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# HEALTH BENEFITS REGISTRATION FOR**FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959Standard Forms No. 2809CHAPTER 1-1 P.P.M.6 C.1-1-5000(Read instructions on back of last page. Use only typewriter or ball pen.)262093614(CARRIER'S CONTROL NO.)072-0001. NAME (LAST) (FIRST) (MIDDLE INITIAL) 2. DATE OF BIRTH 3. Are you now married?   (Month) (Day) (Year)   PART A   WOODG   James   S   2 20 22   YES ☐1   NO ☐2   ALL WHO   REGISTER4. YOUR MAILING ADDRESS (NUMBER AND STREET) (CITY AND ZONE NUMBER) 5. SEX   MUST FILL   THIS   ALCD   APO 725   San Francisco, Calif.   MALE ☐1   FEMALE ☐2   PART.6. 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 by or enrolling in, a plan under the Federal Employees range.   Health Benefits Act of 1959 through the enrollment of another   UNDER $4,000 ☐1 $6,000 TO $7,999 ☐3   United States, or District of Columbia Government employee or   annuitant)? $4,000 TO $5,999 ☐2 $8,000 TO $9,999 ☐4   PART B   FILL IN THIS   YES ☐1   NO ☐2   $10,000 OR OVER ☐5   PART IF YOU   WISH TO EN-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   ROLL IN A to cover my share of the cost of this enrollment. (Copy the information requested below from inside cover of brochure of the plan you select.)   HEALTH BENEFITS   PLAN.   NAME OF PLAN   ENROLLMENT CODE NUMBER   Association Benefits Plan - Family   High   4 2 22. 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 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 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  applicable.  Wife or  Husband  NAMES OF FAMILY MEMBERS  Louise A.  DATE OF BIRTH  (Month, Day, Year)  8 May 37  NAMES OF FAMILY MEMBERS  DATE OF BIRTH  (Month, Day, Year)  THIS PART MUST  ALSO BE FILLED  IN IF YOU  CHANGE 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   YES ☐1   "Yes," attach a doctor's certificate.) NO ☐2   PART C   FILL IN THIS PLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3.   PART IF YOU   WISH NOT TO 1. I elect not to enroll in any plan 3. The reason for my election is: (Place an "X" in proper box.)   ENROLL OR IF   YOU WISH TO under the Health Benefits Act. (a) I am covered by a plan under the Health Benefits Act through the enroll-   CANCEL YOUR ment of my husband, wife, or parent. ☐1   ENROLLMENT.2. I elect to cancel my present enroll-   ment under the Health Benefits Act. (b) I am covered by a health insurance plan which is not under the Health   Benefits Act. ☐2   (c) Any other reason. ☐3   PART D   FILE IN THIS1. I elect to change my enrollment as shown by the enrollment number and other information as in Item 22. Number of event which permits change. 3. Date of event which permits change.   PART IF YOU 1. Enrollment code number of present plan.   (See table on back of supplement for proper number)   WISH TO   CHANGE YOUR   ENROLLMENT.   4 2 5   MONTH DAY YEAR   March 22 1964   PART E   ALL WHO   REGISTER   MUST FILL   IN THIS PART.   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.)   PART F   TO BE 1. NAME AND ADDRESS OF EMPLOYING OFFICE 2. DATE RECEIVED IN   EMPLOYING OFFICE3. EFFECTIVE DATE OF   COMPLETED ELECTION   BY   AGENCY.   HEALTH BENEFITS OFFICER   (SIGNATURE AND DATE)   3-15-64   (TITLE) 4. PAYROLL OFFICE NO. 5. PAYROLL ACTION   (INITIALS AND DATE)   REMARKS   FOR USE ONLY   BY ANNUITANTS   AND AGENCY.   APFE 1750   Triplicate-to Employing Office