Dependent Children Health Plan Enrollment Kit

(Parent must have federal SAMBA Health Benefit Plan coverage)

So that we can lead you to the proper enrollment kit, please choose one of the following:

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
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link below to download a free copy.