Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
Sequence Number: 
Case Number: 
Publication Date: 
May 26, 1970
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Standard Form No. 2810 6 U.S. Civil Service Commission FPM Supplement 890.1 November 1965 1. NAME (LAST) Caranci FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT Part A. IDENTIFYING DATA (FIRST) John (MIDDLE INITIAL) C. 2-7-22 DDRESS 64 Eddy Street Centerdale, Rhode Island 02911 078546 6. ENROLLMENT CODE NO. 422 1 April 1970 1 (bl61 (b131 ONLY THE ITEM W)ilCR 15 CMECtED BELOW AFFECTS YOUR ENROLLMENT. READ THAT ITEM CAREFULLY AND FOLLOW ANY PERTINENT INSTRUCTIONS. KEEP THIS FORM UNLESS YOUR ENROLLMENT IS TERMINATED AND, YOU APPLY FOR CONVERSION. L~J 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 6.-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 El PLAN. Part D.-TRANSFER OUT YOUR ENROLLMENT CONTINUES BUT IS TRANSFERRED TO YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM): YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM) SHOWN IN PART K BELOW HAS ACCEPTED TRANSFER OF YOUR EN-15 ROLLMENT AND WILL CONTINUE IT. (SEE PART D ON THE BACK OF THIS FORM FOR MORE INFORMATION) YOUR ENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON Q THE DATE IN PART A, ITEM 7, ABOVE. YOUR ENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON s THE DATE IN PART A, ITEM 7, ABOVE. Part H.-CHANGE IN NAME OF ENROLLEE 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 Part J: REMARKS Employee Annuitant Chief, Original-To Enrollee APPROVED FOR RELEASE^DATE: 10-Nov-2008 I PART.Z_-TERMI.NATION if Puri B on the ether side of this form is ch'eclcreti, read the fo;?: isi TEMPO!'y:.i'Y "EXTENSION ? OF ,COVE9A0E 'our en-ol!ment terminates on the date ,noWn in Nor` A, Item 7, on the fmni of this form. Coverage under your enrollment continues temporarily for 31 days from the date shown, If you ar cry coeerar.',+ member of your family is a pct''ent:_fh a smc ritof on the-51,t -. d?.:~y of- this temporary ezten- .nn, benefits of the Na, may con :cue for that person for iho rest o` thof confinement, but not beyond 50 more days. For conversion, fill out this box and take or mail this form imr=-lediitelyr to your Flan. DO NOT CENrt IT TO IhC rR;F.1 CER16BFCE COMMAAEC-r-. You esy convert you. enrolin:::ri' to c. .c. r:group contract, without evi. de,ce c. good health. the nongru': which you may -ori ert arly cffcred by your 'lca. It may d ffcr from your group pirn r?esafits,, or cc:, or both, asd yore vri!i ho?.- to Pay the entire .,,at of is - cnaraup contract direct the Nor. ,he nc:ngrouF?. contra ,:t is cr... . iris day elt: