BEN09007 at a glance
What it is: Federal Employees Dental and Vision Insurance Program (FEDVIP) form: use this form only to request approval of a belated enrollment, change, or cancellation.
Who signs: Enter your Signature (Required) and the Date signed (mm/dd/yyyy) (Required).
A filled-in BEN09007 example: a dental enrollment after a medical emergency
How to fill out BEN09007, box by box
Section A: Contact Information
Provide as much accurate information as possible. Your request cannot be processed if you cannot be reached.
Enter your First name, M.I., Last name, Address 1, Address 2, City, State/Territory, Country and Zip/Foreign postal code.
Enter your BENEFEDS user ID, if applicable.
Enter your Daytime phone, Other phone and Best times to call you about your request.
1. This request is for a
Select one: new enrollment, change to an existing enrollment, or cancellation of an enrollment.
2. Date of QLE, new hire, or new eligibility
Fedpoint will consider your request if you were unable to perform, due to specific reasons beyond your control, the requested action during the Federal Benefits Open Season or within 60 days of a qualifying life event (QLE) or becoming a new or newly eligible employee. (Examples of a QLE may be a change in family status that results in the increase or decrease in the number of eligible family members or an employee being restored to civilian status after serving in the uniformed services.) Fedpoint must receive your completed form within three months of the last day of the Federal Benefits Open Season, your QLE date, or your new hire or newly eligible date. Incomplete forms will not be processed.
If this is NOT a Federal Benefits Open Season request and involves a QLE or a new hire or newly eligible request, enter your QLE, new hire, or newly eligible date (mm/dd/yyyy) in the Date of QLE, new hire, or new eligibility box.
3. Dental plan or vision plan
This request is for a FEDVIP dental plan and/or a FEDVIP vision plan: Dental plan, Vision plan.
Please select one of the reasons below
If you did not experience one of the reasons listed, this request is unable to be approved.
Valid reasons for which approval of this request will be considered. Select one of the reasons: you had no access to a telephone or the Internet for the entire duration of the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.
You had a significant medical emergency for yourself or an immediate family member and you were unable to perform your requested action for a significant portion of the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.
A member of your immediate family passed away and you were unable to perform your requested action during the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.
Please explain why you could not enroll, make a change, or cancel your enrollment during the eligible time frame, and be as detailed as possible.
While this information is reviewed, additional documentation to support your reason may be requested.
Section C: Signature and Mailing/Fax Instructions
Section C: Signature and Mailing/Fax Instructions. Enter your Print name (Required).
More rules for BEN09007
Please answer all applicable questions.
If your request is approved, you will have 30 days from the date on your approval letter to contact FedPoint to execute your request.
If your request is approved, a belated enrollment, change, or cancellation must be retroactive to the effective date it would originally have been, had the request for the change been received within the eligible time frame.
If the change results in past due premiums, these premiums must be paid by direct bill, and failure to make this direct bill payment will result in a termination of your enrollment.
All FedPoint decisions are final.
Common questions about BEN09007
Where do I file it?
Return your completed form to: BENEFEDS, P.O. Box 797 | Greenland, NH 03840-0797 | Fax: 1-877-827-3291
Sources
[1] Form BEN09007, The Federal Employees Dental and Vision Insurance Program (FEDVIP) Belated Enrollment/Change Form, FedPoint (BENEFEDS) (the Official source link on this page).
