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# H' TH BENEFITS REGISTRATION FORMFEDERAL EMPLOYEES HEALTH BENEFITS ACT of 1959*Standard Form No. 2809 CHAPTER 1-5 P.M.*(Read instructions on back of last page. Use only typewriter or ballpoint pen.)3362 - 09078## PART AALL WHO REGISTER MUST FILL IN THIS PART1. NAME (LAST)WOODS4. YOUR MAILING ADDRESS (NUMBER AND STREET)FOREST RIVER6. Are you covered by, or is any family member listed below covered by or enrolling in, a plan under the Federal Employees Health Benefits Act of 1959 (through the enrollment of another United States or District of Columbia Government employee or annuitant)?[ ] YES   [X] NO(FIRST)JAMES(CITY AND ZONE NUMBER)NORTH DAKOTA2. DATE OF BIRTHMONTH DAY YEAR2 20 28(STATE)3. Are you now married?[X] YES    [ ] NO5. SEX[ ] MALE    [X] FEMALE7. Place an "X" in proper box to show your annual basic salary range.[ ] UNDER $4,000     [X] $6,000 TO $9,999[ ] $4,000 TO $5,999     [ ] $10,000 OR OVER## PART BFILL IN THIS PART IF YOU WISH TO ENROLL IN A HEALTH BENEFITS PLAN1. 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 PLANASSOCIATION BENEFIT PLANOPTION (HIGH OR LOW)HIGH2. In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under age 19, including legally adopted children, and stepchildren and legitimate children who live with you in a regular parent-child relationship. 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 disabled child age 19 or over.)If 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.NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Year)## THIS PART MUST ALSO BE FILLED IN IF YOU CHANGE YOUR ENROLLMENT.## PART CFILL IN THIS PART IF YOU WISH NOT TO ENROLL OR IF YOU WISH TO CANCEL YOUR ENROLLMENT3. If you are a female (employee or annuitant) – does the family listed above include a husband who is incapable of self-support by reason 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.)[ ] YES   [ ] NOPLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3.1. I elect not to enroll in any plan 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 enrollment of my husband, wife, or parent.2. I elect to cancel my present enrollment under the Health Benefits Act.(b) I am covered by a health insurance plan which is not under the Health Benefits Act.(c) Any other reason.## PART DFILL IN THIS PART IF YOU WISH TO CHANGE YOUR ENROLLMENT.1. Enrollment as shown by the enrollment number and other information in Part A2. Number of event which permits change.3. Date of event which permits change(See table on back of this form for proper number.)MONTH DAY YEAR## PART EALL WHO REGISTER MUST FILL IN THIS PARTWARNING – 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)1. NAME AND ADDRESS OF EMPLOYING OFFICES. Storke 14 June 602. DATE RECEIVED IN EMPLOYING OFFICE6/30/604. PAYROLL OFFICE NO.3. EFFECTIVE DATE OF ELECTION7/10/605. DATE OF ACTION   (INITIALS AND DATE)## PART FTO BE COMPLETED BY AGENCY.## REMARKSFOR USE ONLY BY ANNUITANTS AND AGENCY.FE*Triplicate - to Employing Office.*10564