You may use this form to:
- Enroll in the FEHB program
- Elect not to enroll in the FEHB Program
- Change your FEHB enrollment from Self Only to Self and Family and/or from your present plan or option to another plan or option because of an event described in the table beginning on page 6 of the form
- Change your FEHB enrollment from Self and Family to Self Only
- Cancel your FEHB enrollment
This form is available as a screen-fillable Adobe Acrobat PDF file. Using the free downloadable Adobe Acrobat reader you may complete the form on the screen and then print it out already completed. Note, however, that if you are using the free Acrobat reader software you cannot save the form with the information that you have typed in it on the screen. You need the commercial Adobe Acrobat program in order to save the form with the data. More information is available in our Adobe Acrobat forms help screen.
This is a large form, with nine pages of instructions followed by a five page form. The full form is a 493K PDF file. Some people have had problems using this large a form on their computers. We have thus made it available in two versions the full version, and a second version where the instructions and the fillable form are in two separate files. If you have trouble using the full version, try the two file one.
Download the form:
- Single file version (493K PDF File)
- Two file version
Adobe Acrobat 3 Version.
NOTE: Civil Service Retirement System (CSRS) and Federal Employees Retirement System (FERS) annuitants and former spouses and children of CSRS/FERS annuitants Do not use this form. Instead, call the Retirement Information Office toll-free at 1-888-767-6738. Customers within the local calling distance to Washington, DC, should call 202-606-0500.