NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411856
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: May 26, 1970

Standard Form No. 2810
6 U.S. Civil Service Commission
FPM Supplement 890.1
November 1965
1. NAME (LAST)
Caranci
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
NOTICE OF CHANGE IN HEALTH BENEFITS ENROLLMENT
Part A. IDENTIFYING DATA
(FIRST)
John
(MIDDLE INITIAL)
C.
2-7-22
DDRESS
64 Eddy Street
Centerdale, Rhode Island 02911
078546
6. ENROLLMENT CODE NO.
422
1 April 1970
1
(bl61
(b131
ONLY THE ITEM W)ilCR 15 CMECtED BELOW AFFECTS YOUR ENROLLMENT. READ THAT ITEM CAREFULLY AND FOLLOW ANY PERTINENT
INSTRUCTIONS. KEEP THIS FORM UNLESS YOUR ENROLLMENT IS TERMINATED AND, YOU APPLY FOR CONVERSION.
L~J YOUR ENROLLMENT TERMINATES ON THE DATE IN PART A, ITEM 7, ABOVE.
IMPORTANT NOTICE. -You have the right to convert to an individual contract with the carrier of your plan. See Part 6.-Termination on
the back of this form for information about your extension of coverage and conversion. If you want to convert, fill in the box on the back of
this form and send it to your plan within the time limit specified.
YOUR ENROLLMENT SHOWN IN PART A, ITEM 6, ABOVE HAS BEEN TERMINATED BECAUSE OF YOUR ENROLLMENT IN ANOTHER
El PLAN.
Part D.-TRANSFER OUT
YOUR ENROLLMENT CONTINUES BUT IS TRANSFERRED TO
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM):
YOUR NEW PAYROLL OFFICE (OR RETIREMENT SYSTEM) SHOWN
IN PART K BELOW HAS ACCEPTED TRANSFER OF YOUR EN-15
ROLLMENT AND WILL CONTINUE IT.
(SEE PART D ON THE BACK OF THIS FORM FOR MORE
INFORMATION)
YOUR ENROLLMENT HAS BEEN SUSPENDED, EFFECTIVE ON
Q THE DATE IN PART A, ITEM 7, ABOVE.
YOUR ENROLLMENT HAS BEEN REINSTATED, EFFECTIVE ON
s THE DATE IN PART A, ITEM 7, ABOVE.
Part H.-CHANGE IN NAME OF ENROLLEE
YOUR ENROLLMENT HAS BEEN CHANGED FROM FAMILY COVERAGE TO SELF ONLY. YOUR PLAN WILL
SEND YOU A NEW IDENTIFICATION CARD.
YOUR NEW ENROLLMENT
CODE NUMBER
Part J: REMARKS
Employee Annuitant
Chief,
Original-To Enrollee
APPROVED FOR
RELEASE^DATE:
10-Nov-2008 I
 PART.Z_-TERMI.NATION
if Puri B on the ether side of this form is ch'eclcreti, read the fo;?: isi
TEMPO!'y:.i'Y "EXTENSION ? OF ,COVE9A0E
'our en-ol!ment terminates on the date ,noWn in Nor` A, Item 7, on the
fmni of this form. Coverage under your enrollment continues temporarily
for 31 days from the date shown, If
you ar cry coeerar.',+ member of your
family is a pct''ent:_fh a smc ritof on the-51,t -. d?.:~y of- this temporary ezten-
.nn, benefits of the Na, may con :cue for that person for iho rest o`
thof confinement, but not beyond 50 more days.
For conversion, fill out this box and take or mail
this form imr=-lediitelyr to your Flan. DO NOT
CENrt IT TO IhC rR;F.1 CER16BFCE COMMAAEC-r-.
You esy convert you. enrolin:::ri' to c. .c. r:group contract, without evi.
de,ce c. good health. the nongru': which you may -ori ert
arly cffcred by your 'lca. It may d ffcr from your group pirn
r?esafits,, or cc:, or both, asd yore vri!i ho?.- to Pay the entire .,,at of
is - cnaraup contract direct the Nor. ,he nc:ngrouF?. contra ,:t is cr...
. iris day elt: