Sample Notice 

FEDERAL EMPLOYEES HEALTH BENEFITS (FEHB) 

Request By Enrollee to Remove a Family Member from FEHB Enrollment 

Family Member Type: Child Who Has Reached Age of Majority1

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

Family enrollment if the child is no longer dependent upon the enrollee. The 

enrollee must submit a request to the agency for approval. The request must 

include proof that the child is no longer a dependent (by providing the 

enrollee’s most recent tax return or a signed affidavit attesting that the child is 

no longer a dependent under the IRS definition of dependent) and a Health 

Benefits Election Form (Standard Form (SF) 2809). 

The enrollee must complete the following sections of the SF 2809:

a. Part A (lines 1-12 , and specific information for family member(s) 

being removed starting with line 13)

b. Part B

c. Part H 

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

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

policy, or temporary continuation of coverage (TCC). Eligibility for your 

surviving family members to continue your health benefits enrollment if you die

may be impacted. See your employing office for additional information. 

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 removed child losing 

other health insurance coverage. The enrollee must provide written consent to 

 

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. 
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 types or 

enrollment type.

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.

Please submit the appropriate request and proof the child is no longer your 

dependent to your agency.
FEDERAL EMPLOYEES HEALTH BENEFITS (FEHB)

Request By Enrollee to Remove a Child Who Has Reached the 

Age of Majority from FEHB Enrollment

Family Member Type: Child who has reached age of majority

Name of Enrollee: 

Name of FEHB Health Plan/Enrollment Code:

Name of Family Member:

Address of Family Member:

Email of Family Member: 

Phone Number of Family Member: 

I am the enrollee of the above-indicated FEHB enrollment. I am requesting that 

the above named child be removed from my enrollment. I affirm that the named 

child is of the age of majority in their state of residency (my state of residence if 

the child’s state of residency is unknown) and that the child is no longer my tax 

dependent. By my signature I acknowledge that this is a voluntary action and I

understand the impact this could have on this child’s FEHB coverage and 

ability to regain FEHB coverage in the future and that all the information I have 

provided is true and correct to the best of my knowledge. 

____________________________

(Signature - Enrollee) 

____________________________

(Date)