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Federal Health Benefits Election Form

Wednesday, August 1, 2012

Use this form to:

  • Enroll or reenroll in the FEHB Program; or
  • Elect not to enroll in the FEHB Program (employees only);or
  • Change your FEHB enrollment; or
  • Cancel your FEHB enrollment; or
  • Suspend your FEHB enrollment (annuitants or former spouses only).

Complete, print, sign, and return pages 15 and 16 of the following form to the DCRB Benefits Department. at:

DCRB Benefits Department 
900 7th St, 2nd Floor
Washington, DC 20001

Federal Health Benefits Election Form (Form 2809) [PDF] (will be updated soon to include Self Plus One)