SAMBA Enrollment Kit


I would like to enroll in (Select one at a time): Dental & Vision Program I am actively employed with one of the following agencies: FBI, USSS, DEA, ATF, CBP, CIS, ICE. I am actively employed with a Federal Agency NOT included in the above list. I am retired from a Federal Agency. Dental & Vision Program for children age 26 and older handicapped/incapable of self-support I am actively employed with one of the following agencies: FBI, USSS, DEA, ATF, CBP, CIS, ICE. I am actively employed with a Federal Agency NOT included in the above list. I am retired from a Federal Agency. Employee Benevolent Fund SAMBA Term Life Insurance Personal Accident Insurance I am actively employed with one of the following agencies: FBI, USSS, DEA, ATF, CBP, CIS, ICE. I am actively employed with a Federal Agency NOT included in the above list. I am retired from a Federal Agency. Disability Income Protection I am actively employed with one of the following agencies: FBI, USSS, DEA, ATF, CBP, CIS, ICE. I am actively employed with a Federal Agency NOT included in the above list. I am retired from a Federal Agency.
These fillable forms are best viewed in Adobe Reader 9.2. Click on the link below to download a free copy.
Note: If you would like to enroll in the federal SAMBA Health Benefit Plan, you must contact your Payroll Office. If you are an annuitant, you must contact OPM (Office of Personnel Management). Click here to be directed to OPM's Website.

I would like to enroll in (Select one at a time):