[104-10195-10003.pdf — page 92]
# ALTH BENEFITS REGISTRATION FC 1 6781FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959(Read Instructions on back of last page Use only typewriter or ballpoint pen)PART AALL WHOREGISTERMUST FILLIN THISPART.1.  NAME (LAST)Wilcott4. YOUR MAILING ADDRESS(NUMBER AND STREET)(FIRST)James(MIDDLE INITIAL)D., Jr.(CITY AND ZONE NUMBER)2. DATE OF BIRTHMONTH DAY YEAR9 27 31(STATE)CADRES CONTROL NO0781283. Are you now married?YESNO5. SEXMALEFEMALE6. Are you covered by, or is any family member listed below cov- 7. Place an "X" in proper box to show your annual basic salary   ered be- enrolling in, a plan under the Federal Employees range.   Health Benefits Act of 1959 (through the enrollment of another   United States or District of Columbia Government employee or   annuitant?YES NOUNDER $4,000$4,000 TO $9,999$8,000 TO $9,999$10,000 OR OVERPART BFILL IN THISPARTWISH TO-EN-ROLL IN AHEALTH BENEFITSPLAN.1.  I elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity    to cover my share of the cost of the enrollment. (Copy the information requested below from inside cover of brochure of the plan you select)NAME OF PLANOPTION (HIGH OR LOW)ENROLLMENT CODE NUMBERAssociation BenefitLowIf enrollment is for self only, answer item 1.If enrollment is for self and family, also answer item 2 and item 3 if it applies.2.  In order to en- list all eligible fa- members without exception: List your wife or husband first, then your unmarried children under    age 19, including legally adopted children, and stepchildren and illegitimate children who live with you in a regular parent-child relation-    ship. Include also any unmarried child over 19 who became disabled before age 19 and who, because of the disability, is incapable    of self-support. (Attach a doctor's certificate for a disability at said age 19 or over.)NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)Wife orHusbandElsie Louise9 9 31Steven James (son)2 16 59THIS PART MUSTALSO BE FILLEDIN IF YOUCHANGE YOURENROLLMENT.3. If you are a female (employee or annuitant) - does the family listed above include a husband who is incapable of self-   support because of mental or physical disability which can be expected to continue for more than one year? (If answer   is "Yes" attach a doctor's certificate.)YESNOPART CPLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3.FILL IN THISPART IF YOUWISH NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.1. I elect to enroll in any plan under the Health Benefits Act.2. I elect to cancel my present enroll- ment under the Health Benefits Act.3. The reason for my election is (Place an "X" in proper box):(a) I am covered by a plan under the Health Benefits Act through the enroll- ment of my husband, wife, or parent.(b) I am covered by a health insurance plan which is not under the Health Benefits Act.(c) Any other reason.PART DFILL IN THISPART IF YOUWISH TOCHANGE YOURENROLLMENT.1. I elect to change my enrollment as shown by the enrollment code number and other information in Part B.2. Number of event which permits change.(See table on back of duplicate for proper number.)3. Date of event which permits changeMONTH DAY YEARPART EALL WHOREGISTERMUST FILLIN THIS PARTPART FTO BECOMPLETEDBYAGENCY.1. NAME AND ADDRESS OF EMPLOYING OFFICE(SIGNATURE--DO NOT PRINT)(DATE)WARNING. - Any intentional false statement inthis application or willful misrepresentation relativethereto is a violation of the law punishable by afine of not more than $10.000 or imprisonment ofnot more than 5 years, or both. (18 U.S.C. 1001.)2. DATE RECEIVED IN   EMPLOYING OFFICE3. EFFECTIVE DATE OF   ELECTION4. PAYROLL OFFICE NO.5. OFFICIAL ACTION   (INITIALS AND DATE)REMARKSFOR USE ONLYBY ANNUITANTSAND AGENCY.(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)525772Triplicate - to Employing OfficeAPRIL 195611.367.