Health Benefits Election Form

SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form

Documents and Forms

Document Name Document Type
Form SF 2809 Health Benefits Election Form Form and Instruction
SF 2809 Federal Employees Health Benefits Program Election Form Standard From 2809_2024-09-16.docx Form and Instruction
SF 2809 Federal Employees Health Benefits Program Election Form Standard From 2809_2024-09-16.docx Form and Instruction
OPM 2809 Health Benefits Election Form OPM2809 Updated_2024_10_09.pdf Form and Instruction
OPM 2809 Health Benefits Election Form OPM2809 Updated_2024_10_09.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Benefits Election Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 890.805 through 809.807 5 CFR 890.301 through 890-307 5 CFR 890-1105 through 890.1110 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SF 2809	Federal Employees Health Benefits Program Election Form	Standard From 2809_2024-09-16.docx	opm.gov	Yes	Yes	Fillable Fileable
Form and Instruction	OPM 2809	Health Benefits Election Form	OPM2809 Updated_2024_10_09.pdf	opm.gov	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 73 FR 15013

Number of Respondents: 48,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	48,000	30,000	18,000
Annual IC Time Burden (Hours)	20,667	11,667	9,000
Annual IC Cost Burden (Dollars)	477,514	234,515	242,999

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.