CLE R F ie ld D e s c ript io n s An d Ins tr uc ti o ns Time No entry
This field is system generated. This is the time the record was released for processing.
Processed
Date No entry
This field is system generated. This is the date the record was processed.
Time No entry
This field is system generated. This is the time the record was processed.
Form 2809 View (Part B) Page Field Descriptions
The Form 2809 View (Part B) page (Figure 2:56) displays a selected Form 2809 (Part B)
record. For instructions on using the Form 2809 View (Part B) page, see Viewing 2809
Records in Part 2. Plan Name No entry
This field is system generated. This is the name of the FEHB health insurance plan in which the individual is enrolled/enrolling.
Enrollment Code No entry
This field is system generated. This is the enrollment code, which consists of the plan and option codes.
Last Name Line 1 No entry
This field is system generated. This is the last name of the enrollee’s first family member who is enrolled/enrolling in FEHB.
First Name Line 1 No entry
This field is system generated. This is the first name of the enrollee’s first family member who is enrolled/enrolling in FEHB.
Initial Line 1 No entry
This field is system generated. This is the middle initial of the enrollee’s first family member who is enrolled/enrolling in FEHB.
Date of Birth Line 1 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s first family member who is enrolled/enrolling in FEHB.
3:68 Form 2809 View (Part B) Page Field Descriptions
Code Line 1 No entry
This field is system generated. This code identifies the first family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 1 No entry
This field is system generated. This is the SSN of the enrollee’s first family member who is enrolled/enrolling in FEHB.
Sex Line 1 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s first family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s first family member who is enrolled/enrolling in FEHB is female.
ZIP Line 1 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s first family member who is enrolled/enrolling in FEHB. Last Name Line 2 No entry
This field is system generated. This is the last name of the enrollee’s second family member who is enrolled/enrolling in FEHB.
First Name Line 2 No entry
This field is system generated. This is the first name of the enrollee’s second family member who is enrolled/enrolling in FEHB.
Initial Line 2 No entry
This field is system generated. This is the middle initial of the enrollee’s second family member who is enrolled/enrolling in FEHB.
Date of Birth Line 2 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s second family member who is enrolled/enrolling in FEHB.
3:69
Form 2809 View (Part B) Page Field Descriptions
CLE R F ie ld D e s c ript io n s An d Ins tr uc ti o ns
Code Line 2 No entry
This field is system generated. This code identifies the second family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 2 No entry
This field is system generated. This is the SSN of the enrollee’s second family member who is enrolled/enrolling in FEHB.
Sex Line 2 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s second family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s second family member who is enrolled/enrolling in FEHB is female.
ZIP Line 2 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s second family member who is enrolled/enrolling in FEHB.
Last Name Line 3 No entry
This field is system generated. This is the last name of the enrollee’s third family member who is enrolled/enrolling in FEHB.
First Name Line 3 No entry
This field is system generated. This is the first name of the enrollee’s third family member who is enrolled/enrolling in FEHB.
Initial Line 3 No entry
This field is system generated. This is the middle initial of the enrollee’s third family member who is enrolled/enrolling in FEHB.
Date of Birth Line 3 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s third family member who is enrolled/enrolling in FEHB.
3:70 Form 2809 View (Part B) Page Field Descriptions
Code Line 3 No entry
This field is system generated. This code identifies the third family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 3 No entry
This field is system generated. This is the SSN of the enrollee’s third family member who is enrolled/enrolling in FEHB.
Sex Line 3 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s third family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s third family member who is enrolled/enrolling in FEHB is female.
ZIP Line 3 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s third family member who is enrolled/enrolling in FEHB. Last Name Line 4 No entry
This field is system generated. This is the last name of the enrollee’s fourth family member who is enrolled/enrolling in FEHB.
First Name Line 4 No entry
This field is system generated. This is the first name of the enrollee’s fourth family member who is enrolled/enrolling in FEHB.
Initial Line 4 No entry
This field is system generated. This is the middle initial of the enrollee’s fourth family member who is enrolled/enrolling in FEHB.
Date of Birth Line 4 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s fourth family member who is enrolled/enrolling in FEHB.
3:71
Form 2809 View (Part B) Page Field Descriptions
CLE R F ie ld D e s c ript io n s An d Ins tr uc ti o ns
Code Line 4 No entry
This field is system generated. This code identifies the fourth family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 4 No entry
This field is system generated. This is the SSN of the enrollee’s fourth family member who is enrolled/enrolling in FEHB.
Sex Line 4 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s fourth family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s fourth family member who is enrolled/enrolling in FEHB is female.
ZIP Line 4 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s fourth family member who is enrolled/enrolling in FEHB.
Last Name Line 5 No entry
This field is system generated. This is the last name of the enrollee’s fifth family member who is enrolled/enrolling in FEHB.
First Name Line 5 No entry
This field is system generated. This is the first name of the enrollee’s fifth family member who is enrolled/enrolling in FEHB.
Initial Line 5 No entry
This field is system generated. This is the middle initial of the enrollee’s fifth family member who is enrolled/enrolling in FEHB.
Date of Birth Line 5 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s fifth family member who is enrolled/enrolling in FEHB.
3:72 Form 2809 View (Part B) Page Field Descriptions
Code Line 5 No entry
This field is system generated. This code identifies the fifth family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 5 No entry
This field is system generated. This is the SSN of the enrollee’s fifth family member who is enrolled/enrolling in FEHB.
Sex Line 5 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s fifth family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s fifth family member who is enrolled/enrolling in FEHB is female.
ZIP Line 5 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s fifth family member who is enrolled/enrolling in FEHB. Last Name Line 6 No entry
This field is system generated. This is the last name of the enrollee’s sixth family member who is enrolled/enrolling in FEHB.
First Name Line 6 No entry
This field is system generated. This is the first name of the enrollee’s sixth family member who is enrolled/enrolling in FEHB.
Initial Line 6 No entry
This field is system generated. This is the middle initial of the enrollee’s sixth family member who is enrolled/enrolling in FEHB.
Date of Birth Line 6 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s sixth family member who is enrolled/enrolling in FEHB.
3:73
Form 2809 View (Part B) Page Field Descriptions
CLE R F ie ld D e s c ript io n s An d Ins tr uc ti o ns
Code Line 6 No entry
This field is system generated. This code identifies the sixth family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 6 No entry
This field is system generated. This is the SSN of the enrollee’s sixth family member who is enrolled/enrolling in FEHB.
Sex Line 6 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s sixth family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s sixth family member who is enrolled/enrolling in FEHB is female.
ZIP Line 6 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s sixth family member who is enrolled/enrolling in FEHB. Last Name Line 7 No entry
This field is system generated. This is the last name of the enrollee’s seventh family member who is enrolled/enrolling in FEHB.
First Name Line 7 No entry
This field is system generated. This is the first name of the enrollee’s seventh family member who is enrolled/enrolling in FEHB.
Initial Line 7 No entry
This field is system generated. This is the middle initial of the enrollee’s seventh family member who is enrolled/enrolling in FEHB.
Date of Birth Line 7 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s seventh family member who is enrolled/enrolling in FEHB.
3:74 Form 2809 View (Part B) Page Field Descriptions
Code Line 7 No entry
This field is system generated. This code identifies the seventh family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 7 No entry
This field is system generated. This is the SSN of the enrollee’s seventh family member who is enrolled/enrolling in FEHB.
Sex Line 7 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s seventh family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s seventh family member who is enrolled/enrolling in FEHB is female.
ZIP Line 7 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s seventh family member who is enrolled/enrolling in FEHB.
Last Name Line 8 No entry
This field is system generated. This is the last name of the enrollee’s eighth family member who is enrolled/enrolling in FEHB.
First Name Line 8 No entry
This field is system generated. This is the first name of the enrollee’s eighth family member who is enrolled/enrolling in FEHB.
Initial Line 8 No entry
This field is system generated. This is the middle initial of the enrollee’s eighth family member who is enrolled/enrolling in FEHB.
Date of Birth Line 8 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s eighth family member who is enrolled/enrolling in FEHB.
3:75
Form 2809 View (Part B) Page Field Descriptions
CLE R F ie ld D e s c ript io n s An d Ins tr uc ti o ns
Code Line 8 No entry
This field is system generated. This code identifies the eighth family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 8 No entry
This field is system generated. This is the SSN of the enrollee’s eighth family member who is enrolled/enrolling in FEHB.
Sex Line 8 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s eighth family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s eighth family member who is enrolled/enrolling in FEHB is female.
ZIP Line 8 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s eighth family member who is enrolled/enrolling in FEHB. Last Name Line 9 No entry
This field is system generated. This is the last name of the enrollee’s ninth family member who is enrolled/enrolling in FEHB.
First Name Line 9 No entry
This field is system generated. This is the first name of the enrollee’s ninth family member who is enrolled/enrolling in FEHB.
Initial Line 9 No entry
This field is system generated. This is the middle initial of the enrollee’s ninth family member who is enrolled/enrolling in FEHB.
Date of Birth Line 9 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s ninth family member who is enrolled/enrolling in FEHB.
3:76 Form 2809 View (Part B) Page Field Descriptions
Code Line 9 No entry
This field is system generated. This code identifies the ninth family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 9 No entry
This field is system generated. This is the SSN of the enrollee’s ninth family member who is enrolled/enrolling in FEHB.
Sex Line 9 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s ninth family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s ninth family member who is enrolled/enrolling in FEHB is female.
ZIP Line 9 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s ninth family member who is enrolled/enrolling in FEHB. Last Name Line 10 No entry
This field is system generated. This is the last name of the enrollee’s tenth family member who is enrolled/enrolling in FEHB.
First Name Line 10 No entry
This field is system generated. This is the first name of the enrollee’s tenth family member who is enrolled/enrolling in FEHB.
Initial Line 10 No entry
This field is system generated. This is the middle initial of the enrollee’s tenth family member who is enrolled/enrolling in FEHB.
Date of Birth Line 10 No entry
This field is system generated. This is the date of birth (MMDDYYYY) of the enrollee’s tenth family member who is enrolled/enrolling in FEHB.
3:77
Form 2809 View (Part B) Page Field Descriptions
CLE R F ie ld D e s c ript io n s An d Ins tr uc ti o ns
Code Line 10 No entry
This field is system generated. This code identifies the tenth family member’s relation to the enrollee. The following are relationship codes: 1 for Spouse; 2 for Unmarried dependent child under age 22 (including an adopted child); 3 for Stepchild, foster child, or recognized natural child; 4 for Unmarried disabled child over age 22 incapable of self-support; and 5 for Parent of dependent survivor annuitant.
SSN Line 10 No entry
This field is system generated. This is the SSN of the enrollee’s tenth family member who is enrolled/enrolling in FEHB.
Sex Line 10 No entry
The values listed below indicate the following:
M A selected radio button indicates the enrollee’s tenth family member who is enrolled/enrolling in FEHB is male.
F A selected radio button indicates the enrollee’s tenth family member who is enrolled/enrolling in FEHB is female.
ZIP Line 10 No entry
This field is system generated. This is the domestic ZIP Code or foreign postal code of the enrollee’s tenth family member who is enrolled/enrolling in FEHB. Other Insurance No entry
The values listed below indicate the following:
Y A selected radio button indicates the enrollee’s family member is enrolled in another group health insurance program.
N A selected radio button indicates the enrollee’s family member is not enrolled in another group health insurance program.
Policyholder Last Name No entry
This field is system generated. This is the last name of the individual who holds the policy from another group health insurance program under which the enrollee or family member is covered.
Policyholder First Name No entry