[180-10068-10324.pdf — page 6]
# HEALTH BENEFITS REGISTRATION FORMFEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM(Read instructions on back of page 3.)If typewriter is not available, bear down with ball-point pen to make legible copies.TO EMPLOYING OFFICE: SHOW OLD CARRIER'S CONTROL NUMBER ONLY IF ELECTION IS TO CANCEL ENROLLMENT OR TO CHANGE OPTIONS OR TYPE OF ENROLLMENT IN THE SAME PLAN.## PART A1. NAMECollins(LAST)Wendy(FIRST)S(MIDDLE INITIAL)2. DATE OF BIRTH (Use numbers)MONTH DAY YEAR03 22 53New Carrier's Control No.22933820Old Carrier's Control No3. ARE YOU NOW MARRIED?YesNoALL WHO REGISTER MUST FILL IN THIS PART.4. YOUR MAILING ADDRESS (NUMBER AND STREET)1630 Hobart St., N.W.5. SOCIAL SECURITY ACCOUNT NUMBER024-44-51636. SEXMALEFEMALE(CITY)(STATE)(ZIP CODE).WASHiNgton D.C. 20009IMPORTANTIT 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 FAMILY ENROLLMENT OF ANOTHER FEDERAL OR DISTRICT OF COLUMBIA EMPLOYEE OR ANNUITANT YOU MUST REGISTER NOT TO ENROLL OR THE OTHER ENROLLMENT MUST BE CANCELED OR CHANGED TO SELF ONLY. 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. ALSO SEE BACK OF PAGES.2 AND.3.## PART BFILL IN THIS PART IF YOU WISH TO ENROLL OR CHANGE YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN.1. I elect to enroll in a health benefits plan as shown below. I authorize deductions from my salary, compensation, or annuity to cover-my share of the cost of the enrollment. (Copy the information requested below from back page of brochure of the plan you select.)NAME OF PLANBlue (Ross/Blue Shield Service Benefit PIANOPTION (HIGH OR LOW)HIGHENROLLMENT CODE NUMBER10If enrollment is for Self Only, answer item 1: If enrollment is for. Self and Family, also an swer item 2.2. 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, because of the disability, is incapable of self-support. (Attach a doctor's certificate for a disabled child age 22 or over, if one is not already on file.) 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.Wife or HusbandNAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day: Year)NAMES OF FAMILY MEMBERSDATE OF BIRTH (Month, Day, Yearl## PART CFILL IN THIS PART IF YOU WISH NOT TO ENROLL OR IF YOU WISH TO CANCEL YOUR ENROLLMENTPLACE AN "X" IN ITEM 1 ÖR.2 WHICHEVER APPLIES.1. I ELECT NOT TO ENROLL IN A PLAN UNDER THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM2. I ELECT TO CANCEL MY PRESENT ENROLLMENT UNDER THE CODE NUMBER SHOWN BELOW:Present Enrollment Code NumberIf you elect to cancel be sure to read "Cancellation of Enroll- ment" on back of page 3.## PART DFILL IN THIS PART, AS WELL AS PART B- ΤΟ CHANGE YOUR REGISTRATION.ANSWER ITEMS 1, 2, AND 3 TO SHOW ENROLLMENT CODE BEING CHANGED AND ELIGIBILITY FOR CHANGE.1. ENROLLMENT CODE NUMBER OF PRESENT PLAN2. NUMBER OF EVENT WHICH PERMITS CHANGE. (See table on back of page 2 for proper number.)3. DATE OF EVENT WHICH PERMITS CHANGE.MONTH DAY YEAR## PART EALL WHO REGISTER MUST FILL IN THIS PART.Wendy S Calle(YOUR SIGNATURE. DO NOT PRINT)Aug 5, 1978(DATE)WARNING. Any intentional false statement in this application or wilful 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 FTO BE COMPLETED BY AGENCY1. NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICEU.S. House of RepresentativesOffice of Finance, Washington, D.C. 205152. DATE RECEIVED IN EMPLOYING OFFICE3. EFFECTIVE DATE OF: ELECTION.4. PAYROLL OFFICE NO..000048325. SF 2811 REPORT NO.(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)REMARKSFOR USE ONLY BY AGENCY.Page 2 To Insurance CarrierStandard Form No. 2809 U.S. Civil Service Commission