NOTICE OF CHANGE IN ENROLLMENT STATUS FEDERAL EMPLOYEES HEALTH BENEFITS ACT OF 1959

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP86-00964R000100120018-5
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 7
• Document Creation Date: December 14, 2016
• Document Release Date: July 22, 2003
• Sequence Number: 18
• Content Type: FORM

2810 Standard
1-5 Form F.P.M. P.I NOTICE OF CHANGE IN ENROLLMENT STATUS 6 GAO 5000
Chapt 1
C
Aprroved For FWeL20018-5
(The part(s) marked with an "X" applies to you)
^ YOU ARE ELIGIBLE TO CONVERT TO A NONGROUP CONTRACT.
(SEE PART B ON OTHER SIDE FOR INFORMATION ON TEMPORARY EXTENSION AND CONVERSION)
^ YOUR ENROLLMENT SHOWN BY ITEM 6, ABOVE, HAS BEEN TERMINATED IN ACCORDANCE
WITH YOUR RECENT ELECTION OF ANOTHER PLAN.
YOUR ENROLLMENT IN A HEALTH BENEFITS, PLAN HAS BEEN SUSPENDED WHILE YOU ARE ON ACTIVE MILITARY DUTY
OR FOR THE REASON STATED IN REMARKS.
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN REINSTATED, EFFECTIVE ON DATE SHOWN IN ITEM 7, ABOVE. r
I
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN CHANGED
FROM FAMILY COVERAGE TO SELF ONLY.
NEW ENROLLMENT
CODE NUMBER
proved e-2O0310a/13- : CIA=RDFN6U96 18-5
 PART 8-TERMINATION
Approved For Release 2003/08/13 : CIA-RDP86-00964R000100120018-5
Your enrollment terminates on the date shown in Part A, Item
7. If your enrollment terminated for any reason other than volun-
tary cancellation, coverage under your group plan will be extended
temporarily for 31 days from the date shown. If you or any covered
member of your family is confined in a hospital on the 31st day
of this temporary extension, that person's benefits may continue
for the rest of that confinement, but not beyond 60 additional
days.
To be eligible for the conversion, this form, with the box beltw
completed, must be received by your Plan net later than 31 days
after the date shown in Part A, Item 7, or 15 days after the date
in Item I on other side, whichever gives you more time.
CONVERSION TO NONGROUP CONTRACT
You may convert your group coverage to a nongroup contract,
without evidence of good health. The nongroup contract to which
you may convert is one regularly 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 contract direct to
the Plan. The nongroup contract will become effective on the day
after your 31-day temporary extension of group coverage ends.
Ifyouu are interested in converting to a nongroup contract, fill
in the box at the right and mail this form to the nearest office of
the Plan in which you have been enrolled (see your Plan's brochure
or ask your employing 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,
Print your address if it is different from that shown in
Part A,.Item:4, on the other side.
TRANSFER
If you transfer to another agency or payroll office, your new
employing office will take the necessary action to continue your
enrollment when you enter on duty. 5hcw this form to your new
employing office as evidence of your enrollment. However, if you
are in a Comprehensive Medical Plan and leave the area served by
the Plan, you may have to reregister in another Plan within 31
days.
vivor of the employee or annuitant, group enrollment of each
eligible family member who was covered by the enrollment of the
deceased will be automatically continued. If there is only one
eligible survivor, the enrollment will be changed from family; to
?Ddividual. The. survivors' share of the cost of the enrollment will
be deducted from the annuity, unless the annuity is insufficient,
in which case the enrollment may be canceled. Application fcr
Death Benefits should be filed promptly in order to avoid any
question about health benefits covera?.e.
RETIREMENT
Your group enrollment- will automatically be continued durint
~wdtirement if (1) you are entitled to an immediate annuity, and
(2) you retire 'after completing at least 12 years of creditable
service or for disability, and (3) you have been enrolled in a
health benefits plan under the Federal Employees Health Benefits
Act during all of your service from the time of your first oppor-
tunity to enroll or for. the 5 years of service. immediately preced-
ing retirement. Your share of the cost of 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 avoid any question about your health benefits coverage.
DEATH
If the deceased employee or annuitant was enrolled for himself
and family and had at least 5 years of civilian service and if at
Icast,orr member of the family is entitled to annuity as the sur-
If you are entitled to compensation under the Fedora Emplo-
yees' Compensation Act, your enrollment will be automatically
continued while you are in receipt of monthly compensation and
held by the Secretary of Labor to be unable to return to duty.
Covered family members of a deceased employee or compense-
,ioner will also have their enrollment automatically continued
while they are in receipt of monthly compensation if the deceased
(1) had at least 5 years of civilian service and (2) died as a result
of a compensable injury or illness and (3), in the ease of -.a
deceased compensationer, had been held by the Secretary of Labor
;o be unable to return to duty. The eompensetioner's or survivor's
share of the cost of the enrollment will be deducted from the
mrrethly compensation checks. In any case the compens le
illness or injury rf`i'ust have occurred after the effective date W -the Health Benefits Law.
's'Your enrollment and coverage will be suspended on the date
you enter on active military duty for more than 30 days if you arc
entitlcd'to reemployment rights in your civilian position. The cov-
erage of the members of your family will also be suspended. Your
enrollment will be reinstated without change when you return to
active duty in your civilian position. However, if you return tts r-.
civilian position under conditions whicla do not entitle you io
exercise your reemployment rights, you must register again in the
same manner as a new employee.
Approved For Release 2003/08/13 : CIA-RDP86-00964R000100120018-5
 Standard Form ATO: ~F, 10.
Chapter 1-5 F.IT.M.
[---- ,
NOTICE OF CHANGE IN ENkOLLMENT STATUS
pprgved F9[ aplgapaApi~98 11~Tgli-5WP- 6AQj 9o4 100120018
A. ILIENTIFYING DATA
(LAST) (FIRST) (MIDDLE INITIAL)' i 2. DATE OF FIRTH
(NUMBER AND STREET) 5. PAYROLL OFFICE NO.
3. CARRIER CONTROL NC.
6. ENROLLMENT'CODE NC.
1
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN TERMINATES EFFECTIVE ON THE DATE SHOWN IN
YOU ARE ELIGIBLE TO CONVERT TO A NONGROUP CONTRACT.
(SEE PART B ON BACK OF ORIGINAL FOR INFORMATION ON TEMPORARY EXTENSION AND CONVERSION)
C. CHANGE IN PLAN
YOUR ENROLLMENT SHOWN BY ITEM 6, ABOVE, HAS BEEN TERMINATED IN ACCORDANCE
WITH YOUR RECENT ELECTION OF AN8THER PLAN.
(SEE PART D ON BACK OF ORIGINAL FOR INFORMATION ON TRANSFER OF ENROLLMENT)
E. SUSPENSION OR REINSTATEMENT'
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN SUSPENDED WHILE YOU ARE ON ACTIVE MILITARY DUTY;
OR FOR THE REASON STATED IN REMARKS.
L
(SEE PART E ON BACK OF ORIGINAL FOR INFORMATION ON ENTRY ON ACTIVE MILITARY DUTY)
-------------------- ------------ ---------?-'--------...------------'---.---------------------------?--'--'-----?-------' ?---
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN REINSTATED, EFFECTIVE ON DATE SHOWN IN ITEM 7, ABOVE.
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN CHANGED
FROM FAMILY COVERAGE TO SELF ONLY.
NEW ENROLLMENT
CODE NUMBER
App?60bcf'-F&E 1lease 2003/08/13 : CIA" 86-00964R00010012q'
* GPO: 1960-54$ E53
SIGNATURE OF AUTHORIZED AGENCY OFFICIAL QATE
PAYROLL ACTION
(INITIAL /.ND QATE)
'SF, I
RE, O
 st,aa
nard Fr No. 2810 NOTICE OF CHANGE IN ENROLLMENT STATUS
Ch1
aptero-m5F.P.M. Approved F?D994~010012001
1. NAME (LAST) (FIRST) (MIDDLE INITIAL)
2. DATE OF BIRTH
3. CARRIER CONTROL NO.
4. ADDRESS (NUMBER AND STREET)
5. PAYROLL OFFICE NO.
6. ENROLLMENT CODE NO
(CITY AND ZONE NUMBER) (STATE)
7. DATE ACTION BECOMES EFFECTIVE
LI
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN TERMINATES EFFECTIVE ON THE DATE SHOWN IN ITEM 7, ABOVE.
YOU ARE ELIGIBLE TO CONVERT TO A NONGROUP CONTRACT.
LI
YOUR ENROLLMENT SHOWN BY ITEM 6, ABOVE, HAS BEEN TERMINATED IN ACCORDANCE
WITH YOUR RECENT ELECTION OF ANOTHER PLAN.
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN REINSTATED, EFFECTIVE ON DATE SHOWN IN ITEM 7, ABOVE.
YOUR ENROLLMENT IN A HEALTH BENEFITS, PLAN HAS BEEN SUSPENDED WHILE YOU ARE ON ACTIVE MILITARY DUTY
OR FOR THE REASON STATED IN REMARKS.
THE ENROLLMENT SHOWN IN PART A, ABOVE, HAS BEEN CHANGED TO:
G. CHANGE IN ENROLL ME.NT--SURVIVOR: ANNUITANT
YOUR ENROLLMENT IN A HEALTH BENEFITS PLAN HAS BEEN CHANGED
FROM FAMILY COVERAGE TO SELF ONLY.
NEW ENROLLMENT
CODE NUMBER
El
PAYROLL ACTION
(INITIAL AND LATE)
pp er ease 200310871-3GI C S6=0TJ 4R0U010012C
REPORr`NC,
APR 1960
 Approved FooRpmat gQJ 1i O1r51fti*2 Q80AE00100120018-5
DUPLICATE.-Send to carrier attached to Transmittal and Summary Report to Carrier
(SF 2811) at earliest possible date.
TRIPLICATE.-Use as payroll action document, if necessary.
QUADRUPLICATE.-In cases of death or retirement reported as "Transfer" to Civil
Service Retirement System, send to Commission together with triplicate copy of all of the
employee's Health Benefits Registration Forms (SF 2809) including any Medical Cer-
tificates attached thereto, Individual Retirement Record (SF 2806) and any other
applicable documents, For other retirement systems (including Bureau of Employees'
Compensation, Department of Labor), send these documents (or the equivalent) to the
o.ffice administering the system.
Approved For Release 2003/08/13 : CIA-RDP86-00964R000100120018-5
 ' Ii;E OE F N fi e 1{ :k ~ 5 T ATUSS
~pproved Fob Rye ea e gl?tp$.(aA(: PT?86 999, 4 901001200181
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