[104-10194-10015.pdf — page 38]
If typewriter is not available, bear down with ballpoint pen to make legible copies.# HEALTH BENEFITS REGISTRATION FORMFEDERAL EMPLOYEES HEALTH BENEFITS PROGNew Carrier's Control No.11252435Old Carrier's Control Na.# PART A1. NAME(LAST) Tarasoff,(FIRST) Anna(MIDDLE IN TIAL) A.2. DATE OF BIRTH(MONTH) (DAY) (YEAR)3. ARE YOU NOW MARRIED?YESNOALL WHO REGISTER MUST FILL IN THIS PART.4. YOUR MAILING ADDRESS(NUMBER AND STREET) (CITY) (STATE) (ZIP CODE) 5. SEXMALEFEMALEIMPORTANTIT IS ILLEGAL FOR AN EMPLOYEE OR A MEMBER OF HIS FAMILY TO BE COVERED UNDER MORE THAN ONE ENROLLMENT. IF YOU ARE ALREADY COVERED THROUGH THE ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOUR MUST REGISTER NOT TO ENROLL OF THE OTHER ENROLLMENT MUST BE CANCELLED OR CHANGED TO SO STATE. SIMILARLY, IF A FAMILY MEMBER LISTED BY YOU IN PART B IS COVERED THROUGH HIS (OR HER) OWN ENROLLMENT, YOU CANNOT ELECT A FAMILY ENROLLMENT UNLESS THE FAMILY MEMBER CANCELS HIS (OR HER) ENROLLMENT.# PART Bfill out a health benefits plan on shown below. I authorize deductions from my salary, compensation, or annuity to cover my share of the cost of the plan you select).(Keep this information requested below from back page of brochure of the plan you select)FILL IN THIS PART IF YOU WISH TO ENROLL OR CHANGE YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN.OPTION (HIGH OR LOW)ENROLLMENT CODE NUMBER1. NAME OF PLAN2. In space below list all eligible family members without exception. List your wife or husband first, then your unmarried children under age 22, including (a) legally adopted children and (b) stepchildren, foster children, and illegitimate children who live with you in a regular parent-child relationship; include also any unmarried child over 22 who became disabled before age 22 and who is incapable of self-support. DO NOT LIST PARENTS OR OTHERS WHO ARE NOT ELIGIBLE FAMILY MEMBERS. THEY WILL NOT RECEIVE BENEFITS, EVEN IF THEY ARE DEPENDENT ON YOU AND ARE LISTED.NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)Husband# PART CPLACE AN "X" IN ITEM 1 OR 2, WHICHEVER APPLIESFILL IN THIS PART IF YOU WISH NOT TO ENROLL OR IF YOU WISH TO CANCEL YOUR ENROLLMENT.1. I ELECT NOT TO ENROLL IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAMCovered on hush's policy2. I ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THE CODE NUMBER SHOWN BELOWPresent Enrollment Code Number# PART DANSWER ITEMS 1, 2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE.FILL IN THIS PART AS WELL AS PART B, TO CHANGE YOUR ENROLLMENT.1. ENROLLMENT CODE NUMBER OF PRESENT PLAN2. NUMBER OF EVENT WHICH PERMITS CHANGE. (See table on back of duplicate for proper number.)3. DATE OF EVENT WHICH PERMITS CHANGE.MONTH DAY YEAR# PART ENorma Sue Carpenter forALL WHO REGISTER MUST FILL IN THIS PART.Anna A. Tarasoff(YOUR SIGNATURE - DO NOT PRINT)12-28-67(DATE)1 NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICE# PART FTO BE COMPLETED BY AGENCY.WARNING. - Any Intentional false statement In this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000 or Imprisonment of not more than 5 years, or both. (18 U.S.C. 1001.)2. DATE RECEIVED IN EMPLOYING OFFICE3. EFFECTIVE DATE OF ELECTION12-28-6712-31-674. PAYROLL OFFICE NO.5. SF 2811 REPORT NO.# REMARKSFOR USE ONLY BY AGENCY.Contract Emp.9-8-67WT!5132830Triplicate-For Official Personnel Folder