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If typewriter is not available, bear down with ball-point pen to make legible copies.# HEALTH BENEFITS REGISTRATION FORMFEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM(Read instructions on back of page 3.)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.New Carrier's Control No.22933820Old Carrier's Control No.PART AALL WHO REGIS-TER MUST FILLIN THIS PART.1. NAME4. YOUR MAILING ADDRESS2. DATE OF BIRTH   (Use numbers)3. ARE YOU NOW   MARRIED?Yes 1No 25. SOCIAL SECURITY ACCOUNT NUMBER6. SEX   MALE 1   FEMALE 2IMPORTANTIT 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 THISPART IF YOUWISH TO ENROLLOR CHANGEYOUR ENROLL-MENT IN AHEALTH BENE-FITS 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 PLANOPTION (HIGH OR LOW)ENROLLMENT CODE NUMBER2. 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.If enrollment isfor Self Only,answer item 1.If enrollment isfor Self andFamily, also an-swer item 2.| Wife or Husband | NAMES OF FAMILY MEMBERS | DATE OF BIRTH (Month, Day, Year) |     | NAMES OF FAMILY MEMBERS | DATE OF BIRTH (Month, Day, Year). || --------------- | ----------------------- | -------------------------------- | --- | ----------------------- | --------------------------------- ||                 |                         |                                  | 1   |                         | 6                                 ||                 |                         |                                  | 2   |                         | 7                                 ||                 |                         |                                  | 3   |                         | 8                                 ||                 |                         |                                  | 4   |                         | 9                                 ||                 |                         |                                  | 5   |                         | 10                                |IF YOU ARECHANGING YOURENROLLMENTALSO FILL INPART D.PART CFILL IN THISPART IF YOUWISH NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENTPLACE AN"X" IN ITEM 1 OR 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 Enrollment" on back of page 3.PART DFILL IN THISPART, AS WELLAS PART B, TOCHANGE YOURREGISTRATION.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:PART EALL WHO REGIS-TER MUST FILLIN THIS PART.(YOUR SIGNATURE DO NOT PRINT)(DATE)1. NAME AND ADDRESS (INCLUDING ZIP CODE) OF EMPLOYING OFFICEMONTH DAY YEARWARNING.-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.)2. DATE RECEIVED IN EMPLOYING OFFICE3. EFFECTIVE DATE OF ELECTIONPART FTO BECOMPLETEDBY AGENCY(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL).4. PAYROLL OFFICE NO.5. SF 2811 REPORT NO.REMARKSFOR USE ONLYBY AGENCY.2809-115-01Page 4- To EnrolleeStandard Form No. 2809U.S. Civil Service CommissionFPM Supplement 890-1November 1972: