Claim for Death Benefits Federal Employees’ Group Life Insurance Program (Do not use this form to claim Option C-Family Benefits. Please use form FE-6 DEP to claim those benefits.) Instructions General The Office of Federal Employees' Group Life Insurance (OFEGLI) pays claims under the Federal Employees’ Group Life Insurance Program. “We” and “our” on this form refer to OFEGLI. “I” and “you” refer to the individual completing this form. FEGLI death benefits are not subject to Federal income tax, but the interest that we pay on those benefits is subject to such tax. We will report all interest payments to the Internal Revenue Service. Who receives the death benefits? We will pay benefits in the following order of payment: If the deceased assigned ownership of his/her life insurance to someone else (generally by filing an RI 76-10, Assignment form), then we will pay: First, to the beneficiary(ies) the assignee(s) validly designated; Second, if none, to the assignee(s). If the deceased did not assign ownership and there is a valid court order on file with the agency or OPM, as appropriate, we will pay benefits according to the court order. If the deceased did not assign ownership and there is no valid court order on file with the agency or OPM, as appropriate, then we will pay: First, to the beneficiary(ies) the deceased validly designated; Second, if none, to the deceased’s widow or widower; Third, if none of the above, to the deceased’s child or children and descendants of any deceased children (a court will usually have to appoint a guardian to receive payment for a minor child); Fourth, if none of the above, to the deceased’s parents in equal shares, or the entire amount to the surviving parent; Fifth, if none of the above, to the court-appointed executor or administrator of the deceased’s estate; Sixth, if none of the above, to the deceased’s other next of kin, entitled under the laws of the state where the deceased lived. Don’t skip any questions you’re supposed to answer. That will delay our action on your claim. If a question doesn’t apply, write “N/A” or “not applicable”. If the answer is “No” or “Unknown”, write that. If you are completing this claim on behalf of someone else (such as a minor), complete items 1-3 of Part C with that person’s information, not yours. In part F and page 2, sign your own name “on behalf of ” the other person. Fill in your name, address and phone numbers. However, the Social Security Number should be the other person’s, not yours. What else do I have to submit? In addition to this claim form, you must submit a certified copy of the deceased’s death certificate that contains the cause and manner of death. (However, if you know for sure that another claimant is submitting the deceased’s death certificate, you don’t have to). You can get the certificate from your city or state’s Bureau of Vital Statistics or equivalent agency. We cannot process your claim until we receive the certified death certificate. Please submit an English translation of any foreign language death certificate. In addition, send us all Designation of Beneficiary Form(s) (SF 2823 and/or SF 54) that you may have which show the agency receipt date on the bottom. If you are an executor or administrator filing this claim on behalf of the deceased’s estate, send us a copy of the court appointment papers. We will let you know if we need anything else. Where do I send this form and other documents? If we are paying you $5,000 or more, we will open a money market account in your name and mail you a checkbook. You may write checks for some or all of the money in your account as soon as you receive the checkbook. See page 2 for details. . If we are paying you less than $5,000, we will mail you a check. If the deceased was employed at the time of death Send everything to the deceased’s employing office. We will process your claim after we receive certification from the agency. However, if you are the deceased’s widow(er) and the agency told you to send your claim form and other documents directly to us, you should do that. Please include copies of any letters you received from the agency that mention death benefits. If the deceased was retired or receiving Federal Workers’ Compensation benefits at the time of death Send everything to OFEGLI, P.O. Box 6512, Utica, NY 13504-6512. How do I complete this form? Please type or print legibly in ink. If you need help completing this form, call our service representatives, toll-free, at 1-800-OFE-GLIA (1-800-633-4542). Here is a summary of what parts of the form you must complete: Instructions to the employing agency Forward the completed claim, death certificate and court appointment papers, if any, to OFEGLI, P.O. Box 6512, Utica, NY 13504-6512, together with: 1. The original Agency Certification of Insurance Status (SF 2821); 2. The original Designation of Beneficiary form(s) (SF 2823 or SF 54), if any; 3. All court orders on file, if any; and 4. All other FEGLI forms (for example, SF 2817 or RI 76-27 election forms, RI 76-10 assignment form, etc.) How will I receive benefits? Then Complete These Parts of the Form: If you are a: A Widow or Widower ✔ All Others ✔ C 1-3 Do NOT use previous editions C ✔ ✔ ✔ ✔ ✔ E F Page 2 ✔ D ✔ ✔ ✔ 4-13 B ✔ ✔ Page 1 Form FE-6 Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT INFORMATION ABOUT MONEY MARKET ACCOUNTS AUTOMATIC • If we are paying you $5,000 or more, we will automatically open a money market account in your name and mail you the checkbook. If we are paying you less than $5,000, we will mail you a check. SAFE • The account earns interest starting the first day we open it. • Metropolitan Life Insurance Company guarantees the full amount in the account, including all interest. FREE • You pay nothing for this account. There are no monthly service charges or charges for checks. • You can write checks from $250 up to the full balance at any time. FLEXIBLE • You can withdraw all or part of your money at any time, with no penalty. • You can name a beneficiary for your funds, in case something happens to you. We will send you detailed information about the account when we open one in your name. SPECIAL NOTE Please complete, in ink, the information below and sign your name in the first box. We need this information to open a money market account. Even though you may be giving the same information elsewhere on this form, you must also give it here. We cannot process your claim without this information. Your signature (Do not print) Your name (Please print) Address (Number, street, apt. no.) City, state, ZIP code Your Social Security Number OR Estate/Trust/Tax ID Number Date (mm/dd/yyyy) Daytime telephone no. Evening telephone no. ( ( ) Area Code Do NOT use previous editions ) Area Code Page 2 Form FE-6 Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) American LegalNet, Inc. www.FormsWorkFlow.com Office of Federal Employees’ Group Life Insurance P.O. Box 6512 Utica, NY 13504-6512 Claim for Death Benefits Federal Employees’ Group Life Insurance Program Read the instructions carefully before filling out this form. Part A. Information About the Deceased (Everyone must complete this part.) 1. Deceased’s full name (Last) (First) (Middle) 2. Date of birth (mm/dd/yyyy) 3. Date of death (mm/dd/yyyy) 4. Social Security Number 5. Legal residence at time of death—(City and state) 6. Department or agency in which last employed, including bureau or division 7. Location of last employment (City, state, ZIP code) 8. At the time of death, was the deceased retired and receiving a monthly annuity under any Federal civilian retirement system ? Yes No Unknown If “Yes”, provide the Claim number (CSA, CSF CSI) _____________________________________ , *Special Note: Social Security monthly payments are not Federal civilian retirement annuities. 9. At the time of death, was the deceased receiving Federal Worker’s Compensation benefits ? Yes No Unknown If “Yes”, provide the effective date of Federal Workers’ Compensation benefits ________________ (mm/dd/yyyy) Part B. Information About the Deceased’s Family (Everyone must complete this part.) 1. How many times was the deceased married? 2. Give the name of each spouse (include ALL marriages) 3. How did the marriage end? (Check one in each case) Death ❑ ❑ Divorce Death 5. Did the deceased have any living children on the date of his/her death? Yes No If Yes, how many? ___________ Divorce Death 4. When did the marriage end? (mm/dd/yyyy) Divorce 6. Did the deceased have any children who died before the date of his/her death? Yes No If Yes, how many? __________ ❑ ❑ Part C. Information About You (Everyone must complete items 1, 2 and 3.) 1. Your name (First) (Last) (Middle) 2. Your relationship to the deceased 3. Your date of birth (mm/dd/yyyy) Complete Items 4 through 13 only if you are the deceased’s widow or widower. 4. Date of marriage (mm/dd/yyyy) 5. Place of marriage (City and state) 7. Were you living with the deceased at the time of death? 8. Were you divorced from the deceased at the time of death? 6. Marriage was performed by: Clergy or Justice of the Peace Other (specify) Yes No 10. How many times were you married? Yes 9. If you were divorced from the deceased, give the date (mm/dd/yyyy) and place of the divorce. No 11. Give the name of each spouse (include ALL marriages) 12. How did the marriage end? (Check one in each case) Death Page 3 Divorce Death Do NOT use previous editions Divorce Death 13. When did the marriage end? (mm/dd/yyyy) Divorce Form FE-6 Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) American LegalNet, Inc. www.FormsWorkFlow.com Everyone must complete Parts D and E unless you are the deceased's widow or widower. Part D. Information About the Deceased's Next of Kin 1. List below the name, age, relationship and address of : (a) Widow or widower; (b) If there is no surviving widow or widower, list the child or children of all the deceased's marriages (include adopted children and children born out-of-wedlock) and the descendants of any deceased child or children (use additional sheets if necessary); Name Age (c) If there are no children, list the parents; if one or both parents are deceased, so state and give the date of death; (d) If there are no survivors in (a) through (c), list the next of kin who may be capable of inheriting from the deceased (brothers, sisters, descendants of deceased brothers, sisters, etc.). (Use additional sheets if necessary). Relationship to the deceased Full address Fill in items 2 and 3 only if any of the persons listed above are under age 18. 2. If the court appointed a guardian for the estate of any minor children above, give the name and address of the guardian and attach a copy of the court appointment papers. Natural parentage or custody as a result of a divorce do not constitute guardianship. Name 3. If the court did not appoint a guardian for the estate of any minor children, will it appoint one later? Address (Number, street, apt. no.) City, state, ZIP code Yes No Part E. Information About the Deceased's Estate 1. If the court appointed an executor or administrator to settle the deceased's estate, give his/her name and address and attach a copy of the court appointment papers. Name 2. If the court did not appoint an executor or administrator, will it appoint one later? Address (Number, street, apt. no.) City, state, ZIP code Yes No Part F. Your Certification (Everyone must complete this part.) Are you claiming accidental death benefits (did the deceased die solely through violent, external, and accidental means)? If "Yes", submit coroners and police reports, news clippings, and any other available reports concerning the accident. OFEGLI cannot consider a claim for such benefits if the deceased separated or retired before the accident. If the amount payable to you is $5,000 or more, OFEGLI will open a money market account in your name, giving you complete control of and immediate access to all your funds. You may write checks for all or part of the money in your account when you receive your checkbook. See page 2 for more information, and be sure you complete the information on page 2 under "Special Note". Yes No Your name (Please print) Address (Number, street, apt. no.) City, state, ZIP code Your Social Security Number OR If the amount payable to you is less than $5,000, OFEGLI will send you a check. _ _ Estate / Trust / Tax ID Number _ Under penalty of perjury, I certify: 1. That the number shown on this form is my correct taxpayer identification number; and 2. That I am NOT subject to backup withholding because: (a) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (b) the IRS has notified me that I am no longer subject to backup withholding. If you are currently subject to backup withholding, check this box: Yes No 3. I am a U.S. citizen or a U.S. resident for tax purposes. Check one If you are not a U.S. citizen or resident for tax purposes, we will send you a W-8BEN that you are required to complete to certify your foreign status. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. My signature (Do not print) ( ( ) Area Code Daytime telephone no. ) Area Code Evening telephone no. Warning—If you knowingly and willfully make any materially false, fictitious or fraudulent statement or representation on this form, or conceal a material fact related to the requests for information on this form, you may be subject to a monetary fine or imprisonment for not more than five years, or both, under 18 U.S.C. 1001. Do NOT use previous editions. Page 4 American LegalNet, Inc. www.FormsWorkFlow.com Form FE-6 Revised May 2009 OFEGLI Form in Adobe Acrobat (05/09)