Instructions for Employees
General Information The major provisions of this program are described in the Federal Employees' Group Life Insurance (FEGLI) Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees). Please read the entire booklet carefully. Your completed copy of this election form (SF 2817) and the FEGLI Program Booklet constitute your certificate (proof) of insurance. These publications, as well as comprehensive FEGLI information, are available at www.opm.gov/insure/life.
I Am A New Employee or Newly Eligible for Life Insurance. What
Do I Need To Know? You are automatically enrolled in Basic (even if you don't complete this form) unless you waive it. If you waive Basic, you automatically waive all forms of Optional insurance. You will not have any Optional insurance unless you elect it.
signature. Return the completed form to the employee's employing office. If the insured is an annuitant, return the completed form to OPM, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045. See #11 for where to return the completed form if the insured is a compensationer.
How Do I Complete The Form? Follow the instructions for each item carefully. After you fill out the form, review it to be sure it is complete and correct. The following checklist should help.
If you sign Section 3, you elect (or retain) Basic.
If you sign any block in Section 4, you elect (or retain) Optional Insurance. You must also elect (or retain) Basic by signing Section 3.
To elect Basic: You do not have to submit this form unless you also wish to elect Optional insurance.
If you sign Section 4 for Option B and/or Option C, you must also mark one of the five boxes to show how many multiples you wish to elect (or retain). Do not mark more than one box.
To waive Basic: Sign Section 5 of the form and give it to your employing office. Your agency will withhold Basic premiums from your salary from your first day at work in a pay status UNLESS you submit your waiver before the end of your first pay period.
Be Sure You Sign For All Options You Want. This election supersedes all previous ones. If you have optional coverage and wish to keep it, you must sign the appropriate box(es). If you do not sign for it, you have waived it.
If you sign Section 5, you waive all FEGLI coverage.
To elect Optional: Sign Section 3 and one or more of the blocks in Section 4 of the form and give it to your employing office within 60 days after the date you are appointed or first become eligible for life insurance.
To waive Optional: If you do not sign for a particular type of Optional coverage in Section 4, you automatically waive that coverage.
Only you, the employee, may sign this form. Signatures by guardians, conservators, or through a power of attorney are not acceptable. Exception: If you have assigned your insurance, only the assignee(s) may cancel some or all of your coverage. In that case, the assignee(s) must sign the form (although the information in Section 2 must refer to you).
I Am An Employee With Prior Government Service. What Do I
Need To Know? When you return to work after a break in service of less than 180 days, your human resources office will automatically enroll you in the same coverage that you had before you left your prior position, if any. This coverage will be effective on your first day in a pay and duty status in a FEGLI eligible position. You will have to qualify to elect other coverage (open season, providing medical information, or a life event). If you waived some coverage, then the waiver of that coverage is still in effect.
When you return to work after a break in service of 180 days or more, your human resources office will automatically enroll you in Basic and the same Optional insurance that you had in your prior position. This coverage will be effective on your first day in a pay and duty status in a FEGLI eligible position. You may elect more insurance (if you don't already have the maximum) within 60 days of your appointment to an eligible position. If you previously waived coverage then that waiver is no longer in effect. You will automatically be enrolled in Basic, unless you file a new waiver.
See the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service Employees) for more details.
I Am A Reemployed Annuitant. What Do I Need To Know? If you waive your insurance when you return to Federal Service as a reemployed annuitant, you also waive your insurance with your retirement annuity. You will have no FEGLI life insurance. It is important that you contact your human resources office and inform them that you are a reemployed annuitant. More details can be found in OPM Form 1482, Agency Certification of Status of Reemployed Annuitants.
What If I Assigned My Coverage? If you have assigned your insurance by filing an RI 76-10, Assignment of Federal Employees' Group Life Insurance, you may not cancel any of your insurance coverage (except Option C). Only the assignee(s) may cancel your coverage. However, you may elect new coverage if you otherwise meet the requirements for electing such coverage. Any new coverage you elect will automatically be subject to your existing assignment, except for Option C, which you cannot assign. All assignments are automatically canceled after a break in service of at least 31 days, or upon cancellation of all life insurance coverage by the assignee(s).
REMEMBER THAT YOU, NOT YOUR AGENCY, ARE RESPONSIBLE FOR ENSURING THAT YOUR SF 2817 (OR ITS ELECTRONIC EQUIVALENT) IS CORRECT AND ACCURATELY REFLECTS YOUR INTENTIONS. IF YOU DO NOT SIGN FOR IT, YOU HAVE CANCELED/WAIVED IT.
Open Seasons If you elected coverage during an Open Season, and that coverage has not yet become effective, and you want to make a further change to your FEGLI coverage on this SF 2817, you should check with your employing office. That office can tell you about any special election procedures that may apply.
What If I Waive or Reduce My Coverage? If you do not sign for a particular type of coverage, you have waived that coverage. If you waive Basic or one or more of the options, your opportunities to enroll in the coverage you waived are strictly limited. A waiver may also affect your eligibility to continue coverage into retirement. See the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) for more details.
Where Do I Send The Completed Form? After you have completed this form and verified that it accurately reflects your intentions, send the entire form (without separating the parts) to your human resources office. Do not send the form to OPM or OFEGLI.
What If I Receive Workers' Compensation? If you are receiving compensation payments from the Office of Workers' Compensation Programs (OWCP), provide your OWCP number in Section 2 of the form. If you are still employed, return the completed form to your employing office. If you are not still employed or if you have been receiving compensation payments for at least 12 months, see your human resources office about your continued eligibility under the FEGLI Program.
How Do I Verify That My Agency Processed My Election? After your employing office processes your election form, you will receive an SF 50, Notification of Personnel Action. A two digit code appearing on the SF 50 will explain your insurance coverage. These codes are explained in Part 2 of the SF 2817. Also check your pay statement for the correct withholdings. If you are insured as a compensationer, you will receive a notice from OPM which will explain your insurance coverage.
I Am An Assignee. What Can I Do? If you are completing this form in order to cancel some or all of the employee's life insurance coverage, you must sign the form. The information in Section 2 of the form refers to the employee, but you must sign in Section 3, 4 or 5, as applicable. Indicate "assignee" after your
13. Where Do I Get More Information About The FEGLI Program? Consult the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) or the FEGLI Handbook (RI 76-26), which are available on the FEGLI web site at www.opm.gov/insure/life.
Privacy Act and Public Burden Statements
Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance, authorizes solicitation of this information. The data you furnish will be used to determine your life insurance coverage. This information may be shared and is subject to verification, via paper, electronic media, or through the use of the computer matching programs, with national, state, local or other charitable or social security administrative agencies to determine and issue benefits under their programs or law enforcement agencies, when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number to distinguish between the applicant and people with similar names. Failure to furnish the requested information may result in your agency's inability to determine your life insurance coverage.
We estimate this form takes an average of 15 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0230), Washington, DC 20415-3430. The OMB Number, 3206-0230 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Back of Part 3
Standard Form 2817 Revised November 2011