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Life Insurance Election

Federal Employees' Group Life Insurance

Federal Employees' Group Life Insurance Program

1

1005

E5

1101

F1

1102

F2

1103

F3

1104

F4

1105

F5

1010

G0

1110

H0

INSURANCE

SF 50

INELIGIBLE

A0

0000

B0

1000

C0

1100

D0

1001

E1

1002

E2

1003

E3

1004

E4

1011

I1

1012

I2

1013

I3

1014

I4

1015

I5

1111

J1

1112

J2

1113

J3

1114 1115 1020 1120 1021 1022 1023 1024

SF 50 Equivalents of

Insurance Codes

1025

M5

1121

N1

1122

N2

1123

N3

1124

N4

1125

N5

1030

90

1130

P0

1031

Q1

1032

Q2

1033

Q3

1034

Q4

1035

Q5

1131

R1

1132

R2

1133

R3

J4 J5 K0 L0 M1 M2 M3

M4

1134 1135 1040 1140 1041 1042 1043 1044

R4 R5 S0 T0 U1 U2 U3 U4

2

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

Date of birth (mm/dd/yyyy)

1045

U5

1141

V1

1142

V2

1143

V3

1144

V4

1145

V5

1050

W0

1150

X0

1051 1052 1053 1054 1055 1151 1152 1153

Social Security Number

1154

Z4

1155

Z5

Form Approved: OMB No. 3206-0230

Y1 Y2 Y3 Y4 Y5 Z1 Z2 Z3

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

In item 7: If this block is not signed, enter 0 in ALL FOUR boxes. If this block is signed, enter 1 in box 1.

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

Option A - Standard

Option B - Additional

Option C - Family

In item 7, box 2: If this block is not signed, enter 0 If this block is signed, enter 1.

In item 7, box 3: If this block is not signed, enter 0 If this block is signed, enter the number marked "X"

In item 7, box 4: If this block is not signed, enter 0 If this block is signed, enter the number marked "X"

below.

below.

3 times my pay

3 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.)

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.)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

5

If you want NO life insurance coverage, sign and date below. In item 7: If this block is signed, enter 0 in ALL FOUR boxes.

Waiver of all life insurance coverage

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)

6

Agency Use

Remarks:

Name and address of employing office

Date received in employing office Effective date of coverage

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

Number of event permitting change

(mm/dd/yyyy)

(mm/dd/yyyy)

(See back of Part 2)

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

7

INSTRUCTIONS: Enter codes in the boxes on the right as directed in items 3, 4 and 5 above.

1

Insurance Code 23

4

SF 50 Equivalent

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

PART 2 - For Agency Use

Previous edition is not usable.

Standard Form 2817 Revised November 2011

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