NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411687
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: November 5, 1970

U.S. Civil Service
Commission
NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT
Caranci, John
4. ADDRESS (INCLUDING ZIP CODE)
64 Eddy Street
Centerdale, Rhode Island 02911
APPROVED FOR
RELEASE^DATE:
10-Nov-2008
15 July 1970
ITEM WHICH IS CHECKED BELOW AFFECTS YOUR ENROLLMENT. READ THAT ITEM CAREFULLY AND FOLLOW ANY PERTINENT
DNS. KEEP THIS FORM UNLESS YOUR ENROLLMENT IS TERMINATED AND YOU APPLY FOR CONVERSION.
Part B.-TERMINATION
^ YOUR ENROLLMENT TERMINATES ON THE DATE IN PART A, ITEM 7, ABOVE.
IMPORTANT NOTICE.-You have the right to convert to an individual contract with the carrier of your plan. See Part B.-Termination on
the back of this form for information about your extension of coverage and conversion. If you want to convert, fill in the box on the back
of this form and send it to your plan within the time limit specified,
^ YOUR ENROLLMENT SHOWN IN PART A, ITEM 6, ABOVE HAS BEEN TERMINATED BECAUSE OF YOUR ENROLLMENT IN ANOTHER PLAN.
(SEE PART D ON THE BACK OF THIS FORM FOR MORE
INFORMATION)
YOUR ENROLLMENT CONTINUES BUT IS TRANSFERRED TO
YOIJR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM):
^ YOUR ENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON
THE DATE IN PART A, ITEM 7, ABOVE.
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM)
SHOWN IN PART K BELOW HAS ACCEPTED TRANSFER OF
YOUR ENROLLMENT AND WILL CONTINUE IT.
YOUR ENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON
THE DATE IN PART A, ITEM 7, ABOVE.
YOUR ENROLLMENT HAS BEEN CHANGED FROM FAMILY COVERAGE TO SELF ONLY. YOUR PLAN WILL
SEND YOU A NEW IDENTIFICATION CARD.
YOUR NEW ENROLLMENT
CODE NUMBER
Chief, Retirement Operations Branch
(bl61
(b131
SEX
W] MALE
^ FEMALE
Standard Form No. 2010
Original -To Enrollee April 1969
FPM Supplement 0901
 PART,$.-TERMINATION
If Part B on the other side of this form is checked, read the following instructions carefully.
TEMPORARY EXTENSION OF COVERAGE
Your enrollment terminates on the date shown in Port A, Item 7, on the
front of this form. Coverage under your enrollment continues temporarily for 31
days from the date shown: ? If you "or any covered member of your family
is a patient in a hospital on the 31st day of this temporary extension, benefits
of the Plan may continue for that person for the rest of that confinement, but
not beyond 60 more days. - -
You may convert your enrollment to a nongroup contract, without evidence
of good health. The nongroup contract to which you may convert is one reg-
ularly offered by your Plan. It may differ from your group plan in benefits,
or cost, or both, and you will have to pay the entire cost of the nongroup con-
tract direct to the Plan. The nongroup contract is effective on the day after
your 31-day temporary extension of coverage ends:
If you are interested in converting to a nongroup contract, fill in the box
to the right and take or mail this form to the nearest office of the Plan in
which you have been enrolled' (see your*Plaii's brochure or ask your ernploy-
Ing office for the address of the Plan's nearest office) The Plan will promptly
send you an application form and details concerning benefits and rates of the
nongroup contract to which you may convert.
For conversion, fill out this box and take or mail this
form immediately to your Plan. DO NOT SEND IT TO
THE CIVIL SERVICE COMMISSION.
YOUR SIGNATURE (DO NOT PRINT)
DATE
Printyour address (including ZIP Code) below if it is different from that
shown in Part A, Item 4, on the other side.
NUMBER AND STREET
CITY, STATE, AND ZIP CODE
To be eligible for the conversion, this form, with the box to the right com-
pleted, must be received by your Plan not later than 31 days after the date
shown in Part A, Item 7, or 15 days after the date in Part K on the other
side, whichever gives you more time.
If your enrollment is being terminated because you are entering military
service, you may convert to a nongroup contract ever: though your family mem-
bers are entitled to care under the military dependents, Medicare program.
If you return to civilian duty in the exercise of reemployment rights, your en-
rollment will be reinstated effective on the day you return to aclivh civilian duty.
If you return to civilian duty not in the exercise of reemployment rights, you must
register again the some as a new employee.
PARTS D AND E.-TRANSFER OF ENROLLMENT
If either Part Dor E on the other side of this form is checked, read core, ~t?ty v~ (s(,.hovor of the Xo lr F (ss instrRtcHod s cspplies.
If you tronsfer to another agency or payroll office, your enrollment con-
tinues. Show this form to your new employing office as evidence of your en-
rollment. Shortly offer you enter on duty,'your new employing office should
give you another form like this one to show that your health benefits cover-
age has been officially continued. (However, if you ore in c group- or indivrS-
uol-practice plan and leave the area served by the plan, you may he able to
register in another plan. For details on your right to change plans, check with
your employing office.)
the family is entitled to survivor annuitt, enrollment of each eligible family
member who was covered by the enrollment of the deceased continues auto-
matically.
If there Is only crC eligible survivor, the enrollment will be changed from
family to indivldua( -he survivors' share of the cost of the enrollment will
he deducted from the annuity. Application for death benefits should be filed
promptly to avoid any n uestion about health benefits coverage. Shortly after
the survivor annuity is approved, another form like this one will be issued to
show that the retirement system which pays the survivor annuity has officially
continued the health benefits enrollment in the survivor's name.
Your enrollment continues automatically during retirement if you retire
on an immediate annuity with at least 12 years of creditable service of for
disability, and you hove been enrolled under the Health Benefits Program(i)
during all your service since your first opportunity to enroll, or (2) during the
5 years of service immediately preceding retirement, or (3) continuously
to '
the full period or periods of service beginning with the enrollment which be-
came effective no later than December 31, 196x. Your shore of the cost o`
your enrollment will be deducted'from your annuity. if you have not already
filed an Application for Retirement, you should do so promptly in order to
ovoid any question about your health benefits- cbverage:'?At' the tiine `your re-
tirement is approved, . or shortly .'after., . you should receive another torm like
this one to show that your retirement system has officially continued your health
benefits coverage.
If the deceased employee or annuitant was enrolled for self and family
and had at least 5 years of civilian service, and if of least one member of
Your enrollment continues automatically while you receive monthly com-
ner;sa'ion from the Bureau of. Employees' Compensation if the Secretary of labor
has held tnai you ore unable to return to duty and if you have been enrolled
under the Health Benefits Program (1) during all your service since your first
;r .t mi y to enroll, or (2) during the 5 years of service immediately preceding
is start of your compensation, or (3) continuouslyafor the.,f5ll period or periods
at uervice beginning with the enrollment which became effective no later than
December 31, 1964. Enrollment of covered family members of a deceased-em-
ployee or compensotioner also continues automatically while they receive monthly
compeiacition, if (1) the deceased employee or campensationer had at least
5 years of service, and (2) the former employee had: been determined by the
Secretary of tabor to be unable to return to duty. The compensationer's or
survivor's share of the cost of the enrollment will be deducted from his monthly
compensation checks.
KEEP THIS FORM FOR YOUR RECORDS UNLESS YOUR ENROLLMENT IS TERMINATED
AN" YOU CONVERT TO A NONGROUP CONTP''`^,T