Agency Certification of Status of Reemployed Annuitants Federal Employees' Group Life Insurance (FEGLI) Program Complete this form for all reemployed annuitants who are entitled to elect or continue life insurance coverage as employees. If the reemployed annuitant continues any life insurance as an employee, the Office of Personnel Management (OPM) will suspend the annuity withholdings for that coverage. If the reemployed annuitant waives any life insurance as an employee, he or she has also waived that coverage as an annuitant. (Option B is an exception. See Item 10.) If the reemployed annuitant waives Basic, all life insurance coverage stops, both as an employee and as an annuitant. 1. Reemployed annuitant's name (Last, first, middle) 2. Date of birth (mm/dd/yyyy) 4. Reemployment date (mm/dd/yyyy) 3. Social Security Number 6. Reemployment of annuitants under conditions which do not terminate annuity requires appropriate offset against salary. You must reduce the salary. Salary reduced by $ 5. CSA or CSI number (if known) 7. Check, if applicable: Reemployment allows Life Insurance coverage. per pay period. Reemployment within 3 calendar days without a break in service. Salary not reduced Explain in Remarks Section. 8. Type of appointment 9. Basic, Option A and Option C OPM suspends applicable annuity withholdings for Basic, Option A and Option C for all annuitants who are reemployed in positions eligible for FEGLI coverage. You must withhold premiums for Basic, Option A and Option C if the reemployed annuitant has that coverage as an annuitant, is eligible for the coverage in the reemployed position, and does not waive the coverage. If the reemployed annuitant waives Basic as an employee, all life insurance terminates, both as an employee and as an annuitant. If the reemployed annuitant waives Option A or Option C as an employee, that coverage as an annuitant also terminates. 10. Option B The reemployed annuitant has a choice: If he/she has Option B as an annuitant and does nothing, he/she will continue to have Option B as an annuitant. OPM will continue to withhold Option B premiums from his/her annuity. If he/she has Option B as an annuitant but wants to carry it as an employee, he/she must elect Option B on Standard Form (SF) 2817, Life Insurance Election within 31 days of reemployment. Then you must withhold Option B premiums from his or her pay. He/she must be sure to sign the SF 2817 for ALL coverage he/she has (including coverage held as an annuitant), and not just for Option B. Check the appropriate box: Continuing as an annuitant with withholdings made from annuity. Date deductions from pay began (mm/dd/yyyy) Elected coverage as an employee. Please suspend coverage as an annuitant. Not eligible. Uncancelled waiver of Option B is on file. Notes: (1) If the reemployed annuitant elects Option B as an employee and later decides to continue it as an annuitant, he/she must complete an SF 2817 waiving Option B. Unlike with Basic, Option A and Option C, that action does not cancel the annuitant Option B. Instead, it restores the Option B suspended as an annuitant. You must notify OPM about this action so that we can resume Option B premium withholdings from the annuity. (2) If the reemployed annuitant wants to cancel Option B held as an annuitant, he/she must send a signed letter to OPM, giving his/her name, date of birth, annuitant claim number, and an explanation of exactly what he/she wishes to do. 11. I certify that the above information correctly reflects official records and that the employee named either elected or waived FEGLI coverage(s) as shown above. Signature of authorized agency official Name and address of agency, including ZIP code Name and title of authorized agency official Telephone no. (include area code) Fax number (include area code) Email address Date (mm/dd/yyyy) Return completed form and send other notifications to: 12. Remarks U.S. Office of Personnel Management Retirement Operations Center P.O. Box 45 Boyers, PA 16017-0045 U.S. Office of Personnel Management Previous editions are not usable May Be Locally Reproduced OPM Form 1482 Revised April 2000 American LegalNet, Inc. www.FormsWorkFlow.com