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Instructions for Agencies

Who Should File This Form?

Y

New employees eligible for life insurance who want optional insurance or no insurance. Note: New employees who want only Basic do not have to file.

Y

Employees appointed to positions that allow life insurance coverage following service in positions that did not allow life insurance coverage.

1.

Y Y

Employees who want to change their life insurance.

Reinstated employees who filed a previous waiver of any type of life insurance, were separated from service for at least 180 days, and wish to elect coverage.

Y

3.

An employee who is already enrolled in Option B and/or Option C may elect from 1 to 5 multiples (up to 5 total) within 60 days based on the life event.

What Should You Review After The Employee Submits This Form?

Review all three parts of the SF 2817 to see that they are legible and complete. If an employee signs the box for Option A, Option B, or Option C, he or she must also sign Section 3, Basic. If the employee uses a downloaded copy, be sure all parts are completed. Contact the employee if any part is unclear.

Y Y

Assignees who want to decrease or cancel coverage.

Department of Defense employees designated "emergency essential" and civilian employees deployed in support of a contingency operation per Public Law 110-417.

Give a new employee a copy of the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) when he or she reports for duty and ask the employee to return the completed SF 2817 as soon as possible (preferably before the end of the first pay period), but no later than 60 days after his or her appointment.

Only the employee may sign this form in Sections 3, 4, or 5, with one exception (noted below). Signatures by guardians, conservators, or through a power of attorney are NOT valid.

Exception: If the employee assigned the insurance, only the assignee(s) may waive or reduce some or all of the employee's coverage. In that case, the assignee(s) must sign the form (although the information in Section 2 must refer to the employee). Please note that assignees cannot increase the employee's coverage. Only the employee can do that.

The employee is solely responsible for ensuring that the SF 2817 accurately reflects his or her intentions.

Employees with prior government service in non-excluded positions who were separated after March 31, 1981, should have an SF 2817 on file in their personnel folders, and that election or waiver of coverage may still be in effect. Do not accept a new SF 2817 unless the employee has a break in Federal service of at least 180 days or is eligible to cancel a previous waiver that has been in effect for at least one year, or wishes to reduce coverage.

Until you verify an employee's SF 2817 on file, make deductions based on his or her statement about earlier insurance coverage. Once coverage is confirmed, make any necessary adjustments to correct the withholdings.

If the employee is electing new coverage, always make sure that the authorized agency official confirms that the employee is eligible for the coverage, and that the official signs the form in Section 6.

  • 4.

    When Did You Receive This? Enter the date the employing office received this form.

  • 5.

    What Is The Event Permitting The Change? Enter the number of the event permitting a change, if applicable. See the Table of Effective Dates on the back of

Part 2 for event numbers.

2.

An employee may at any time file an SF 2817 to waive or reduce coverage, unless the employee has assigned his/her insurance coverage. If the employee has assigned the insurance, only the assignee(s) may waive or reduce the coverage (except for Option C which cannot be assigned).

How Else Can An Employee Elect More Coverage?

Y

Provide Medical Information. An employee may elect or increase Basic, Option A, or Option B insurance (but not Option C), if a previously completed SF 2817 waiving coverage has been in effect for more than one year, by submitting satisfactory evidence of insurability via a Request for Insurance, SF 2822. If approved, the employee should make the election on the SF 2817 and submit to the employing agency. More details are contained on the SF 2822.

Y

Experience A Qualifying Life Event. An employee may elect Basic, Option A, Option B and/or Option C within 60 days following a FEGLI qualifying life event. These events are: marriage, divorce, spouse's death, or the acquisition of an eligible child.

For Option B and Option C, an employee may elect from 1 to 5 multiples (up to 5 total) based on the life event.

  • 6.

    What Is The Effective Date Of The Coverage? Enter the effective date of coverage. For new and newly eligible employees: Basic is effective on the first day the employee is in a pay and duty status; Optional coverage is effective on the first day the employee is in a pay and duty status on or after the day the employing office receives the SF 2817. For changes in elections, see the Table of Effective Dates on the back of Part 2. If there is more than one effective date for this election, the 2nd effective date should be notated in Part 6 under "Remarks."

  • 7.

    What Do You Do With Parts 1, 2, and 3? After completion, give Part 3 to the employee. File Part 1 in the employee's personnel folder. Destroy Part 2 after payroll office use. Part 3, and the FEGLI Program Booklet (FE 76-21, or FE 76-20 for U.S. Postal Service employees), serve as the employee's certificate of insurance.

8.

Where Can You Find More Information?

Consult the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) or the FEGLI Handbook, which are available on the FEGLI web site at www.opm.gov/insure/life.

Back of Part 1

Standard Form 2817 Revised November 2011

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