Statement of Claim — Option C Family Life Insurance Federal Employees' Group Life Insurance Program 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. How do I complete this form? • Read the instructions carefully. • Please type or print legibly in ink. • Complete parts A, B and C. What else do I have to send with this claim form? In addition to this claim form, you must send a certified copy of the deceased’s death certificate that contains the cause and manner of death. You can get the certificate from your city’s or state’s Bureau of Vital Statistics or equivalent agency. We cannot accept a photocopy of the death certificate. We will let you know if we need anything else. What should I do if I need help completing this form? If you need help in completing this form, you may contact our customer service representatives, toll-free, at 1-800-OFE-GLIA (1-800-633-4542). Where do I send this form and other documents? Please do not send your claim form and other documents directly to OFEGLI. • If you are an active employee, send everything to your employing office. • If you are retired or receiving Federal Workers' Compensation benefits, send everything to: Office of Personnel Management (OPM) Retirement Operations Center Attention: FE6-DEP Boyers, PA 16017 What should I do if I no longer want Option C — Family Life Insurance? • If you are an active employee, contact your employing office. • If you are retired or receiving Federal Workers' Compensation benefits, write to: Office of Personnel Management (OPM) Retirement Operations Center Attention: Annuity Adjustment Section Boyers, PA 16017 Please include your retirement or compensation claim number and be sure to sign your letter. Instructions to the employing agency/retirement system • Complete Part D of this claim form. • If the claim requires that you determine eligibility for foster children or disabled children older than age 22, first review the definitions on page 4 and then complete Part D of this claim form. Please note that OFEGLI does not need the background documentation. • Send the completed claim form and certified death certificate to: OFEGLI P.O. Box 6512 Utica, NY 13504-6512 Do NOT use previous editions Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Form FE-6 DEP Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) 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 this 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 American LegalNet, Inc. www.FormsWorkFlow.com Form FE-6 DEP Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) Statement of Claim — Option C Family Life Insurance Federal Employees’ Group Life Insurance (FEGLI) Office of Federal Employees’ Group Life Insurance P.O. Box 6512 Utica, NY 13504-6512 Read the instructions carefully before filling out this form. Part A. Information about You 1. Your name (Last) (First) (Middle) 3. Social Security Number 2. Date of birth (mm/dd/yyyy) 5. Location of employment (City, state, ZIP code) 4. Department or agency in which employed, including bureau or division 6. Are you retired and receiving a monthly annuity under any Federal civilian retirement system ? Yes If “Yes”, provide the Claim number (CSA, CSF, CSI) No *Special Note: Social Security monthly payments are not Federal civilian retirement annuities. If “Yes”, provide the effective date of Retirement (mm/dd/yyyy) Part B. Information about the Deceased Family Member (Last) 1. Deceased’s full name (First) (Middle) 2. Date of birth (mm/dd/yyyy) 3. Date of death (mm/dd/yyyy) Complete Items 4 through 9 if this claim is for your spouse 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? Yes No Yes 6. Marriage was performed by: Clergy or Justice of the Peace Other (Specify) 9. If you were divorced from the deceased, give the date (mm/dd/yyyy) and place of the divorce (City and state) No Complete Items 10 through 13 if this claim is for your child 10. Child's marital status Single Married 11. Child's relationship to you Legitimate child Adopted child 13. If the deceased was a recognized natural child and was not living with you at the time of death, did you provide financial support for the child? 12. If the deceased was a stepchild, recognized natural child, or foster child was the child living with you at the time of death? Yes Foster child Disabled dependent child 22 yrs. or over Other (Specify) Stepchild Recognized natural child No (Explain on separate sheet) No (Explain on separate sheet) Yes Part C. Your Certification Your name Part C. Your Certification(Please print) 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. Address (Number, street, apt. no.) See page 2 for more information, and be sure you complete the information on page 2 under "Special Note". City, state, ZIP code If the amount payable to you is less than $5,000, OFEGLI will send you a check. Your Social Security Number _ Estate / Trust / 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 3 American LegalNet, Inc. www.FormsWorkFlow.com Form FE-6 DEP Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09) Part D. Employing Agency/OPM Certification of Insurance Status • Employing agency completes items 1, 2 and 4 through 8 for Active Employees • OPM completes all items 1 through 8 for Retirees and Compensationers 1. Did the insured have Option C on the date of death of the family member? No Yes 2. Did the insured indicate in Part B - Item 11 that the deceased was a foster child or disabled dependent child? If "Yes" provide effective date of election (mm/dd/yyyy) No Yes If “Yes” do you certify that the child qualifies for Option C coverage? If "Yes" mark the box to show the number of multiples 1 2 3 4 No 5 Yes If the insured is retired or receiving compensation, complete items 3a. through 3c. 3a. What is the effective date of the insured’s retirement or receipt of compensation? 3c. What was the insured’s Option C election? Number of multiples for full reduction 3b. What is the insured’s date of birth? 1 2 3 4 5 Number of multiples for no reduction (mm/dd/yyyy) 1 2 3 4 5 (mm/dd/yyyy) 4. Agency Name 5. Agency Mailing Address ____________________________________________________ __________________________________________________ ___________________________________________________ _________________________________________________ Number, Street Agency Telephone Number ( ) ________________________________________ Area Code _________________________________________________ City, state, ZIP code I certify that the information I gave in Part D of this form is correct and that I obtained it from the employee’s/retiree’s/compensationer’s official records. 6. Name of authorized agency official (Please print) __________________________________________ 7. Signature of authorized agency official (Do not print) __________________________________________ 8. Date Signed __________________________________ (mm/dd/yyyy) Definition of Terms Disabled dependent child age 22 years or over means a child who was incapable of self-support because of a mental or physical disability that existed before the child became 22 years of age. Foster child means a child living with you in a regular parent-child relationship where you are the primary source of financial support for the child and expect to raise the child to adulthood. A child placed in your home by a welfare or social service agency under an agreement where the agency retains control of the child or pays for maintenance does not qualify as a foster child. Grandchildren, as such, are not eligible family members. However, grandchildren can qualify as foster children if they meet all of the requirements. Recognized natural child means a child born out of wedlock whom you recognized as your child during the child’s lifetime. In addition, at the time of the child’s death, he/she must have either lived with you in a regular parent-child relationship or been dependent on you financially. Regular parent-child relationship means that you exercise parental authority, responsibility, and control over the child by caring for, supporting, disciplining, and guiding the child, including making decisions about the child’s education and health care. If you have any questions concerning your child’s eligibility for coverage, you must contact your employing agency or retirement system, and not OFEGLI. Do NOT use previous editions Page 4 American LegalNet, Inc. www.FormsWorkFlow.com Form FE-6 DEP Revised May 2009 OFEGLI Form in Adobe Acrobat PDF (05/09)