12th Annual Federal Workers' Compensation Conference S i #39 ...

Agency Information &
Certification
• SF 3104 – • Unless not covered
Application for Death
under an FEHB plan)
Benefits (Required)
• SF 2809s –
Employee Health
Benefit Election
Forms (Required)
• DD 214 – Military
Discharge
(Recommended in
all cases with
military service)
• SF 2810s – Notice of
Change in Health
Benefits Election
Form (Required,
• SF3104B, Section 1
– Certified Summary
of Federal Service
(Required)
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