Assignment Federal Employees' Group Life Insurance (FEGLI) Program *This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries. A. Information About the Insured (not the Assignee) (type or print) Date of birth of Insured (mm/dd/yyyy) Name of Insured (Last, first, middle) Note: Read instructions on the back of Part 2 before completing this form. Social Security Number of Insured The Insured is: Place an "X" in the appropriate box. An employee A retiree A compensationer If the Insured is retired or receiving Federal Employees' Compensation, give "CSA", "CSI", or OWCP claim number: Department or agency in which the Insured is presently employed (If retired, last department or agency where the Insured worked): Department or agency Bureau or Division Location (City, state, and ZIP code) B. Information About the Assignee(s) (type or print) First name, middle initial, and last name of each assignee Social Security Number Address (Including ZIP code) Relationship Percent or fraction assigned Total (Must equal 100% or 1.0) (Do not use dollar amounts or types of insurance) C. Statement of Insured or Assignee (type or print) Please check one: I am: the Insured an Assignee Please check both of these: I have signed this form in the presence of the two witnesses who have signed below. I did not name either witness as an assignee. See back of Part 2 for definitions. I understand that upon the Insured's death, the Office of Federal Employees' Group Life Insurance (OFEGLI) will pay the share of any living assignee to the assignee's designated beneficiary, if there is one. If the assignee did not designate a beneficiary, OFEGLI will pay the assignee, if living. If the assignee dies before the Insured dies, and he/she did not designate a beneficiary, or all of the beneficiary(ies) die(s) before the Insured dies, OFEGLI will pay the assignee's estate. I understand that the Insured must continue to pay life insurance premiums, even after the assignment. I understand that I can never cancel this assignment. Your name and address (Including ZIP code) I assign all present and future right, title, interest, and incidents of ownership in the Insured's FEGLI coverage (except Option C -- Family) to the Assignee(s) listed above. Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney Date (mm/dd/yyyy) are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box. D. ! ! ! Witnesses To Signature (A witness cannot be an assignee) Address (Including ZIP code) Signature of witness Signature of witness Address (Including ZIP code) E. For Agency Use Only Date of receipt (mm/dd/yyyy) Signature of authorized agency official Title Receiving agency See back of Part 2 for instructions on where to send this form. Do not send it to the Office of Federal Employees' Group Life Insurance. U.S. Office of Personnel Management FEGLI Handbook (RI 76-26) Part 1 - Original American LegalNet, Inc. www.FormsWorkFlow.com RI 76-10 Revised April 2000 Previous editions are not usable. Examples of Assignments 1. How to assign to one individual First name, middle initial, and last name of each assignee Show assignee's full name. Do not write names as M.E. Brown or as Mrs. John H. Brown. Social Security Number Address (Including ZIP code) Relationship Percent or fraction assigned Niece 100% Mary E. Brown 000-00-0000 214 Central Avenue Muncie, IN 47303 2. How to assign to more than one individual First name, middle initial, and last name of each assignee Be sure that the shares add up to 100 percent or 1.0. Address (Including ZIP code) Relationship Percent or fraction assigned Nephew Mother one-half one-half Social Security Number Jose P. Lopez Rosa L. Rowe 111-11-1111 222-22-2222 360 Williams Street Red Bank, NJ 07701 792 Broadway Whiting, IN 46394 3. How to assign to a trust First name, middle initial, and last name of each assignee Trustee(s) or Successor Trustee(s) as provided in the John Q. Public Trust Agreement dated 02/18/2000 Social Security Number Address (Including ZIP code) Relationship Percent or fraction assigned Not Applicable Not Applicable Trustee 100% 4. How to assign to a firm Show the firm's Taxpayer Identification Number instead of a Social Security Number. Social Security Number Address (Including ZIP code) Relationship Percent or fraction assigned Corporation 100% First name, middle initial, and last name of each assignee XYZ Corporation Attn: John Smith TIN 999-99-9999 5909 Pacific Avenue, NW Washington, DC 20019 American LegalNet, Inc. www.FormsWorkFlow.com Information for the Person Completing This Form (Either the Insured or an Assignee Who Is Reassigning Coverage) The "Insured" is the employee, annuitant or compensationer. The "Assignee" is the person(s), firm(s), or trust(s) (usually named on an Assignment form, RI 76-10) who owns and controls the Insured's life insurance coverage. An assignment is not the same as a designation of beneficiary. exclude FEGLI benefits from your estate. It is also possible that you could inherit General What Is An Assignment? An assignment of life insurance is the transfer of ownership and control of life insurance coverage from the Insured person to one or more persons, firms or trusts. The assignee receives the death benefits when the Insured dies, or may designate someone else to receive those benefits. How Does An Assignment Differ From A Designation Of Beneficiary? An assignment transfers ownership and control of life insurance coverage. A designation does not. An assignee has the right to reassign the coverage to someone else. A designated beneficiary does not. The Insured can cancel a designation of beneficiary at any time, but cannot cancel an assignment. You should use this form (RI 76-10) to make an assignment and SF 2823 to make a designation. How Does This Assignment Affect My Rights? By assigning the insurance, you give up: 1. 2. 3. 4. 5. The right to cancel the insurance coverage; The right to designate and change beneficiaries; The right to port (continue) Option B, if eligible, after the Insured resigns or ends 12 months nonpay status; The right to convert to a private insurance policy when the FEGLI coverage terminates for any reason other than cancellation; The right to change the post-65 reduction schedule for Basic insurance after the Insured makes the original election when he/she retires or begins to receive compensation. If th