Sample Notice 

FEDERAL EMPLOYEES HEALTH BENEFITS (FEHB) 

Request By Child to be Removed from an FEHB Enrollment 

Family Member Type: Child Who Has Reached Age of Majority1 and 

Wants to be Removed

An eligible child may be removed from a Self Plus One or a Self and Family 

enrollment if a request is submitted to the enrollee’s agency for approval. The 

child’s request must include a notarized statement from the child. 

A child’s removal is considered a cancellation. The removed child is not 

eligible for the 31-day temporary extension of coverage, conversion to an 

individual policy, or temporary continuation of coverage (TCC). 

A removed child may only regain coverage under the applicable Self Plus One 

or Self and Family enrollment if requested by the enrollee during the annual 

Federal Benefits Open Season or within 60 days of the child losing other 

health insurance coverage. The enrollee must provide written consent to 

reinstatement of coverage from the child and demonstrate eligibility of the child

as a family member.

In most cases, this is not an opportunity to change plans, plan options or 

enrollment type. In the event of the enrollee’s death the child’s eligibility for 

coverage as a survivor may be impacted. See the enrollee’s employing office 

for more information.

The effective date of removal is the first day of the third pay period following 

the date the request is approved by the agency for enrollees who pay biweekly and the second pay period following the date that the request is 

approved by the agency for enrollees who pay premiums monthly.

Complete the appropriate request, attach the applicable documentation, and 

submit to the enrollee’s agency.

 

1

 The "age of majority" is the age at which a child legally becomes an adult and is governed by state law. 

In most states the age is 18; however, some states allow minors to be emancipated through a court 

action. OPM will not maintain a list of state age laws on our website, but for more information visit: 

http://statelaws.findlaw.com/family-laws/legal-ages.html. The age listed in statute for each state is all 

that needs to be determined unless the parent provides an emancipation court order. 
FEDERAL EMPLOYEES HEALTH BENEFITS (FEHB) Program

Request From a Child Who Has Reached the 

Age of Majority to be Removed from an FEHB Enrollment

Family Member Type: Child who has reached age of majority and wants to be 

removed

Name of Enrollee: 

Name of FEHB Health Plan/Enrollment Code:

Name of Family Member:

I am the child of the above named enrollee and covered under the abovenamed FEHB enrollment. I am requesting that I be removed from this 

enrollment as a covered family member. I affirm that I have reached the age of 

majority in my state of residence. By my signature I acknowledge that this is a 

voluntary action and I understand the impact this has on my FEHB coverage 

and ability to regain FEHB coverage in the future. 

____________________________

(Signature – Child, Age of Majority) 

____________________________

(Date) 

State of: 

 SS:

County of: 

On this, the________day of __________, 20____, before me a notary public, the 

undersigned officer, personally appeared________________, known to me (or 

satisfactorily proven) to be the person whose name is subscribed to the within 

instrument, and acknowledged that he executed the same for the purposes therein 

contained. 
In witness hereof, I hereunto set my hand and official seal. 

___________________________ 

Notary Public