SF 2810 Notice of Change in Health Benefits Enrollment

What is SF 2810?

SF 2810, Notice of Change in Health Benefits Enrollment, is the FEHB form an employing office uses to record enrollment events it initiates: terminating an enrollment when an employee separates, transferring the enrollment when the employee moves to another payroll office, reinstating an enrollment, or recording a name change. It is the counterpart to SF 2809, which employees use for elections they sign themselves.

The form matters most at separation, because the termination copy documents the employee's eligibility for the 31-day temporary extension of coverage and the right to convert to an individual policy or elect temporary continuation of coverage. The employing office completes the form, files a copy in the official personnel folder, and gives the employee and the carrier their copies.

Who files SF 2810?

• Agency HR and payroll offices recording FEHB terminations, transfers, and reinstatements
• Employing offices documenting an enrollee's name change with the health plan carrier
• Gaining payroll offices transferring in an enrollment when an employee changes agencies
• Separating employees, who receive a copy documenting their conversion and continuation rights

How to fill out SF 2810

1. The employing office fills in the enrollee's identifying information and current enrollment code.
2. The office checks the type of action, such as termination, transfer in, reinstatement, or name change, and enters the effective date.
3. The remarks section records anything the carrier or the next payroll office needs to process the action.
4. An authorized agency official signs the form; the employee does not sign an SF 2810.
5. Copies are distributed: one to the official personnel folder, one to the carrier, and one to the employee, who should keep the termination copy as proof of the 31-day coverage extension.