The information you provide is needed for your enrollment in the Federal Employees Health Benefits Program under Chapter 89, title 5, U.S. Code. This information will be shared with the health insurance carrier you select, so that they may (1) identify your enrollment in the plan, (2) verify you and/or your family's eligibility for payment of claims for health benefits services or supplies, and (3) coordinate payment of claims with other carriers with whom you might also make a claim for payment of benefits. This information may be disclosed to other Federal agencies or Congressional offices that may have need to know it in connection with your application for a job, license, grant or other benefit. It may also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social security administrative agencies to determine and issue benefits under this program. In addition, to the extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law enforcement agency. While the law does not require you to supply all the information requested, doing so will assist in the prompt processing of your enrollment.

We think this collection of information takes an average of 10 minutes to complete, including the time for reviewing instructions and getting the needed data.  Send comments regarding our estimate or any other aspect of this information collection, including suggestions for reducing completion time, to the Office of Personnel Management, OPM Forms Officer (3206-0201), Washington, DC 20415-7900.  The OMB number 3206-0201 expires on July 31, 2007.   OPM may not collect this information, and you are not required to respond, unless this number is displayed.