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Life Insurance Election

Form Approved: OMB No. 3206-0230

Federal Employees' Group Life Insurance

Federal Employees' Group Life Insurance Program See Privacy Act Statement on back of Part 3

1 G e n e r a l I n s t r u c t i o n s .Read the back of Part 3 - Employee Copy carefully. . B y l a w , u n l e s s y o u w a i v e a l l c o v e r a g e o r a r e i n e l i g i b l e , y o u a r e a u t o m a t i c covered for Basic life insurance as an employee. When you first become eligible for FEGLI, you may (1) do nothing and have Basic automatically, (2) elect Basic and any or all of the options, or (3) waive all life insurance coverage. If you are changing a previous election, see the back of Part 3 - E m p l o y e e ally Assignees completing this form should read Items 5 and 6 on the back of Part 3. Give all parts of your completed form to your employing office. Your employing office will complete Section 6 of this form (or its electronic equivalent) and return your copy to you. . C o py. *This election supersedes all previous elections.*

2

Fill in identifying information concerning the employee. Name (last, first, middle)

Date of birth (mm/dd/yyyy)

Social Security Number

Employing department or agency

OWCP claim number, if applicable

Location of department or agency where you Daytime telephone number

work (city, state, ZIP code)

(including area code)

3

To elect or retain Basic, sign and date below. If you do not sign for Basic, you (or your assignee) may not elect or retain any form of optional insurance. If you do not want any insurance at all, skip to Section 5.

I want Basic. I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)

Basic

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of Date (mm/dd/yyyy) attorney are not valid.)

4

Optional

If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS you have previously waived any or all of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI Program Booklet). Sign the box(es) below for any option(s) you are eligible for and wish to elect or retain. If you do not sign for an option, you have waived it and your future opportunities to enroll in it are strictly limited.

You will not be covered for any option(s) for which you do not sign below, regardless of whether you previously elected the option(s).

I want Option A.

I want Option B in the multiple of my annual basic pay I

I authorize deductions to pay the full cost.

indicate below. I authorize deductions to pay the full cost.

Option A - Standard

Option B - Additional

Option C - Family

I want Option C in the multiple I indicate below.

I understand that each multiple is worth $5,000 upon the death of my spouse, and $2,500 upon the death of an eligible child. I authorize deductions to pay the full cost.

3 times my pay

3 multiples

1 times my pay

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of attorney are not valid.)

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of attorney are not valid.)

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of attorney are not valid.)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

5 I f y o u w a n t N O l i f e i n s u r a n c e c o v e r a g e , s i g n a n d d a t e b e l o w . I w a n t N O l i f e i n s u r a n c e c o v e r a g e . I u n d e r s t a n d t h a t a n y l i f e i n s u r a n c e I h a v e w i l l s t o p a t t h e e n d o f t h e l a s t d a y o f t h e p a y p e r i o d i n w h i c h m y employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form and submit satisfactory medical information, or (2) I experience a life event, or (3) I have a break in Federal service of at least 180 days, or (4) I participate in an open season, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand that my decision to Waiver of all life insurance coverage waive life insurance coverage now may affect my eligibility for coverage as a retiree. SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through Date (mm/dd/yyyy) a power of attorney are not valid.)

Date received in employing office Effective date of coverage

Number of event permitting change

(mm/dd/yyyy)

(mm/dd/yyyy)

(See back of Part 2)

6

Agency Use

Remarks:

Name and address of employing office

If new/newly eligible employee, enter "0" for event.

I followed the instructions on the back of Part 1. Signature of authorized agency official

The employee's copy of this form, when completed by the employing office, together with the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) constitute the employee's Certificate (proof) of Insurance.

U.S. Office of Personnel Management www.opm.gov/insure/life

Previous edition is not usable.

Standard Form 2817 Revised November 2011

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