
| * | *\*FEHB | city name**    | * | * | *5 | 19, Pg.   |               |
| 4 | Family  |                | Y | 2 | 40 | 68**      |               |
| 2 | Home    | **Example:     | / | 3 | -5 |           |               |
| * | City    | MACON**        | N | * | 62 |           |               |
| * | (1)**   |                | * | * | ** |           |               |
|   |         | **             | * |   |    |           |               |
|   | ***If   | Justification: |   |   |    |           |               |
|   | F       | Left**         |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country | ***Edits:      |   |   |    |           |               |
|   | Name*** | Occurrence 1   |   |   |    |           |               |
|   |         | is REQUIRED    |   |   |    |           |               |
|   |         | for family     |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  | **N402,   |               |
| * | *\*FEHB | Valid State    | * | * | *5 | 156, Pg.  |               |
| 4 | Family  | Abbreviation** | Y | 2 | 63 | 68**      |               |
| 3 | Home    |                | / | * | -5 |           |               |
| * | State   | **Example:     | N | * | 64 |           |               |
| * | Abbre   | GA**           | * |   | ** |           |               |
|   | viation |                | * |   |    |           |               |
|   | (1)**   | ***Edits:      |   |   |    |           |               |
|   |         | Occurrence 1   |   |   |    |           |               |
|   | ***If   | is REQUIRED    |   |   |    |           |               |
|   | F       | for family     |   |   |    |           |               |
|   | oreign, | coverage***    |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Edits: 5     | * | * | *  | **N403,   |               |
| * | *\*FEHB | REQUIRED, 4    | * | * | *5 | 116, Pg.  |               |
| 4 | Family  | Optional**     | Y | 1 | 65 | 69**      |               |
| 4 | Home    |                | / | 1 | -5 |           |               |
| * | Zip     | **Values:      | N | * | 75 |           |               |
| * | (1)**   | Valid Zip Code | * | * | ** |           |               |
|   |         | or Zip+4       | * |   |    |           |               |
|   | ***If   | code**         |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, | **Examples:    |   |   |    |           |               |
|   | Foreign | 31206,         |   |   |    |           |               |
|   | Postal  | 312064204**    |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
|   |         | ***Edits:      |   |   |    |           |               |
|   |         | Occurrence 1   |   |   |    |           |               |
|   |         | is REQUIRED    |   |   |    |           |               |
|   |         | for family     |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Values:      | * | * | *  |           |               |
| * | *\*FEHB | Y/N**          | * | * | *5 |           |               |
| 4 | Family  |                | Y | 1 | 76 |           |               |
| 5 | Foreign | **Edits: Y     | / | * | -5 |           |               |
| * | /       | indicates that | N | * | 76 |           |               |
| * | O       | the dependent  | * |   | ** |           |               |
|   | verSeas | has a foreign  | * |   |    |           |               |
|   | Address | home address   |   |   |    |           |               |
|   | In      | (not an        |   |   |    |           |               |
|   | dicator | APO/FPO        |   |   |    |           |               |
|   | (1)**   | address).**    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | **Edits: N     |   |   |    |           |               |
|   |         | indicates that |   |   |    |           |               |
|   |         | the dependent  |   |   |    |           |               |
|   |         | has a US       |   |   |    |           |               |
|   |         | address, which |   |   |    |           |               |
|   |         | includes       |   |   |    |           |               |
|   |         | APO/FPO        |   |   |    |           |               |
|   |         | addresses and  |   |   |    |           |               |
|   |         | US             |   |   |    |           |               |
|   |         | Territories.** |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits:      |   |   |    |           |               |
|   |         | Occurrence 1   |   |   |    |           |               |
|   |         | is REQUIRED    |   |   |    |           |               |
|   |         | for family     |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | ***Edits: If   |   |   |    |           |               |
|   |         | family member  |   |   |    |           |               |
|   |         | 1 is used,     |   |   |    |           |               |
|   |         | REQUIRED for   |   |   |    |           |               |
|   |         | family         |   |   |    |           |               |
|   |         | coverage***    |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *5 | to Family |               |
| 4 | Family  | 1 for values & | Y | 2 | 77 | Member    |               |
| 6 | Member  | edits**        | / | 0 | -5 | 1**       |               |
| * | Last    |                | N | * | 96 |           |               |
| * | Name    |                | * | * | ** |           |               |
|   | (2)**   |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *5 | to Family |               |
| 4 | Family  | 1 for values & | Y | 1 | 97 | Member    |               |
| 7 | Member  | edits**        | / | 4 | -6 | 1**       |               |
| * | First   |                | N | * | 10 |           |               |
| * | Name    |                | * | * | ** |           |               |
|   | (2)**   |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 4 | Family  | 1 for values & | Y | 1 | 11 | Member    |               |
| 8 | Member  | edits**        | / | * | -6 | 1**       |               |
| * | Middle  |                | N | * | 11 |           |               |
| * | Initial |                | * |   | ** |           |               |
|   | (2)**   |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 4 | FEHB    | Refer to       | Y | 8 | 6  | **Refer   |               |
| 9 | Family  | family member  | / |   | 12 | to Family |               |
|   | DOB (2) | 1 for values & | N |   | -6 | Member    |               |
|   |         | edits          |   |   | 19 | 1**       |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 5 | FEHB    | Refer to       | # | 1 | 6  | **Refer   |               |
| 0 | Family  | family member  | # |   | 20 | to Family |               |
|   | Sex     | 1 for values & | # |   | -6 | Member    |               |
|   | Code    | edits          | # |   | 20 | 1**       |               |
|   | (2)     |                | # |   |    |           |               |
|   |         |                | # |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 2 | 21 | Member    |               |
| 1 | Relat   | edits**        | / | * | -6 | 1**       |               |
| * | ionship |                | N | * | 22 |           |               |
| * | (2)**   |                | * |   | ** |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 5 | FEHB    | Refer to       | N | 9 | 6  | **Refer   |               |
| 2 | Family  | family member  |   |   | 23 | to Family |               |
|   | SSN (2) | 1 for values & |   |   | -6 | Member    |               |
|   |         | edits          |   |   | 31 | 1**       |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 1 | 32 | Member    |               |
| 3 | Other   | edits**        | / | * | -6 | 1**       |               |
| * | In      |                | N | * | 32 |           |               |
| * | surance |                | * |   | ** |           |               |
|   | In      |                | * |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 1 | 33 | Member    |               |
| 4 | M       | edits**        | / | * | -6 | 1**       |               |
| * | edicare |                | N | * | 33 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                | * |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 1 | 34 | Member    |               |
| 5 | Medi    | edits**        | / | * | -6 | 1**       |               |
| * | care--A |                | N | * | 34 |           |               |
| * | (2)**   |                | * |   | ** |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 1 | 35 | Member    |               |
| 6 | Medi    | edits**        | / | * | -6 | 1**       |               |
| * | care--B |                | N | * | 35 |           |               |
| * | (2)**   |                | * |   | ** |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 1 | 36 | Member    |               |
| 7 | TRICARE | edits**        | / | * | -6 | 1**       |               |
| * | (in     |                | N | * | 36 |           |               |
| * | cluding |                | * |   | ** |           |               |
|   | C       |                | * |   |    |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 3 | 37 | Member    |               |
| 8 | Other   | edits**        | / | 5 | -6 | 1**       |               |
| * | In      |                | N | * | 71 |           |               |
| * | surance |                | * | * | ** |           |               |
|   | Name    |                | * |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *6 | to Family |               |
| 5 | Family  | 1 for values & | Y | 3 | 72 | Member    |               |
| 9 | Other   | edits**        | / | 0 | -7 | 1**       |               |
| * | In      |                | N | * | 01 |           |               |
| * | surance |                | * | * | ** |           |               |
|   | Policy  |                | * |   |    |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *7 | to Family |               |
| 6 | Family  | 1 for values & | Y | 3 | 02 | Member    |               |
| 0 | Home    | edits**        | / | 5 | -7 | 1**       |               |
| * | Street  |                | N | * | 36 |           |               |
| * | 1 (2)** |                | * | * | ** |           |               |
|   |         |                | * |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *7 | to Family |               |
| 6 | Family  | 1 for values & | Y | 3 | 37 | Member    |               |
| 1 | Home    | edits**        | / | 5 | -7 | 1**       |               |
| * | Street  |                | N | * | 71 |           |               |
| * | 2 (2)** |                | * | * | ** |           |               |
|   |         |                | * |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *7 | to Family |               |
| 6 | Family  | 1 for values & | Y | 3 | 72 | Member    |               |
| 2 | Home    | edits**        | / | 5 | -8 | 1**       |               |
| * | Street  |                | N | * | 06 |           |               |
| * | 3 (2)** |                | * | * | ** |           |               |
|   |         |                | * |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 2 | 07 | Member    |               |
| 3 | Home    | edits**        | / | 3 | -8 | 1**       |               |
| * | City    |                | N | * | 29 |           |               |
| * | (2)**   |                | * | * | ** |           |               |
|   |         |                | * |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 2 | 30 | Member    |               |
| 4 | Home    | edits**        | / | * | -8 | 1**       |               |
| * | State   |                | N | * | 31 |           |               |
| * | Abbre   |                | * |   | ** |           |               |
|   | viation |                | * |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 1 | 32 | Member    |               |
| 5 | Home    | edits**        | / | 1 | -8 | 1**       |               |
| * | Zip     |                | N | * | 42 |           |               |
| * | (2)**   |                | * | * | ** |           |               |
|   |         |                | * |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 6 | Foreign | edits**        | / | * | -8 | 1**       |               |
| * | /       |                | N | * | 43 |           |               |
| * | O       |                | * |   | ** |           |               |
|   | verSeas |                | * |   |    |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (2)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 2 | 44 | Member    |               |
| 7 | Member  | edits**        | / | 0 | -8 | 1**       |               |
| * | Last    |                | N | * | 63 |           |               |
| * | Name    |                | * | * | ** |           |               |
|   | (3)**   |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 1 | 64 | Member    |               |
| 8 | Member  | edits**        | / | 4 | -8 | 1**       |               |
| * | First   |                | N | * | 77 |           |               |
| * | Name    |                | * | * | ** |           |               |
|   | (3)**   |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 6 | Family  | 1 for values & | Y | 1 | 78 | Member    |               |
| 9 | Member  | edits**        | / | * | -8 | 1**       |               |
| * | Middle  |                | N | * | 78 |           |               |
| * | Initial |                | * |   | ** |           |               |
|   | (3)**   |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 7 | FEHB    | Refer to       | Y | 8 | 8  | **Refer   |               |
| 0 | Family  | family member  | / |   | 79 | to Family |               |
|   | DOB (3) | 1 for values & | N |   | -8 | Member    |               |
|   |         | edits          |   |   | 86 | 1**       |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 7 | FEHB    | Refer to       | Y | 1 | 8  | **Refer   |               |
| 1 | Family  | family member  | / |   | 87 | to Family |               |
|   | Sex     | 1 for values & | N |   | -8 | Member    |               |
|   | Code    | edits          |   |   | 87 | 1**       |               |
|   | (3)     |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *8 | to Family |               |
| 7 | Family  | 1 for values & | Y | 2 | 88 | Member    |               |
| 2 | Relat   | edits**        | / | * | -8 | 1**       |               |
| * | ionship |                | N | * | 89 |           |               |
| * | (3)**   |                | * |   | ** |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 7 | FEHB    | Refer to       | N | 9 | 8  | **Refer   |               |
| 3 | Family  | family member  |   |   | 90 | to Family |               |
|   | SSN (3) | 1 for values & |   |   | -8 | Member    |               |
|   |         | edits          |   |   | 98 | 1**       |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *8 | to Family |               |
| 7 | Family  | 1 for values & | # | 1 | 99 | Member    |               |
| 4 | Other   | edits**        | # | * | -8 | 1**       |               |
| * | In      |                | # | * | 99 |           |               |
| * | surance |                | # |   | ** |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                | * |   |    |           |               |
|   | (3)**   |                | * |   |    |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *9 | to Family |               |
| 7 | Family  | 1 for values & | # | 1 | 00 | Member    |               |
| 5 | M       | edits**        | # | * | -9 | 1**       |               |
| * | edicare |                | # | * | 00 |           |               |
| * | In      |                | # |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (3)**   |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *9 | to Family |               |
| 7 | Family  | 1 for values & | # | 1 | 01 | Member    |               |
| 6 | Medi    | edits**        | # | * | -9 | 1**       |               |
| * | care--A |                | # | * | 01 |           |               |
| * | (3)**   |                | # |   | ** |           |               |
|   |         |                |   |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *9 | to Family |               |
| 7 | Family  | 1 for values & | # | 1 | 02 | Member    |               |
| 7 | Medi    | edits**        | # | * | -9 | 1**       |               |
| * | care--B |                | # | * | 02 |           |               |
| * | (3)**   |                | # |   | ** |           |               |
|   |         |                |   |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *9 | to Family |               |
| 7 | Family  | 1 for values & | # | 1 | 03 | Member    |               |
| 8 | TRICARE | edits**        | # | * | -9 | 1**       |               |
| * | (in     |                | # | * | 03 |           |               |
| * | cluding |                | # |   | ** |           |               |
|   | C       |                |   |   |    |           |               |
|   | HAMPUS) |                | * |   |    |           |               |
|   | In      |                | * |   |    |           |               |
|   | dicator |                | Y |   |    |           |               |
|   | (3)**   |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *9 | to Family |               |
| 7 | Family  | 1 for values & | # | 3 | 04 | Member    |               |
| 9 | Other   | edits**        | # | 5 | -9 | 1**       |               |
| * | In      |                | # | * | 38 |           |               |
| * | surance |                | # | * | ** |           |               |
|   | Name    |                |   |   |    |           |               |
|   | (3)**   |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *9 | to Family |               |
| 8 | Family  | 1 for values & | Y | 3 | 39 | Member    |               |
| 0 | Other   | edits**        | / | 0 | -9 | 1**       |               |
| * | In      |                | N | * | 68 |           |               |
| * | surance |                | * | * | ** |           |               |
|   | Policy  |                | * |   |    |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (3)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | ** | **Refer   |               |
| * | *\*FEHB | family member  | # | * | 96 | to Family |               |
| 8 | Family  | 1 for values & | # | 3 | 9- | Member    |               |
| 1 | Home    | edits**        | # | 5 | 10 | 1**       |               |
| * | Street  |                | # | * | 03 |           |               |
| * | 1 (3)** |                | # | * | ** |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                | * |   |    |           |               |
|   | F       |                | * |   |    |           |               |
|   | oreign, |                | Y |   |    |           |               |
|   | Foreign |                | / |   |    |           |               |
|   | Street  |                | N |   |    |           |               |
|   | 1***    |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | # | 3 | 00 | Member    |               |
| 2 | Home    | edits**        | # | 5 | 4- | 1**       |               |
| * | Street  |                | # | * | 10 |           |               |
| * | 2 (3)** |                | # | * | 38 |           |               |
|   |         |                |   |   | ** |           |               |
|   | ***If   |                | * |   |    |           |               |
|   | F       |                | * |   |    |           |               |
|   | oreign, |                | Y |   |    |           |               |
|   | Foreign |                | / |   |    |           |               |
|   | Street  |                | N |   |    |           |               |
|   | 2***    |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | # | 3 | 03 | Member    |               |
| 3 | Home    | edits**        | # | 5 | 9- | 1**       |               |
| * | Street  |                | # | * | 10 |           |               |
| * | 3 (3)** |                | # | * | 73 |           |               |
|   |         |                |   |   | ** |           |               |
|   | ***If   |                | * |   |    |           |               |
|   | F       |                | * |   |    |           |               |
|   | oreign, |                | Y |   |    |           |               |
|   | Foreign |                | / |   |    |           |               |
|   | Street  |                | N |   |    |           |               |
|   | 3***    |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | # | 2 | 07 | Member    |               |
| 4 | Home    | edits**        | # | 3 | 4- | 1**       |               |
| * | City    |                | # | * | 10 |           |               |
| * | (3)**   |                | # | * | 96 |           |               |
|   |         |                |   |   | ** |           |               |
|   | ***If   |                | * |   |    |           |               |
|   | F       |                | * |   |    |           |               |
|   | oreign, |                | Y |   |    |           |               |
|   | Foreign |                | / |   |    |           |               |
|   | City    |                | N |   |    |           |               |
|   | Name*** |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | # | 2 | 09 | Member    |               |
| 5 | Home    | edits**        | # | * | 7- | 1**       |               |
| * | State   |                | # | * | 10 |           |               |
| * | Abbre   |                | # |   | 98 |           |               |
|   | viation |                |   |   | ** |           |               |
|   | (3)**   |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
|   | ***If   |                | Y |   |    |           |               |
|   | F       |                | / |   |    |           |               |
|   | oreign, |                | N |   |    |           |               |
|   | Country |                | * |   |    |           |               |
|   | Code*** |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | # | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | # | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | # | 1 | 09 | Member    |               |
| 6 | Home    | edits**        | # | 1 | 9- | 1**       |               |
| * | Zip     |                | # | * | 11 |           |               |
| * | (3)**   |                | # | * | 09 |           |               |
|   |         |                |   |   | ** |           |               |
|   | ***If   |                | * |   |    |           |               |
|   | F       |                | * |   |    |           |               |
|   | oreign, |                | Y |   |    |           |               |
|   | Foreign |                | / |   |    |           |               |
|   | Postal  |                | N |   |    |           |               |
|   | Code*** |                | * |   |    |           |               |
|   |         |                | * |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | Y | 1 | 11 | Member    |               |
| 7 | Foreign | edits**        | / | * | 0- | 1**       |               |
| * | /       |                | N | * | 11 |           |               |
| * | O       |                | * |   | 10 |           |               |
|   | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (3)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | Y | 2 | 11 | Member    |               |
| 8 | Member  | edits**        | / | 0 | 1- | 1**       |               |
| * | Last    |                | N | * | 11 |           |               |
| * | Name    |                | * | * | 30 |           |               |
|   | (4)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 8 | Family  | 1 for values & | Y | 1 | 13 | Member    |               |
| 9 | Member  | edits**        | / | 4 | 1- | 1**       |               |
| * | First   |                | N | * | 11 |           |               |
| * | Name    |                | * | * | 44 |           |               |
|   | (4)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 1 | 14 | Member    |               |
| 0 | Member  | edits**        | / | * | 5- | 1**       |               |
| * | Middle  |                | N | * | 11 |           |               |
| * | Initial |                | * |   | 45 |           |               |
|   | (4)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 9 | FEHB    | Refer to       | Y | 8 | 1  | **Refer   |               |
| 1 | Family  | family member  | / |   | 14 | to Family |               |
|   | DOB (4) | 1 for values & | N |   | 6- | Member    |               |
|   |         | edits          |   |   | 11 | 1**       |               |
|   |         |                |   |   | 53 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 9 | FEHB    | Refer to       | Y | 1 | 1  | **Refer   |               |
| 2 | Family  | family member  | / |   | 15 | to Family |               |
|   | Sex     | 1 for values & | N |   | 4- | Member    |               |
|   | Code    | edits          |   |   | 11 | 1**       |               |
|   | (4)     |                |   |   | 54 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 2 | 15 | Member    |               |
| 3 | Relat   | edits**        | / | * | 5- | 1**       |               |
| * | ionship |                | N | * | 11 |           |               |
| * | (4)**   |                | * |   | 56 |           |               |
|   |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 9 | FEHB    | Refer to       | N | 9 | 1  | **Refer   |               |
| 4 | Family  | family member  |   |   | 15 | to Family |               |
|   | SSN (4) | 1 for values & |   |   | 7- | Member    |               |
|   |         | edits          |   |   | 11 | 1**       |               |
|   |         |                |   |   | 65 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 1 | 16 | Member    |               |
| 5 | Other   | edits**        | * | * | 6- | 1**       |               |
| * | In      |                | * | * | 11 |           |               |
| * | surance |                |   |   | 66 |           |               |
|   | In      |                |   |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (4)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 1 | 16 | Member    |               |
| 6 | M       | edits**        | / | * | 7- | 1**       |               |
| * | edicare |                | N | * | 11 |           |               |
| * | In      |                | * |   | 67 |           |               |
|   | dicator |                | * |   | ** |           |               |
|   | (4)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 1 | 16 | Member    |               |
| 7 | Medi    | edits**        | / | * | 8- | 1**       |               |
| * | care--A |                | N | * | 11 |           |               |
| * | (4)**   |                | * |   | 68 |           |               |
|   |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 1 | 16 | Member    |               |
| 8 | Medi    | edits**        | / | * | 9- | 1**       |               |
| * | care--B |                | N | * | 11 |           |               |
| * | (4)**   |                | * |   | 69 |           |               |
|   |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 9 | Family  | 1 for values & | Y | 1 | 17 | Member    |               |
| 9 | TRICARE | edits**        | / | * | 0- | 1**       |               |
| * | (in     |                | N | * | 11 |           |               |
| * | cluding |                | * |   | 70 |           |               |
|   | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (4)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 17 | Member    |               |
| 0 | Other   | edits**        | / | 5 | 1- | 1**       |               |
| 0 | In      |                | N | * | 12 |           |               |
| * | surance |                | * | * | 05 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (4)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 20 | Member    |               |
| 0 | Other   | edits**        | / | 0 | 6- | 1**       |               |
| 1 | In      |                | N | * | 12 |           |               |
| * | surance |                | * | * | 35 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (4)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 23 | Member    |               |
| 0 | Home    | edits**        | / | 5 | 6- | 1**       |               |
| 2 | Street  |                | N | * | 12 |           |               |
| * | 1 (4)** |                | * | * | 70 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 27 | Member    |               |
| 0 | Home    | edits**        | / | 5 | 1- | 1**       |               |
| 3 | Street  |                | N | * | 13 |           |               |
| * | 2 (4)** |                | * | * | 05 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 30 | Member    |               |
| 0 | Home    | edits**        | / | 5 | 6- | 1**       |               |
| 4 | Street  |                | N | * | 13 |           |               |
| * | 3 (4)** |                | * | * | 40 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 34 | Member    |               |
| 0 | Home    | edits**        | / | 3 | 1- | 1**       |               |
| 5 | City    |                | N | * | 13 |           |               |
| * | (4)**   |                | * | * | 63 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 36 | Member    |               |
| 0 | Home    | edits**        | / | * | 4- | 1**       |               |
| 6 | State   |                | N | * | 13 |           |               |
| * | Abbre   |                | * |   | 65 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (4)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 36 | Member    |               |
| 0 | Home    | edits**        | / | 1 | 6- | 1**       |               |
| 7 | Zip     |                | N | * | 13 |           |               |
| * | (4)**   |                | * | * | 76 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 37 | Member    |               |
| 0 | Foreign | edits**        | / | * | 7- | 1**       |               |
| 8 | /       |                | N | * | 13 |           |               |
| * | O       |                | * |   | 77 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (4)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 37 | Member    |               |
| 0 | Member  | edits**        | / | 0 | 8- | 1**       |               |
| 9 | Last    |                | N | * | 13 |           |               |
| * | Name    |                | * | * | 97 |           |               |
| * | (5)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 39 | Member    |               |
| 1 | Member  | edits**        | / | 4 | 8- | 1**       |               |
| 0 | First   |                | N | * | 14 |           |               |
| * | Name    |                | * | * | 11 |           |               |
| * | (5)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 41 | Member    |               |
| 1 | Member  | edits**        | / | * | 2- | 1**       |               |
| 1 | Middle  |                | N | * | 14 |           |               |
| * | Initial |                | * |   | 12 |           |               |
| * | (5)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 8 | 1  | **Refer   |               |
| 1 | Family  | family member  | / |   | 41 | to Family |               |
| 2 | DOB (5) | 1 for values & | N |   | 3- | Member    |               |
|   |         | edits          |   |   | 14 | 1**       |               |
|   |         |                |   |   | 20 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 1 | 1  | **Refer   |               |
| 1 | Family  | family member  | / |   | 42 | to Family |               |
| 3 | Sex     | 1 for values & | N |   | 1- | Member    |               |
|   | Code    | edits          |   |   | 14 | 1**       |               |
|   | (5)     |                |   |   | 21 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 42 | Member    |               |
| 1 | Relat   | edits**        | / | * | 2- | 1**       |               |
| 4 | ionship |                | N | * | 14 |           |               |
| * | 5**     |                | * |   | 23 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | N | 9 | 1  | **Refer   |               |
| 1 | Family  | family member  |   |   | 42 | to Family |               |
| 5 | SSN (5) | 1 for values & |   |   | 4- | Member    |               |
|   |         | edits          |   |   | 14 | 1**       |               |
|   |         |                |   |   | 32 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 1 | Other   | edits**        | / | * | 3- | 1**       |               |
| 6 | In      |                | N | * | 14 |           |               |
| * | surance |                | * |   | 33 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (5)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 1 | M       | edits**        | / | * | 4- | 1**       |               |
| 7 | edicare |                | N | * | 14 |           |               |
| * | In      |                | * |   | 34 |           |               |
| * | dicator |                | * |   | ** |           |               |
|   | (5)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 1 | Medi    | edits**        | / | * | 5- | 1**       |               |
| 8 | care--A |                | N | * | 14 |           |               |
| * | (5)**   |                | * |   | 35 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 1 | Medi    | edits**        | / | * | 6- | 1**       |               |
| 9 | care--B |                | N | * | 14 |           |               |
| * | (5)**   |                | * |   | 36 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 2 | TRICARE | edits**        | / | * | 7- | 1**       |               |
| 0 | (in     |                | N | * | 14 |           |               |
| * | cluding |                | * |   | 37 |           |               |
| * | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (5)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 43 | Member    |               |
| 2 | Other   | edits**        | / | 5 | 8- | 1**       |               |
| 1 | In      |                | N | * | 14 |           |               |
| * | surance |                | * | * | 72 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (5)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 47 | Member    |               |
| 2 | Other   | edits**        | / | 0 | 3- | 1**       |               |
| 2 | In      |                | N | * | 15 |           |               |
| * | surance |                | * | * | 02 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (5)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 50 | Member    |               |
| 2 | Home    | edits**        | / | 5 | 3- | 1**       |               |
| 3 | Street  |                | N | * | 15 |           |               |
| * | 1 (5)** |                | * | * | 37 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 53 | Member    |               |
| 2 | Home    | edits**        | / | 5 | 8- | 1**       |               |
| 4 | Street  |                | N | * | 15 |           |               |
| * | 2 (5)** |                | * | * | 72 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 57 | Member    |               |
| 2 | Home    | edits**        | / | 5 | 3- | 1**       |               |
| 5 | Street  |                | N | * | 16 |           |               |
| * | 3 (5)** |                | * | * | 07 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 60 | Member    |               |
| 2 | Home    | edits**        | / | 3 | 8- | 1**       |               |
| 6 | City    |                | N | * | 16 |           |               |
| * | (5)**   |                | * | * | 30 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 63 | Member    |               |
| 2 | Home    | edits**        | / | * | 1- | 1**       |               |
| 7 | State   |                | N | * | 16 |           |               |
| * | Abbre   |                | * |   | 32 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (5)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 63 | Member    |               |
| 2 | Home    | edits**        | / | 1 | 3- | 1**       |               |
| 8 | Zip     |                | N | * | 16 |           |               |
| * | (5)**   |                | * | * | 43 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 64 | Member    |               |
| 2 | Foreign | edits**        | / | * | 4- | 1**       |               |
| 9 | /       |                | N | * | 16 |           |               |
| * | O       |                | * |   | 44 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (5)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 64 | Member    |               |
| 3 | Member  | edits**        | / | 0 | 5- | 1**       |               |
| 0 | Last    |                | N | * | 16 |           |               |
| * | Name    |                | * | * | 64 |           |               |
| * | (6)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 66 | Member    |               |
| 3 | Member  | edits**        | / | 4 | 5- | 1**       |               |
| 1 | First   |                | N | * | 16 |           |               |
| * | Name    |                | * | * | 78 |           |               |
| * | (6)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 67 | Member    |               |
| 3 | Member  | edits**        | / | * | 9- | 1**       |               |
| 2 | Middle  |                | N | * | 16 |           |               |
| * | Initial |                | * |   | 79 |           |               |
| * | (6)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 8 | 1  | **Refer   |               |
| 3 | Family  | family member  | / |   | 68 | to Family |               |
| 3 | DOB (6) | 1 for values & | N |   | 0- | Member    |               |
|   |         | edits          |   |   | 16 | 1**       |               |
|   |         |                |   |   | 87 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | # | 1 | 1  | **Refer   |               |
| 3 | Family  | family member  | # |   | 68 | to Family |               |
| 4 | Sex     | 1 for values & | # |   | 8- | Member    |               |
|   | Code    | edits          | # |   | 16 | 1**       |               |
|   | (6)     |                |   |   | 88 |           |               |
|   |         |                | Y |   |    |           |               |
|   |         |                | / |   |    |           |               |
|   |         |                | N |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 68 | Member    |               |
| 3 | Relat   | edits**        | / | * | 9- | 1**       |               |
| 5 | ionship |                | N | * | 16 |           |               |
| * | (6)**   |                | * |   | 90 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | N | 9 | 1  | **Refer   |               |
| 3 | Family  | family member  |   |   | 69 | to Family |               |
| 6 | SSN (6) | 1 for values & |   |   | 1- | Member    |               |
|   |         | edits          |   |   | 16 | 1**       |               |
|   |         |                |   |   | 99 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 70 | Member    |               |
| 3 | Other   | edits**        | / | * | 0- | 1**       |               |
| 7 | In      |                | N | * | 17 |           |               |
| * | surance |                | * |   | 00 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (6)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 70 | Member    |               |
| 3 | M       | edits**        | / | * | 1- | 1**       |               |
| 8 | edicare |                | N | * | 17 |           |               |
| * | In      |                | * |   | 01 |           |               |
| * | dicator |                | * |   | ** |           |               |
|   | (6)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 70 | Member    |               |
| 3 | Medi    | edits**        | / | * | 2- | 1**       |               |
| 9 | care--A |                | N | * | 17 |           |               |
| * | (6)**   |                | * |   | 02 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 70 | Member    |               |
| 4 | Medi    | edits**        | / | * | 3- | 1**       |               |
| 0 | care--B |                | N | * | 17 |           |               |
| * | (6)**   |                | * |   | 03 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 70 | Member    |               |
| 4 | TRICARE | edits**        | / | * | 4- | 1**       |               |
| 1 | (in     |                | N | * | 17 |           |               |
| * | cluding |                | * |   | 04 |           |               |
| * | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (6)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 70 | Member    |               |
| 4 | Other   | edits**        | / | 5 | 5- | 1**       |               |
| 2 | In      |                | N | * | 17 |           |               |
| * | surance |                | * | * | 39 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (6)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 74 | Member    |               |
| 4 | Other   | edits**        | / | 0 | 0- | 1**       |               |
| 3 | In      |                | N | * | 17 |           |               |
| * | surance |                | * | * | 69 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (6)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 77 | Member    |               |
| 4 | Home    | edits**        | / | 5 | 0- | 1**       |               |
| 4 | Street  |                | N | * | 18 |           |               |
| * | 1 (6)** |                | * | * | 04 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 80 | Member    |               |
| 4 | Home    | edits**        | / | 5 | 5- | 1**       |               |
| 5 | Street  |                | N | * | 18 |           |               |
| * | 2 (6)** |                | * | * | 39 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 84 | Member    |               |
| 4 | Home    | edits**        | / | 5 | 0- | 1**       |               |
| 6 | Street  |                | N | * | 18 |           |               |
| * | 3 (6)** |                | * | * | 74 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 87 | Member    |               |
| 4 | Home    | edits**        | / | 3 | 5- | 1**       |               |
| 7 | City    |                | N | * | 18 |           |               |
| * | (6)**   |                | * | * | 97 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 89 | Member    |               |
| 4 | Home    | edits**        | / | * | 8- | 1**       |               |
| 8 | State   |                | N | * | 18 |           |               |
| * | Abbre   |                | * |   | 99 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (6)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 90 | Member    |               |
| 4 | Home    | edits**        | / | 1 | 0- | 1**       |               |
| 9 | Zip     |                | N | * | 19 |           |               |
| * | (6)**   |                | * | * | 10 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 91 | Member    |               |
| 5 | Foreign | edits**        | / | * | 1- | 1**       |               |
| 0 | /       |                | N | * | 19 |           |               |
| * | O       |                | * |   | 11 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (6)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 91 | Member    |               |
| 5 | Member  | edits**        | / | 0 | 2- | 1**       |               |
| 1 | Last    |                | N | * | 19 |           |               |
| * | Name    |                | * | * | 31 |           |               |
| * | (7)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 93 | Member    |               |
| 5 | Member  | edits**        | / | 4 | 2- | 1**       |               |
| 2 | First   |                | N | * | 19 |           |               |
| * | Name    |                | * | * | 45 |           |               |
| * | (7)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 94 | Member    |               |
| 5 | Member  | edits**        | / | * | 6- | 1**       |               |
| 3 | Middle  |                | N | * | 19 |           |               |
| * | Initial |                | * |   | 46 |           |               |
| * | (7)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 8 | 1  | **Refer   |               |
| 5 | Family  | family member  | / |   | 94 | to Family |               |
| 4 | DOB (7) | 1 for values & | N |   | 7- | Member    |               |
|   |         | edits          |   |   | 19 | 1**       |               |
|   |         |                |   |   | 54 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 1 | 1  | **Refer   |               |
| 5 | Family  | family member  | / |   | 95 | to Family |               |
| 5 | Sex     | 1 for values & | N |   | 5- | Member    |               |
|   | Code    | edits          |   |   | 19 | 1**       |               |
|   | (7)     |                |   |   | 55 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 95 | Member    |               |
| 5 | Relat   | edits**        | / | * | 6- | 1**       |               |
| 6 | ionship |                | N | * | 19 |           |               |
| * | (7)**   |                | * |   | 57 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | N | 9 | 1  | **Refer   |               |
| 5 | Family  | family member  |   |   | 95 | to Family |               |
| 7 | SSN (7) | 1 for values & |   |   | 8- | Member    |               |
|   |         | edits          |   |   | 19 | 1**       |               |
|   |         |                |   |   | 66 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 96 | Member    |               |
| 5 | Other   | edits**        | / | * | 7- | 1**       |               |
| 8 | In      |                | N | * | 19 |           |               |
| * | surance |                | * |   | 67 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (7)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 96 | Member    |               |
| 5 | M       | edits**        | / | * | 8- | 1**       |               |
| 9 | edicare |                | N | * | 19 |           |               |
| * | In      |                | * |   | 68 |           |               |
| * | dicator |                | * |   | ** |           |               |
|   | (7)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 96 | Member    |               |
| 6 | Medi    | edits**        | / | * | 9- | 1**       |               |
| 0 | care--A |                | N | * | 19 |           |               |
| * | (7)**   |                | * |   | 69 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 97 | Member    |               |
| 6 | Medi    | edits**        | / | * | 0- | 1**       |               |
| 1 | care--B |                | N | * | 19 |           |               |
| * | (7)**   |                | * |   | 70 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 97 | Member    |               |
| 6 | TRICARE | edits**        | / | * | 1- | 1**       |               |
| 2 | (in     |                | N | * | 19 |           |               |
| * | cluding |                | * |   | 71 |           |               |
| * | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (7)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *1 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 97 | Member    |               |
| 6 | Other   | edits**        | / | 5 | 2- | 1**       |               |
| 3 | In      |                | N | * | 20 |           |               |
| * | surance |                | * | * | 06 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (7)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 00 | Member    |               |
| 6 | Other   | edits**        | / | 0 | 7- | 1**       |               |
| 4 | In      |                | N | * | 20 |           |               |
| * | surance |                | * | * | 36 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (7)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 03 | Member    |               |
| 6 | Home    | edits**        | / | 5 | 7- | 1**       |               |
| 5 | Street  |                | N | * | 20 |           |               |
| * | 1 (7)** |                | * | * | 71 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 07 | Member    |               |
| 6 | Home    | edits**        | / | 5 | 2- | 1**       |               |
| 6 | Street  |                | N | * | 21 |           |               |
| * | 2 (7)** |                | * | * | 06 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 10 | Member    |               |
| 6 | Home    | edits**        | / | 5 | 7- | 1**       |               |
| 7 | Street  |                | N | * | 21 |           |               |
| * | 3 (7)** |                | * | * | 41 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 14 | Member    |               |
| 6 | Home    | edits**        | / | 3 | 2- | 1**       |               |
| 8 | City    |                | N | * | 21 |           |               |
| * | (7)**   |                | * | * | 64 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 16 | Member    |               |
| 6 | Home    | edits**        | / | * | 5- | 1**       |               |
| 9 | State   |                | N | * | 21 |           |               |
| * | Abbre   |                | * |   | 66 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (7)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 16 | Member    |               |
| 7 | Home    | edits**        | / | 1 | 7- | 1**       |               |
| 0 | Zip     |                | N | * | 21 |           |               |
| * | (7)**   |                | * | * | 77 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 17 | Member    |               |
| 7 | Foreign | edits**        | / | * | 8- | 1**       |               |
| 1 | /       |                | N | * | 21 |           |               |
| * | O       |                | * |   | 78 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (7)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 17 | Member    |               |
| 7 | Member  | edits**        | / | 0 | 9- | 1**       |               |
| 2 | Last    |                | N | * | 21 |           |               |
| * | Name    |                | * | * | 98 |           |               |
| * | (8)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 19 | Member    |               |
| 7 | Member  | edits**        | / | 4 | 9- | 1**       |               |
| 3 | First   |                | N | * | 22 |           |               |
| * | Name    |                | * | * | 12 |           |               |
| * | (8)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 21 | Member    |               |
| 7 | Member  | edits**        | / | * | 3- | 1**       |               |
| 4 | Middle  |                | N | * | 22 |           |               |
| * | Initial |                | * |   | 13 |           |               |
| * | (8)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 8 | 2  | **Refer   |               |
| 7 | Family  | family member  | / |   | 21 | to Family |               |
| 5 | DOB (8) | 1 for values & | N |   | 4- | Member    |               |
|   |         | edits          |   |   | 22 | 1**       |               |
|   |         |                |   |   | 21 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 1 | 2  | **Refer   |               |
| 7 | Family  | family member  | / |   | 22 | to Family |               |
| 6 | Sex     | 1 for values & | N |   | 2- | Member    |               |
|   | Code    | edits          |   |   | 22 | 1**       |               |
|   | (8)     |                |   |   | 22 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 22 | Member    |               |
| 7 | Relat   | edits**        | / | * | 3- | 1**       |               |
| 7 | ionship |                | N | * | 22 |           |               |
| * | (8)**   |                | * |   | 24 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | N | 9 | 2  | **Refer   |               |
| 7 | Family  | family member  |   |   | 22 | to Family |               |
| 8 | SSN (8) | 1 for values & |   |   | 5- | Member    |               |
|   |         | edits          |   |   | 22 | 1**       |               |
|   |         |                |   |   | 33 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 23 | Member    |               |
| 7 | Other   | edits**        | / | * | 4- | 1**       |               |
| 9 | In      |                | N | * | 22 |           |               |
| * | surance |                | * |   | 34 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (8)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 23 | Member    |               |
| 8 | M       | edits**        | / | * | 5- | 1**       |               |
| 0 | edicare |                | N | * | 22 |           |               |
| * | In      |                | * |   | 35 |           |               |
| * | dicator |                | * |   | ** |           |               |
|   | (8)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 23 | Member    |               |
| 8 | Medi    | edits**        | / | * | 6- | 1**       |               |
| 1 | care--A |                | N | * | 22 |           |               |
| * | (8)**   |                | * |   | 36 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 23 | Member    |               |
| 8 | Medi    | edits**        | / | * | 7- | 1**       |               |
| 2 | care--B |                | N | * | 22 |           |               |
| * | (8)**   |                | * |   | 37 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 23 | Member    |               |
| 8 | TRICARE | edits**        | / | * | 8- | 1**       |               |
| 3 | (in     |                | N | * | 22 |           |               |
| * | cluding |                | * |   | 38 |           |               |
| * | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (8)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 23 | Member    |               |
| 8 | Other   | edits**        | / | 5 | 9- | 1**       |               |
| 4 | In      |                | N | * | 22 |           |               |
| * | surance |                | * | * | 73 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (8)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 27 | Member    |               |
| 8 | Other   | edits**        | / | 0 | 4- | 1**       |               |
| 5 | In      |                | N | * | 23 |           |               |
| * | surance |                | * | * | 03 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (8)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 30 | Member    |               |
| 8 | Home    | edits**        | / | 5 | 4- | 1**       |               |
| 6 | Street  |                | N | * | 23 |           |               |
| * | 1 (8)** |                | * | * | 38 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 33 | Member    |               |
| 8 | Home    | edits**        | / | 5 | 9- | 1**       |               |
| 7 | Street  |                | N | * | 23 |           |               |
| * | 2 (8)** |                | * | * | 73 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 3 | 37 | Member    |               |
| 8 | Home    | edits**        | / | 5 | 4- | 1**       |               |
| 8 | Street  |                | N | * | 24 |           |               |
| * | 3 (8)** |                | * | * | 08 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 40 | Member    |               |
| 8 | Home    | edits**        | / | 3 | 9- | 1**       |               |
| 9 | City    |                | N | * | 24 |           |               |
| * | (8)**   |                | * | * | 31 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 43 | Member    |               |
| 9 | Home    | edits**        | / | * | 2- | 1**       |               |
| 0 | State   |                | N | * | 24 |           |               |
| * | Abbre   |                | * |   | 33 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (8)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 43 | Member    |               |
| 9 | Home    | edits**        | / | 1 | 4- | 1**       |               |
| 1 | Zip     |                | N | * | 24 |           |               |
| * | (8)**   |                | * | * | 44 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 44 | Member    |               |
| 9 | Foreign | edits**        | / | * | 5- | 1**       |               |
| 2 | /       |                | N | * | 24 |           |               |
| * | O       |                | * |   | 45 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (8)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 44 | Member    |               |
| 9 | Member  | edits**        | / | 0 | 6- | 1**       |               |
| 3 | Last    |                | N | * | 24 |           |               |
| * | Name    |                | * | * | 65 |           |               |
| * | (9)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 46 | Member    |               |
| 9 | Member  | edits**        | / | 4 | 6- | 1**       |               |
| 4 | First   |                | N | * | 24 |           |               |
| * | Name    |                | * | * | 79 |           |               |
| * | (9)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 1 | 48 | Member    |               |
| 9 | Member  | edits**        | / | * | 0- | 1**       |               |
| 5 | Middle  |                | N | * | 24 |           |               |
| * | Initial |                | * |   | 80 |           |               |
| * | (9)**   |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 8 | 2  | **Refer   |               |
| 9 | Family  | family member  | / |   | 48 | to Family |               |
| 6 | DOB (9) | 1 for values & | N |   | 1- | Member    |               |
|   |         | edits          |   |   | 24 | 1**       |               |
|   |         |                |   |   | 88 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | Y | 1 | 2  | **Refer   |               |
| 9 | Family  | family member  | / |   | 48 | to Family |               |
| 7 | Sex     | 1 for values & | N |   | 9- | Member    |               |
|   | Code    | edits          |   |   | 24 | 1**       |               |
|   | (9)     |                |   |   | 89 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 1 | Family  | 1 for values & | Y | 2 | 49 | Member    |               |
| 9 | Relat   | edits**        | / | * | 0- | 1**       |               |
| 8 | ionship |                | N | * | 24 |           |               |
| * | (9)**   |                | * |   | 91 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 1 | FEHB    | Refer to       | N | 9 | 2  | **Refer   |               |
| 9 | Family  | family member  |   |   | 49 | to Family |               |
| 9 | SSN (9) | 1 for values & |   |   | 2- | Member    |               |
|   |         | edits          |   |   | 25 | 1**       |               |
|   |         |                |   |   | 00 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 50 | Member    |               |
| 0 | Other   | edits**        | / | * | 1- | 1**       |               |
| 0 | In      |                | N | * | 25 |           |               |
| * | surance |                | * |   | 01 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (9)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 50 | Member    |               |
| 0 | M       | edits**        | / | * | 2- | 1**       |               |
| 1 | edicare |                | N | * | 25 |           |               |
| * | In      |                | * |   | 02 |           |               |
| * | dicator |                | * |   | ** |           |               |
|   | (9)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 50 | Member    |               |
| 0 | Medi    | edits**        | / | * | 3- | 1**       |               |
| 2 | care--A |                | N | * | 25 |           |               |
| * | (9)**   |                | * |   | 03 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 50 | Member    |               |
| 0 | Medi    | edits**        | / | * | 4- | 1**       |               |
| 3 | care--B |                | N | * | 25 |           |               |
| * | (9)**   |                | * |   | 04 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 50 | Member    |               |
| 0 | TRICARE | edits**        | / | * | 5- | 1**       |               |
| 4 | (in     |                | N | * | 25 |           |               |
| * | cluding |                | * |   | 05 |           |               |
| * | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (9)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 50 | Member    |               |
| 0 | Other   | edits**        | / | 5 | 6- | 1**       |               |
| 5 | In      |                | N | * | 25 |           |               |
| * | surance |                | * | * | 40 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (9)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 54 | Member    |               |
| 0 | Other   | edits**        | / | 0 | 1- | 1**       |               |
| 6 | In      |                | N | * | 25 |           |               |
| * | surance |                | * | * | 70 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (9)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 57 | Member    |               |
| 0 | Home    | edits**        | / | 5 | 1- | 1**       |               |
| 7 | Street  |                | N | * | 26 |           |               |
| * | 1 (9)** |                | * | * | 05 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 60 | Member    |               |
| 0 | Home    | edits**        | / | 5 | 6- | 1**       |               |
| 8 | Street  |                | N | * | 26 |           |               |
| * | 2 (9)** |                | * | * | 40 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 64 | Member    |               |
| 0 | Home    | edits**        | / | 5 | 1- | 1**       |               |
| 9 | Street  |                | N | * | 26 |           |               |
| * | 3 (9)** |                | * | * | 75 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 2 | 67 | Member    |               |
| 1 | Home    | edits**        | / | 3 | 6- | 1**       |               |
| 0 | City    |                | N | * | 26 |           |               |
| * | (9)**   |                | * | * | 98 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 2 | 69 | Member    |               |
| 1 | Home    | edits**        | / | * | 9- | 1**       |               |
| 1 | State   |                | N | * | 27 |           |               |
| * | Abbre   |                | * |   | 00 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (9)**   |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 70 | Member    |               |
| 1 | Home    | edits**        | / | 1 | 1- | 1**       |               |
| 2 | Zip     |                | N | * | 27 |           |               |
| * | (9)**   |                | * | * | 11 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 71 | Member    |               |
| 1 | Foreign | edits**        | / | * | 2- | 1**       |               |
| 3 | /       |                | N | * | 27 |           |               |
| * | O       |                | * |   | 12 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (9)**   |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 2 | 71 | Member    |               |
| 1 | Member  | edits**        | / | 0 | 3- | 1**       |               |
| 4 | Last    |                | N | * | 27 |           |               |
| * | Name    |                | * | * | 32 |           |               |
| * | (10)**  |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 73 | Member    |               |
| 1 | Member  | edits**        | / | 4 | 3- | 1**       |               |
| 5 | First   |                | N | * | 27 |           |               |
| * | Name    |                | * | * | 46 |           |               |
| * | (10)**  |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 74 | Member    |               |
| 1 | Member  | edits**        | / | * | 7- | 1**       |               |
| 6 | Middle  |                | N | * | 27 |           |               |
| * | Initial |                | * |   | 47 |           |               |
| * | (10)**  |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Refer to       | Y | 8 | 2  | **Refer   |               |
| 1 | Family  | family member  | / |   | 74 | to Family |               |
| 7 | DOB     | 1 for values & | N |   | 8- | Member    |               |
|   | (10)    | edits          |   |   | 27 | 1**       |               |
|   |         |                |   |   | 55 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Refer to       | Y | 1 | 2  | **Refer   |               |
| 1 | Family  | family member  | / |   | 75 | to Family |               |
| 8 | Sex     | 1 for values & | N |   | 6- | Member    |               |
|   | Code    | edits          |   |   | 27 | 1**       |               |
|   | (10)    |                |   |   | 56 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 2 | 75 | Member    |               |
| 1 | Relat   | edits**        | / | * | 7- | 1**       |               |
| 9 | ionship |                | N | * | 27 |           |               |
| * | (10)**  |                | * |   | 58 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Refer to       | N | 9 | 2  | **Refer   |               |
| 2 | Family  | family member  |   |   | 75 | to Family |               |
| 0 | SSN     | 1 for values & |   |   | 9- | Member    |               |
|   | (10)    | edits          |   |   | 27 | 1**       |               |
|   |         |                |   |   | 67 |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 76 | Member    |               |
| 2 | Other   | edits**        | / | * | 8- | 1**       |               |
| 1 | In      |                | N | * | 27 |           |               |
| * | surance |                | * |   | 68 |           |               |
| * | In      |                | * |   | ** |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (10)**  |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 76 | Member    |               |
| 2 | M       | edits**        | / | * | 9- | 1**       |               |
| 2 | edicare |                | N | * | 27 |           |               |
| * | In      |                | * |   | 69 |           |               |
| * | dicator |                | * |   | ** |           |               |
|   | (10)**  |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 77 | Member    |               |
| 2 | Medi    | edits**        | / | * | 0- | 1**       |               |
| 3 | care--A |                | N | * | 27 |           |               |
| * | (10)**  |                | * |   | 70 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 77 | Member    |               |
| 2 | Medi    | edits**        | / | * | 1- | 1**       |               |
| 4 | care--B |                | N | * | 27 |           |               |
| * | (10)**  |                | * |   | 71 |           |               |
| * |         |                | * |   | ** |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 77 | Member    |               |
| 2 | TRICARE | edits**        | / | * | 2- | 1**       |               |
| 5 | (in     |                | N | * | 27 |           |               |
| * | cluding |                | * |   | 72 |           |               |
| * | C       |                | * |   | ** |           |               |
|   | HAMPUS) |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (10)**  |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 77 | Member    |               |
| 2 | Other   | edits**        | / | 5 | 3- | 1**       |               |
| 6 | In      |                | N | * | 28 |           |               |
| * | surance |                | * | * | 07 |           |               |
| * | Name    |                | * |   | ** |           |               |
|   | (10)**  |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 80 | Member    |               |
| 2 | Other   | edits**        | / | 0 | 8- | 1**       |               |
| 7 | In      |                | N | * | 28 |           |               |
| * | surance |                | * | * | 37 |           |               |
| * | Policy  |                | * |   | ** |           |               |
|   | Number  |                |   |   |    |           |               |
|   | (10)**  |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 83 | Member    |               |
| 2 | Home    | edits**        | / | 5 | 8- | 1**       |               |
| 8 | Street  |                | N | * | 28 |           |               |
| * | 1 (10)  |                | * | * | 72 |           |               |
| * | *If     |                | * |   | ** |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 1***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 87 | Member    |               |
| 2 | Home    | edits**        | / | 5 | 3- | 1**       |               |
| 9 | Street  |                | N | * | 29 |           |               |
| * | 2 (10)  |                | * | * | 07 |           |               |
| * | *If     |                | * |   | ** |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 2***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 3 | 90 | Member    |               |
| 3 | Home    | edits**        | / | 5 | 8- | 1**       |               |
| 0 | Street  |                | N | * | 29 |           |               |
| * | 3 (10)  |                | * | * | 42 |           |               |
| * | *If     |                | * |   | ** |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Street  |                |   |   |    |           |               |
|   | 3***    |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 2 | 94 | Member    |               |
| 3 | Home    | edits**        | / | 3 | 3- | 1**       |               |
| 1 | City    |                | N | * | 29 |           |               |
| * | (10)**  |                | * | * | 65 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | City    |                |   |   |    |           |               |
|   | Name*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 2 | 96 | Member    |               |
| 3 | Home    | edits**        | / | * | 6- | 1**       |               |
| 2 | State   |                | N | * | 29 |           |               |
| * | Abbre   |                | * |   | 67 |           |               |
| * | viation |                | * |   | ** |           |               |
|   | (10)**  |                |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Country |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 96 | Member    |               |
| 3 | Home    | edits**        | / | 1 | 8- | 1**       |               |
| 3 | Zip     |                | N | * | 29 |           |               |
| * | (10)**  |                | * | * | 78 |           |               |
| * |         |                | * |   | ** |           |               |
|   | ***If   |                |   |   |    |           |               |
|   | F       |                |   |   |    |           |               |
|   | oreign, |                |   |   |    |           |               |
|   | Foreign |                |   |   |    |           |               |
|   | Postal  |                |   |   |    |           |               |
|   | Code*** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| * | *       | **Refer to     | * | * | *  | **Refer   |               |
| * | *\*FEHB | family member  | * | * | *2 | to Family |               |
| 2 | Family  | 1 for values & | Y | 1 | 97 | Member    |               |
| 3 | Foreign | edits**        | / | * | 9- | 1**       |               |
| 4 | /       |                | N | * | 29 |           |               |
| * | O       |                | * |   | 79 |           |               |
| * | verSeas |                | * |   | ** |           |               |
|   | Address |                |   |   |    |           |               |
|   | In      |                |   |   |    |           |               |
|   | dicator |                |   |   |    |           |               |
|   | (10)**  |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Values: FEHB   | Y | 3 | 2  | **HD04,   | Must be       |
| 3 | Present | enrollment     |   |   | 98 | 1204, Pg. | PRESENT when  |
| 5 | Enr     | code the       |   |   | 0- | 130**     | (Nature of    |
|   | ollment | employee or    |   |   | 29 |           | Transaction = |
|   | Code    | annuitant is   |   |   | 82 | **Second  | \"STOP\")     |
|   |         | currently      |   |   |    | 10 bytes. |               |
|   |         | enrolled in    |   |   |    | Pad left  | **OR**        |
|   |         |                |   |   |    | with      |               |
|   |         | Edits: Blank   |   |   |    | zeroes.   | (Nature of    |
|   |         | for Starts     |   |   |    | Will be   | Transaction = |
|   |         |                |   |   |    | the       | \"CHANGE\")   |
|   |         | Edits:         |   |   |    | second    |               |
|   |         | REQUIRED valid |   |   |    | element   |               |
|   |         | code for       |   |   |    | in the    |               |
|   |         | Stops, Changes |   |   |    | free form |               |
|   |         |                |   |   |    | field.**  |               |
|   |         | Example: 451   |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | FEHB    | Values: Blank, | # | 2 | 2  | **HD04,   |               |
| 3 | Event   | 1B, 2A, 1C     | # |   | 98 | 1204, Pg. |               |
| 6 | Code    | etc. depending | # |   | 3- | 130**     |               |
|   |         | on the time of | # |   | 29 |           |               |
|   |         | year and type  | # |   | 84 | **Will be |               |
|   |         | of action      | # |   |    | the third |               |
|   |         |                |   |   |    | element   |               |
|   |         | Edits: Refer   | Y |   |    | in the    |               |
|   |         | to current     |   |   |    | free form |               |
|   |         | FEHB           |   |   |    | field.**  |               |
|   |         | documentation  |   |   |    |           |               |
|   |         | for various    |   |   |    |           |               |
|   |         | Event Codes,   |   |   |    |           |               |
|   |         | and see the    |   |   |    |           |               |
|   |         | Field          |   |   |    |           |               |
|   |         | Descriptions   |   |   |    |           |               |
|   |         | in this        |   |   |    |           |               |
|   |         | document for   |   |   |    |           |               |
|   |         | more details   |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Premium | Values: The    | Y | 8 | 2  | **Will    |               |
| 3 | Ef      | date Payroll   |   |   | 98 | not       |               |
| 7 | fective | or Annuity     |   |   | 5- | map.**    |               |
|   | Date    | Deduction      |   |   | 29 |           |               |
|   |         | changes take   |   |   | 92 |           |               |
|   | **@     | effect.        |   |   |    |           |               |
|   | Used by |                |   |   |    |           |               |
|   | Agency  | Edits:         |   |   |    |           |               |
|   | Payroll | MMDDYYYY       |   |   |    |           |               |
|   | systems |                |   |   |    |           |               |
|   | or      | Example:       |   |   |    |           |               |
|   | Annui   | 01112004       |   |   |    |           |               |
|   | tants** |                |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | C       | Values: The    | Y | 8 | 2  | *         | REJECT if not |
| 3 | overage | date the       |   |   | 99 | *START:** | present or    |
| 8 | Ef      | requested      |   |   | 3- |           | invalid date  |
|   | fective | Coverage       |   |   | 30 | **DTP01,  |               |
|   | Date    | changes take   |   |   | 00 | 374, Pg.  |               |
|   |         | effect         |   |   |    | 132/133 = |               |
|   | **@     |                |   |   |    | '348'**   |               |
|   | Used by | Edits:         |   |   |    |           |               |
|   | Car     | MMDDYYYY       |   |   |    | **DTP02,  |               |
|   | riers** |                |   |   |    | 1250, Pg. |               |
|   |         | Example:       |   |   |    | 133 =     |               |
|   |         | 01112004       |   |   |    | 'D8'**    |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP03,  |               |
|   |         |                |   |   |    | 1251, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | c         |               |
|   |         |                |   |   |    | cyymmdd** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **CHANG   |               |
|   |         |                |   |   |    | E-Gaining |               |
|   |         |                |   |   |    | Carrier** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP01,  |               |
|   |         |                |   |   |    | 374, Pg.  |               |
|   |         |                |   |   |    | 132/133 = |               |
|   |         |                |   |   |    | '348'**   |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP02,  |               |
|   |         |                |   |   |    | 1250, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | 'D8'**    |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP03,  |               |
|   |         |                |   |   |    | 1251, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | c         |               |
|   |         |                |   |   |    | cyymmdd** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **CHAN    |               |
|   |         |                |   |   |    | GE-Losing |               |
|   |         |                |   |   |    | Carrier** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP01,  |               |
|   |         |                |   |   |    | 374, Pg.  |               |
|   |         |                |   |   |    | 132/133 = |               |
|   |         |                |   |   |    | '349'**   |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP02,  |               |
|   |         |                |   |   |    | 1250, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | 'D8'**    |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP03,  |               |
|   |         |                |   |   |    | 1251, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | c         |               |
|   |         |                |   |   |    | cyymmdd** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **CHAN    |               |
|   |         |                |   |   |    | GE-Within |               |
|   |         |                |   |   |    | a Plan:** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP01,  |               |
|   |         |                |   |   |    | 374, Pg.  |               |
|   |         |                |   |   |    | 132/133 = |               |
|   |         |                |   |   |    | '303'**   |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP02,  |               |
|   |         |                |   |   |    | 1250, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | 'D8'**    |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP03,  |               |
|   |         |                |   |   |    | 1251, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | c         |               |
|   |         |                |   |   |    | cyymmdd** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **STOP:** |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP01,  |               |
|   |         |                |   |   |    | 374, Pg.  |               |
|   |         |                |   |   |    | 132/133 = |               |
|   |         |                |   |   |    | '349'**   |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP02,  |               |
|   |         |                |   |   |    | 1250, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | 'D8'**    |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP03,  |               |
|   |         |                |   |   |    | 1251, Pg. |               |
|   |         |                |   |   |    | 133 =     |               |
|   |         |                |   |   |    | c         |               |
|   |         |                |   |   |    | cyymmdd** |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Date of | Values: The    | Y | 8 | 3  | **DTP01,  |               |
| 3 | Action  | date of this   |   |   | 00 | 374, Pg.  |               |
| 9 |         | election       |   |   | 1- | 59 =      |               |
|   |         |                |   |   | 30 | '300'**   |               |
|   |         | Edits:         |   |   | 08 |           |               |
|   |         | MMDDYYYY       |   |   |    | **DTP02,  |               |
|   |         |                |   |   |    | 1250, Pg. |               |
|   |         | Example:       |   |   |    | 60 =      |               |
|   |         | 12012003       |   |   |    | 'D8'**    |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **DTP03,  |               |
|   |         |                |   |   |    | 1251, Pg. |               |
|   |         |                |   |   |    | 60 =      |               |
|   |         |                |   |   |    | c         |               |
|   |         |                |   |   |    | cyymmdd** |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Time of | Values: The    | Y | 6 | 3  | **Will    |               |
| 4 | Action  | time of this   |   |   | 00 | not       |               |
| 0 |         | election       |   |   | 9- | map.**    |               |
|   |         |                |   |   | 30 |           |               |
|   |         | Edits: HHMMSS, |   |   | 14 |           |               |
|   |         | 24 hour time   |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Example:       |   |   |    |           |               |
|   |         | 162206         |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | CPDF    | Values: Valid  | Y | 4 | 3  | **Will    |               |
| 4 | Agency  | Federal CPDF   |   |   | 01 | not       |               |
| 1 | Code    | code for the   |   |   | 5- | map.**    |               |
|   |         | agency the     |   |   | 30 |           |               |
|   |         | employee is    |   |   | 18 |           |               |
|   |         | serviced by.   |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Edits:         |   |   |    |           |               |
|   |         | Annuitants     |   |   |    |           |               |
|   |         | ONLY will pass |   |   |    |           |               |
|   |         | 0000           |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Example: OM00  |   |   |    |           |               |
|   |         | for OPM        |   |   |    |           |               |
|   |         | employees      |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Pe      | Values: Valid  | Y | 8 | 3  | **REF01,  | Sent only in  |
| 4 | rsonnel | Federal        |   |   | 01 | 128, Pg.  | Subscriber    |
| 2 | Office  | Personnel      |   |   | 9- | 55 =      | loop.         |
|   | ID      | Office ID      |   |   | 30 | '17'**    |               |
|   |         |                |   |   | 26 |           | Will not be   |
|   |         | Edits:         |   |   |    | **REF02,  | sent in       |
|   |         | Annuitants     |   |   |    | 127, P.   | Dependent     |
|   |         | ONLY will pass |   |   |    | 56**      | loops.        |
|   |         | 24900002       |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Payroll | Values: Valid  | Y | 8 | 3  | **REF01,  | Sent in       |
| 4 | Office  | Federal        |   |   | 02 | 128, Pg.  | Subscriber    |
| 3 | Number  | Payroll Office |   |   | 7- | 55/56 =   | **AND**       |
|   |         | Number         |   |   | 30 | 'DX'**    | Dependent     |
|   |         |                |   |   | 34 |           | loops.        |
|   |         | Edits:         |   |   |    | **REF02,  |               |
|   |         | Annuitants     |   |   |    | 127, Pg.  | REJECT if not |
|   |         | ONLY will pass |   |   |    | 56**      | present       |
|   |         | 24900002 for   |   |   |    |           |               |
|   |         | all actions.   |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Annuity | Values: Valid  | Y | 9 | 3  | **REF01,  | Sent only in  |
| 4 | Claim   | Annuitant      | \ |   | 03 | 128, Pg.  | Subscriber    |
| 4 | Number  | Claim Number   | \ |   | 5- | 55 =      | loop.         |
|   |         |                | N |   | 30 | '23'**    |               |
|   |         | Edits:         |   |   | 43 |           | Will not be   |
|   |         | REQUIRED for   |   |   |    | **REF02,  | sent in       |
|   |         | annuitants     |   |   |    | 127, Pg.  | Dependent     |
|   |         | Only           |   |   |    | 56**      | loops.        |
|   |         |                |   |   |    |           |               |
|   |         | Edits: All     |   |   |    |           | Must be       |
|   |         | other          |   |   |    |           | PRESENT when  |
|   |         | agencies,      |   |   |    |           | Report# =     |
|   |         | blank          |   |   |    |           | OEOPM         |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | HB      | Values: SSN of | Y | 9 | 3  | **REF01,  | Sent only in  |
| 4 | Identif | the original   | \ |   | 04 | 128, Pg.  | Subscriber    |
| 5 | ication | enrollee in    | \ |   | 4- | 55 =      | loop.         |
|   | Number  | this FEHB plan | N |   | 30 | '6O'**    |               |
|   |         |                |   |   | 52 |           | Will not be   |
|   |         | Edits:         |   |   |    | **REF02,  | sent in       |
|   |         | REQUIRED for   |   |   |    | 127, Pg.  | Dependent     |
|   |         | annuitants     |   |   |    | 56**      | loops.        |
|   |         | Only           |   |   |    |           |               |
|   |         |                |   |   |    |           | Must be       |
|   |         | Edits: All     |   |   |    |           | PRESENT when  |
|   |         | other          |   |   |    |           | Report# =     |
|   |         | agencies,      |   |   |    |           | OEOPM         |
|   |         | blank          |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Fo      | Values: Y/N    | Y | 1 | 3  | **Will    | If blank,     |
| 4 | reign/O |                | / |   | 05 | not map** | assume a      |
| 6 | verSeas | Edits: Y       | N |   | 3- |           | \"N\"         |
|   | Address | indicates that |   |   | 30 |           |               |
|   | In      | the employee   |   |   | 53 |           |               |
|   | dicator | has a foreign  |   |   |    |           |               |
|   |         | home address   |   |   |    |           |               |
|   |         | (not an        |   |   |    |           |               |
|   |         | APO/FPO        |   |   |    |           |               |
|   |         | address).      |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Edits: N       |   |   |    |           |               |
|   |         | indicates that |   |   |    |           |               |
|   |         | the employee   |   |   |    |           |               |
|   |         | has a US       |   |   |    |           |               |
|   |         | address, which |   |   |    |           |               |
|   |         | includes       |   |   |    |           |               |
|   |         | APO/FPO        |   |   |    |           |               |
|   |         | addresses and  |   |   |    |           |               |
|   |         | US             |   |   |    |           |               |
|   |         | Territories.   |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Report  | Values:        | # | 1 | 3  | **REF01,  | Sent only in  |
| 4 | Number  | Agencies leave | # | 5 | 05 | 128, Pg.  | Subscriber    |
| 7 |         | blank, further | # |   | 4- | 55 =      | loop.         |
|   |         | descriptions   | # |   | 30 | 'ZZ'**    |               |
|   |         | included in    | # |   | 68 |           | Will not be   |
|   |         | the Field      | # |   |    | **REF02,  | sent in       |
|   |         | Descriptions   |   |   |    | 127, Pg.  | Dependent     |
|   |         | portion of     | N |   |    | 55**      | loops.        |
|   |         | this document  |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Edits:         |   |   |    |           |               |
|   |         | Generated by   |   |   |    |           |               |
|   |         | OPM-Macon      |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | O       | Values: Used   | # | 2 | 3  | **NM101,  | Sent in       |
| 4 | riginal | [ONL           | # | 0 | 06 | 98, Pg.   | Subscriber    |
| 8 | E       | Y]{.underline} | # |   | 9- | 115/116 = | **AND**       |
|   | mployee | by DPRS        | # |   | 30 | \'QD\'**  | Dependent     |
|   | Last    |                | # |   | 88 |           | loops.        |
|   | Name    | Edits: No      | # |   |    | **NM102,  |               |
|   |         | punctuation    |   |   |    | 1065, Pg. |               |
|   |         |                | N |   |    | 116 =     |               |
|   |         | Example:       |   |   |    | \'1\'**   |               |
|   |         | JOHNSON JR     |   |   |    |           |               |
|   |         |                |   |   |    | **NM103,  |               |
|   |         | Justification: |   |   |    | 1035, Pg. |               |
|   |         | LEFT           |   |   |    | 116**     |               |
|   |         |                |   |   |    |           |               |
|   |         |                |   |   |    | **Re      |               |
|   |         |                |   |   |    | sponsible |               |
|   |         |                |   |   |    | Person    |               |
|   |         |                |   |   |    | Loop for  |               |
|   |         |                |   |   |    | person in |               |
|   |         |                |   |   |    | Field     |               |
|   |         |                |   |   |    | #3-#5**   |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | O       | Values: Used   | # | 1 | 3  | **NM104,  | Sent in       |
| 4 | riginal | [ONL           | # | 5 | 08 | 1036, Pg. | Subscriber    |
| 9 | E       | Y]{.underline} | # |   | 9- | 116**     | **AND**       |
|   | mployee | by DPRS        | # |   | 31 |           | Dependent     |
|   | First   |                | # |   | 03 |           | loops.        |
|   | Name    | Edits: No      | # |   |    |           |               |
|   |         | punctuation    |   |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         | Example:       |   |   |    |           |               |
|   |         | WILLIAM        |   |   |    |           |               |
|   |         |                |   |   |    |           |               |
|   |         | Justification: |   |   |    |           |               |
|   |         | LEFT           |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | O       | Values: Used   | # | 1 | 3  | **NM105,  | Sent in       |
| 5 | riginal | [ONL           | # |   | 10 | 1037, Pg. | Subscriber    |
| 0 | E       | Y]{.underline} | # |   | 4- | 116**     | **AND**       |
|   | mployee | by DPRS        | # |   | 31 |           | Dependent     |
|   | Middle  |                | # |   | 04 |           | loops.        |
|   | Initial | Edits: No      | # |   |    |           |               |
|   |         | punctuation    |   |   |    |           |               |
|   |         |                | N |   |    |           |               |
|   |         | Example: R     |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | O       | Values: Used   | # | 9 | 3  | **NM108,  | Sent in       |
| 5 | riginal | [ONL           | # |   | 10 | 66, Pg.   | Subscriber    |
| 1 | E       | Y]{.underline} | # |   | 5- | 117 =     | **AND**       |
|   | mployee | by DPRS        | # |   | 31 | \'34\'**  | Dependent     |
|   | Social  |                | # |   | 13 |           | loops.        |
|   | S       | Edits: No      | # |   |    | **NM109,  |               |
|   | ecurity | dashes         |   |   |    | 67, Pg.   |               |
|   | Number  |                | N |   |    | 117**     |               |
|   |         | Example:       |   |   |    |           |               |
|   |         | 123456789      |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+
| 2 | Exp     | Values: Used   | # | 8 | 3  | **DTP01,  | REJECT if not |
| 5 | iration | [ONL           | # |   | 11 | 374, Pg.  | present       |
| 2 | Date    | Y]{.underline} | # |   | 4- | 59 =      | **[AND]{      |
|   |         | by DPRS        | # |   | 31 | \'357\'** | .underline}** |
|   |         |                | # |   | 21 |           | Payroll       |
|   |         | Values:        | # |   |    | **DTP02,  | Office Number |
|   |         | '12319999' for |   |   |    | 1250, Pg. | (field #243)  |
|   |         | Spouse Equity  | N |   |    | 60 =      | =             |
|   |         |                |   |   |    | \'D8\'**  | \'24777777\'  |
|   |         | Values:        |   |   |    |           |               |
|   |         | \'mmddyyyy\'   |   |   |    | **DTP03,  | Sent in       |
|   |         | for Temporary  |   |   |    | 1251, Pg. | Subscriber    |
|   |         | Continuation   |   |   |    | 60 =      | **AND**       |
|   |         | of Coverage    |   |   |    | c         | Dependent     |
|   |         | (TCC)          |   |   |    | cyymmdd** | loops.        |
|   |         |                |   |   |    |           |               |
|   |         | Edits:         |   |   |    | **Map for |               |
|   |         | MMDDYYYY       |   |   |    | person in |               |
|   |         |                |   |   |    | Fields    |               |
|   |         | Example:       |   |   |    | #3-#5**   |               |
|   |         | 05032004       |   |   |    |           |               |
+---+---------+----------------+---+---+----+-----------+---------------+

***[Required 834 fields not specific to the flat file EEX/Data-Hub 2809
layout]{.underline}***

**Sponsor Name (Loop 1000A, Pg. 35)**

N101, 98, Pg. 35 = \'P5\'

N103, 66, Pg. 36 = \'ZZ\'

N104, 67, Pg. 36 = \'AGENCY\'

**Payer (Loop 1000B, Pg. 37)**

N101, 98, Pg. 37 = \'IN\'

N103, 66, Pg. 38 = \'FI\'

N104, 67, Pg. 38 = FEHB Carriers\' Federal Taxpayer ID will be
crosswalked between the FEHB carrier code and their Federal Taxpayer ID

**[MISCELLANEOUS]{.underline}**

### Benefit Status Code

### INS05, 1216, Pg. 47 = 'A' (Active)

### 

### Employment Status Code

### INS08, 584, Pg. 49

'FT' = Full-Time (All records except 'OEOPM' records)

'RT' = Retired (Report field 'OEOPM' records)

\'RT\' = Retired (If Payroll Office ID = \'24900003\' or \'24900002\')

**Member Policy Number**

REF01, 128, Pg. 53 = \'1l\'

REF02, 127, Pg. 53 = \'FEHB\'

**Mapping of EEX/Data-Hub Nature of Transaction Field to the 834**

> **OLD FORMAT 834 FORMAT**

+--------+-----------------------------+---+----+----+----+----+-------+
| **Tr   | **Nature of Transaction**   |   | *  | *  | ** | ** | **H   |
| ansmis |                             |   | *I | *I | HD | HD | DO4** |
| sion** |                             |   | NS | NS | O1 | O3 |       |
|        |                             |   | O3 | O4 | ** | ** |       |
|        |                             |   | ** | ** |    |    |       |
+--------+-----------------------------+---+----+----+----+----+-------+
| ***St  | **An individual not         |   | *  | ** | *  | *  | **En  |
| art*** | previously enrolled,        |   | *0 | 28 | *0 | *H | rollm |
|        | enrolls. The plan he/she    |   | 21 | ** | 21 | LT | ent** |
|        | selects receives a *Sta*rt  |   | ** |    | ** | ** |       |
|        | transmission.**             |   |    |    |    |    | **    |
|        |                             |   |    |    |    |    | Codes |
|        |                             |   |    |    |    |    | &     |
|        |                             |   |    |    |    |    | Event |
|        |                             |   |    |    |    |    | C     |
|        |                             |   |    |    |    |    | ode** |
+--------+-----------------------------+---+----+----+----+----+-------+
| ***Ch  | **A subscriber enrolled in  |   | *  | ** | *  | *  | **En  |
| ange-G | one plan (BC/BS) switches   |   | *0 | 22 | *0 | *H | rollm |
| aining | to another plan (Aetna).    |   | 21 | ** | 21 | LT | ent** |
| Carr   | The gaining plan (Aetna)    |   | ** |    | ** | ** |       |
| ier*** | received a *Change*         |   |    |    |    |    | **    |
|        | transmission.**             |   |    |    |    |    | Codes |
|        |                             |   |    |    |    |    | &     |
|        |                             |   |    |    |    |    | Event |
|        |                             |   |    |    |    |    | C     |
|        |                             |   |    |    |    |    | ode** |
+--------+-----------------------------+---+----+----+----+----+-------+
| ***C   | **A subscriber enrolled in  |   | *  | ** | *  | *  | **En  |
| hange- | one plan (BC/BS) switches   |   | *0 | 22 | *0 | *H | rollm |
| Losing | to another plan (Aetna).    |   | 24 | ** | 24 | LT | ent** |
| Carr   | The losing plan (BC/BS)     |   | ** |    | ** | ** |       |
| ier*** | receives a *Change*         |   |    |    |    |    | **    |
|        | transmission.**             |   |    |    |    |    | Codes |
|        |                             |   |    |    |    |    | &     |
|        |                             |   |    |    |    |    | Event |
|        |                             |   |    |    |    |    | C     |
|        |                             |   |    |    |    |    | ode** |
+--------+-----------------------------+---+----+----+----+----+-------+
| ***C   | **A subscriber switches     |   | *  | ** | *  | *  | **En  |
| hange- | his/her enrollment type     |   | *0 | 29 | *0 | *H | rollm |
| Within | (self to self and family or |   | 01 | ** | 01 | LT | ent** |
| a      | vice versa) or plan option  |   | ** |    | ** | ** |       |
| P      | (high to standard or vice   |   |    |    |    |    | **    |
| lan*** | versa) within a plan.**     |   |    |    |    |    | Codes |
|        |                             |   |    |    |    |    | &     |
|        |                             |   |    |    |    |    | Event |
|        |                             |   |    |    |    |    | C     |
|        |                             |   |    |    |    |    | ode** |
+--------+-----------------------------+---+----+----+----+----+-------+
| ***S   | **A subscriber cancels his  |   | *  | ** | *  | *  | **00  |
| top*** | enrollment. The plan he/she |   | *0 | 14 | *0 | *H | 00000 |
|        | was enrolled in receives a  |   | 24 | ** | 24 | LT | 000** |
|        | *Stop* transmission.**      |   | ** |    | ** | ** |       |
|        |                             |   |    |    |    |    | (10   |
|        |                             |   |    |    |    |    | ze    |
|        |                             |   |    |    |    |    | roes) |
+--------+-----------------------------+---+----+----+----+----+-------+

Coding Constants: HD03 will always be "HLT"

> HD04 will always include 10 characters for the gaining carrier, 10
> characters for the losing carrier and 2 characters for the event. This
> would also allow for expanse of enrollment code.

-   Exception to above: In *Stop 1*, HD04 will be 10 zeroes (000000000)