Get Dos Ds-5112 2019-2025

The DoS DS-5112 form is an essential document for employees concerning their Federal Employees Health Benefits (FEHB) coverage during nonpay status. This guide provides a comprehensive, step-by-step approach to help you complete the form accurately online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your name in the format of Last, First, and Middle Initial. Ensure accuracy, as this identifies you clearly.
3. Enter today's date in the mm-dd-yyyy format to document when you are submitting the form.
4. Input your Social Security Number. This is vital for tracking your health benefits.
5. Fill in your date of birth in mm-dd-yyyy format to verify your identity.
6. Locate your enrollment code from your Earnings and Leave Statement and enter it accordingly.
7. Input the effective date of your nonpay status in mm-dd-yyyy format. This is the date when your nonpay status begins.
8. Select your option regarding your FEHB enrollment. You can either terminate or continue your enrollment. If you choose to terminate, check the corresponding box, acknowledging the 31 days of temporary coverage extension.
9. If you are opting to continue your enrollment, check the relevant box and indicate how you plan to handle premium payments—either directly or as a debt.
10. Provide your contact information for during the nonpay status, including your address, city/state/ZIP, telephone number, and email address.
11. Sign and date the form at the bottom to confirm your understanding of the information and agreements stated.
12. Once completed, save your changes and ensure that you download or print a copy for your records.
13. Lastly, forward the signed and dated form to the specified email addresses to complete the submission process.

Complete your DoS DS-5112 form online to ensure your health benefits are managed appropriately.