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# HEALTH BENEFITS REGISTRATION FOR**FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959**Guided Form No. 2802****CHAPTER 1-A1PM****6 GAO 25**1. NAME (Last)FLORES(First)(Middle Initial)2. YOUR MAILING ADDRESS (Insured and street)3. Are you now married?YESNO45364904. AGEPART AALL WHOREGISTERMUST FILEIN THISPART5. SEXFEMALEMALE(City and Zone Number)(State)1/27th StAre you covered by, or applying for, coverage under a plan on a proper basis to show your annual basic salary range.of or enrolling in a plan under the Federal EmployeesHealth Benefits Act of 1959 (through the enrollment of anotherUnited States or District of Columbia Government employee or annuitant)?$5,000 to $5,999$6,000 to $6,999$7,000 to $7,999$10,000 and overPART BFILL IN THISPART IF YOUWISH TO ENROLL IN AHEALTH BENEFITSPLANI elect to enroll in a health benefits plan as shown below.I authorize deductions to be made from my salary, compensation, or annuityto cover my share of the cost of the enrollment selected below from inside cover of brochure.NAME OF PLANOPTION HIGH OR LOWTHIS ENROLLMENTis for self only,answer item 1.If enrollmentis for self andfamily, alsoanswer items 2and 3 ifapplies.In space below list all eligible family members exception if your wife (or husband) is not, then your unmarried children and stepchildren, (or legally adopted children, and stepchildren who live with you in a regular parent-child relationship) under age 19, including legally adopted children, and stepchildren who became disabled before age 19 and who, because of the disability, is incapableof self-support. Include also any unmarried child over 19 who became disabled before age 19 or over.(Attach a doctor's certificate to a disabled child age 19 or over.)NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)Wife orHusbandNAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)THIS PART MUSTALSO BE FILLEDIN IF YOUCHANGE YOURENROLLMENTIf "yes" do you expect it to continue for more than one year? (If answer "yes", attach a doctor's certificate.)Is the employee (employee or annuitant) for whom the family listed above include a husband who is incapable of self-support because of mental or physical cause.YESNOITEM 1 FOR ITEM 2, WHICH SUPERSEDES ITEM 11. I elect to enroll in any plan   under the Health Benefits Act.1. For my election is (Place an "X" in proper box)1. I am covered by a plan under the Health Benefits Art through the enrollment of my husband, wife, or parent.2. I am covered by a health insurance plan which is not under the Health Benefits Act.PART CFILL IN THISPART IF YOUDO NOT WISH TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.2. I elect to cancel my present enroll-   ment under the Health Benefits Act3. For any other reason5. Date of event which permits change.4. Enrollment code number of present planPART DFILL IN THISPART IF YOUWISH TOCHANGE YOURENROLLMENT3. Date of event which permits changePART ESIGN HEREIN THIS PART(Your signature-Do not print)(Date)(Home and Address of Employing Office)PART FTO BECOMPLETEDBYAGENCY(Signature of authorized agency officer)(Title)(Date)REMARKSFOR AGENCYUSE ONLYTripmore - To Employing OfficeWARNING. Any intentional false statement or willful misrepresentation relating thereto in this application or willful misrepresentation relating thereto is a violation of the law punishable bya fine of not more than $10 000 or imprisonment ofnot more than 5 years, or both. (18 USC 1001)2. DATE RECEIVED INEMPLOYING OFFICE3. EFFECTIVE DATE OFELECTION4. PLAN CODE (Office use)5. PAYROLL ACTION(Initials and date)SEBI 1950