U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Employees 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. Make sure you allow it to download completely before you start to use it.

To accessible version.

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• 493K PDF File

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Accessible Acrobat Version.

The first nine pages of this form consists of instructions. We have posted these instructions as an accessible HTML file.

Download the accessible PDF form here. The actual form is on page 10. It is a five page form consisting of 5 copies of that page. You only need to fill out the first copy (page 10) of the form. The other four copies are automatically completed with a duplicate of what you enter on the first copy. Print the form after you finish filling it in on the screen. Remember that if you are using the free Acrobat Reader to complete the form you cannot save it with the information that you entered in the form. You must print it out before you close the form.