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Health and Life Insurance Forms

Health Care Forms

Federal Health Benefits Election Form  - If you were hired prior to October 1, 1987, you participate in the Federal health care program. The form should be used to enroll in the Federal Plan upon retirement or to make changes in your coverage during Open Enrollment periods or upon a change in family status.

District Health Benefits Registration Form - If you were hired on or after October 1, 1987, you participate in the District health care program. The following form should be used to enroll in the District Plan upon retirement or to make changes in your coverage during Open Enrollment periods or upon a change in family status.

District of Columbia Temporary Continuation of Coverage Benefits Enrollment Form   - If you participate in the District health care program, you may complete this form to enroll in the District's Temporary Continuation of Coverage (TCC) within certain periods of a qualifying event or recieving notice of eligibilty.

If you have further questions, please contact DCRB Member Services at the number below, or call the Member Services toll-free number at (866) 456-3272.
 

Federal Employees' Group Life Insurance (FEGLI) Program Forms

Designation of Beneficiary Form

Life Insurance Election Form 
 

Special Insurance Forms

Health Coverage Certification for Grandchildren

Service Contact: 
Member Services Center
Contact Email: 
Contact Phone: 
(202) 343-3272
Contact Fax: 
(202) 566-5001
Contact TTY: 
711