HEALTH BENEFITS REGISTRATION FORM - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: CARANCI JOHN C
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001496331
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: July 10, 1960

Standard Form N
2809
o
HEALTH BENEFITS REGISTRATION FOR
CARRIER'S CONTROL NO.
CHAPTER I-5
.
F.P.M.
FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959
-' '
6 GAO 500
0
(Rea tructions on back of last page. Use only typewriter or in pen,
1. NAME (LAST) (FIRST) (MIDDLE INITIAL)
2. DATE OF BIRTH
3. Are you now married?
(Use numbers)
MONTH DAY YEAR
YES FLE1Ib1I61
PART A
CA ?C I; C .
2 >7 1a 2 1 32
NO E11111131
ALL WHO
REGISTER
4. YOUR MAILING ADDRESS (NUMBER AND STREET) (CITY AND ZONE NUMBER) (STATE)
5. SEX
MALE ?^
MUST FILL
^
FEMALE ^~
IN THIS
6. Are you covered by, or is any family member listed below cov-
7. Place an "X" in proper box to show your annual basic salary
I
PART
ered by or enrolling in, a plan under the Federal Employees
range.
APPROVED FOR
Health Benefits Act of 1959 (through the enrollment of another
United States or District of Columbia Government employee or
UNDER $4,000 ^~ $6,000 TO $9,999
R ELEASE ^ DATE:
annuitant)? YES 0 NO ?
$4,000 TO $5,999 ~^2 $10,000 OR OVER ^~
12-Nov-200
1. 1 elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity
to cover my share of the cost of the enrollment. (Copy the information requested below from inside cover of brochure of the plan you select.)
FILL IN THIS
PART iF YOU
NAME OF PLAN OPTION (HIGH OR LOW) ENROLLMENT CODE NUMBER
WISH TO EN-
ROLL IN A
ASSOCIATION IS- PTA- LOW 4 2 5
HEALTH BENEFITS
PLAN,
2. In space below list all eligible family members without exception: List your wife or husband first, then your unmarried children under
age 19, including legally adopted children, and stepchildren and illegitimate children who live with you in a regular parent-child relation-
ship. Include also any unmarried child over 19 who became disabled before age 19 and who, because of the disability, is incapable
of self-support. (Attach a doctor's certificate for a disabled child age 19 or over.)
?
If enrollment
if far self only,
answer item 1.
NAMES OF FAMILY MEMBERS
DATE OF BIRTH
(Month, Day, Year)
NAMES Of FAMILY MEMBERS
DATE OF BIRTH
(Month, Day, Year)
If enrollment
is for self and
Wife or
family, also
Husband
`-"
answer item 2
and item 3 if
it applies.
THIS PART MUST
la
ALSO BE FILLED
IN IF YOU
3. If you
area female emp oy - listed above include a husband who is incapable of self-
YES
CHANGE YOUR
suppor
"
t by reason of mental or physical disability which can be expected to continue for more than one year? (if answer
NO
'
"
ENROLLMENT.
is
Ye
s certificate.)
attach a doctor
s,
LJ
PART C
PLACE AN "X" IN ITEM I OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3.
FILL IN THIS
1. I elect not to enroll in any plan
3. The reason for my election is (Place an "X" in proper box):
PART IF YOU
under the Health Benefits Act.
(a) I am covered by a plan under the Health Benefits Act through the enroll- 7
WISH NOT TO
ment of my husband, wife, or parent.
ENROLL IF
YOU WISH H TO
2. I elect to cancel my present enroll-
(b) I am covered by a health insurance plan which is not under the Health D0
CANCEL YOUR
went under the Health Benefits Act. 1:1
Benefits Act.
(c) Any other reason. DIE
ENROLLMENT,
1
PART D
I elect to change my enrollment as shown by. the enrollment number and other information in Part B.
FILL Ill THIS
1. Enrollment cod Limberr -present pl 2. Number of event which permits change. 3. Date of event whit permits ch ge.
li
number
)
f d
t
b
k
f
bl
PART IF YOU
.
up
ca
e
or proper
ac
o
e on
(See ta
WISH TO
MONTH DAY YEAR
F
CHANGE YOU
R . 9t Q 1
F
ENROLLMENT.
/
PART E
WARNING.-Any intentional false statement in
ALL WHO
this application or willful misrepresentation relative
unishable by a
to is a violation of the law
r
th
,
REGISTER
MUST FILL
p
e
e
fine of not more than $10,000 or imprisonment of
/ 20
V
`
3 - 1 C)~f~ not more than 5 years, or both. (18 U.S.C. 1001.)
,T17Y1p l
IN THIS PART.
OUR SIGNATURE-DO NOT PRINT) (DATE)
1 AME AND ADDRESS OF EMPLOYING OFFICE
2. DATE RECEIVED IN
3. EFFECTIVE DATE OF
EMPLOYING OFFICE
ELECTION
PART F
TO BE
COMPLETED
4. P ROLL OffftE NO.
5. YROLL ION
BY
(INITIALS AND DATE)
AGENCY.
UN
~~~
(SIGNATURE OF AUTHORIZED AGENCY OFFICIAL)
- -
REMARKS
FOR USE ONLY
BY ANNUITANTS
AND AGENCY.