Agency Certification of Insurance Status Federal Employees' Group Life Insurance Program To Agency: See reverse for information and instructions 1. Name of employee (Last, first, middle) 2. Date of birth (Month, day, year) 4a. Event requiring certification 4b. Employee's retirement system CIA Other (Specify) Separation (includes resignation) CSRS/FERS FICA Retirement TVA Death as an employee DCRS* Had employee filed Application for Retirement FSRS *D.C. Police & Fire/Public School Teachers (SF 2801 or SF 3107) with OPM? 4c. OWCP number (if applicable) No Yes Death as a reemployed annuitant End of 12 months non-pay status Other (Specify) 8. Date of event checked in item 4a 6. Did the employee assign his/her insurance? 3. Social Security number 5. Disposition of Designations of Beneficiary (SF 54, SF 2823) Attached None on file with this agency On file in employee's Official Personnel Folder 7. Did the employee elect living benefits? Amount elected (check one and attach EOB) No Yes (attach RI 76-10) No Yes Partial (post-election BIA $ Full 9. Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose coverage as an employee terminates, including all retiring employees) 10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert hourly, daily, piecework, etc., rate to annual rate) 11. Effective date of continuous coverage under the FEGLI Program (If any break in service, list dates) 12a. Did employee have Option A - Standard Insurance on date in item 8? 12b. Amount of Option A ) 13a. Did employee have Option C - Family Insurance on date in item 8? No Yes No Yes 12c. Effective date of election 14a. Did employee have Option B - Additional Insurance on date in item 8? 14b. Effective date of election No 13b. Effective date of election 14c. Number of multiples on date in item 8 Yes 14d. Lowest number of multiples during last 5 years 15. Personnel records certification (This form will not be accepted without both personnel and payroll certification.) I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal Employee's Group Life Insurance on the date in item 8. 15e. Name and address of agency (Including ZIP Code) 15a. Signature of certifying official (Facsimile not acceptable) 15b. Typed name of certifying official 15c. Title 15f. Telephone number (Including area code) 15d. Date 16. Payroll records certification (This form will not be accepted without dual certification.) I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree. Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code (Insurance code and SF 50 equivalent) on the date in item 8. Alpha code 16f. Name and address of payroll office (If different from that given in item 15e) 16a. Signature of certifying official (Facsimile not acceptable) 16b. Typed name of certifying official 16c. Title 16d. Date 16e. Telephone number (Including area code) Remarks (For agency use only) U.S. Office of Personnel Management The FEGLI Handbook for Personnel and Payroll Offices 16g. Payroll office number OPM use only PART 1 - Original NSN 7540-01-231-5587 Previous editions are not usable Standard Form 2821 Revised May 1995 American LegalNet, Inc. www.FormsWorkFlow.com Agency Certification of Insurance Status Federal Employees' Group Life Insurance Program To Agency: See reverse for information and instructions 1. Name of employee (Last, first, middle) 2. Date of birth (Month, day, year) 4a. Event requiring certification 4b. Employee's retirement system CIA Other (Specify) Separation (includes resignation) CSRS/FERS FICA Retirement TVA Death as an employee DCRS* Had employee filed Application for Retirement FSRS *D.C. Police & Fire/Public School Teachers (SF 2801 or SF 3107) with OPM? 4c. OWCP number (if applicable) No Yes Death as a reemployed annuitant End of 12 months non-pay status Other (Specify) 8. Date of event checked in item 4a 6. Did the employee assign his/her insurance? 3. Social Security number 5. Disposition of Designations of Beneficiary (SF 54, SF 2823) Attached None on file with this agency On file in employee's Official Personnel Folder 7. Did the employee elect living benefits? Amount elected (check one and attach EOB) No Yes (attach RI 76-10) No Yes Partial (post-election BIA $ Full 9. Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose coverage as an employee terminates, including all retiring employees) 10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert hourly, daily, piecework, etc., rate to annual rate) 11. Effective date of continuous coverage under the FEGLI Program (If any break in service, list dates) 12a. Did employee have Option A - Standard Insurance on date in item 8? 12b. Amount of Option A ) 13a. Did employee have Option C - Family Insurance on date in item 8? No Yes 12c. Effective date of election 14a. Did employee have Option B - Additional Insurance on date in item 8? 14b. Effective date of election No No Yes 13b. Effective date of election 14c. Number of multiples on date in item 8 Yes 14d. Lowest number of multiples during last 5 years 15. Personnel records certification (This form will not be accepted without both personnel and payroll certification.) I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal Employee's Group Life Insurance on the date in item 8. 15a. Signature of certifying official (Facsimile not acceptable) 15e. Name and address of agency (Including ZIP Code) 15b. Typed name of certifying official 15c. Title 15f. Telephone number (Including area code) 15d. Date 16. Payroll records certification (This form will not be accepted without dual certification.) I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree. Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code (Insurance code and SF 50 equivalent) on the date in the item 8. 16a. Signature of certifying official (Facsimile not acceptable) Alpha code 16f. Name and address of payroll office (If different from that given in item 15e) 16b. Typed name of certifying official 16c. Title 16d. Date 16e. Telephone number (Including area code) Remarks (For agency use only) U.S. Office of Personnel Management The FEGLI Handbook for Personnel and Payroll Offices 16g. Payroll office number OPM use only NSN 7540-01-231-5587 Previous editions are not usable Standard Form 2821 Revised May 1995 American LegalNet, Inc. www.FormsWorkFlow.com Agency Certification of Insurance Status Federal Employees' Group Life Insurance Program To Agency: See reverse for information and instructions 1. Name of employee (Last, first, middle) 2. Date of birth (Month, day, year) 4a. Event requiring certification 4b. Employee's retirement system CIA Other (Specify) Separation (includes resignation) CSRS/FERS FICA Retirement TVA Death as an employee DCRS* Had employee filed Application for Retirement FSRS *D.C. Police & Fire/Public School Teachers (SF 2801 or SF 3107) with OPM? 4c. OWCP number (if applicable) No Yes Death as a reemployed annuitant End of 12 months non-pay status Other (Specify) 8. Date of event checked in item 4a 6. Did the employee assign his/her insurance? 3. Social Security number 5. Disposition of Designations of Beneficiary (SF 54, SF 2823) Attached None on file with this agency On file in employee's Official Personnel Folder 7. Did the employee elect living benefits? Amount elected (check one and attach EOB) No Yes (attach RI 76-10) No Yes Partial (post-election BIA $ Full 9. Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose coverage as an employee terminates, including all retiring employees) 10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert hourly, daily, piecework, etc., rate to annual rate) 11. Effective date of continuous coverage under the FEGLI Program (If any break in service, list dates) 12a. Did employee have Option A - Standard Insurance on date in item 8? 12b. Amount of Option A ) 13a. Did employee have Option C - Family Insurance on date in item 8? No Yes 12c. Effective date of election 14a. Did employee have Option B - Additional Insurance on date in item 8? 14b. Effective date of election No No Yes 13b. Effective date of election 14c. Number of multiples on date in item 8 Yes 14d. Lowest number of multiples during last 5 years 15. Personnel records certification (This form will not be accepted without both personnel and payroll certification.) I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal Employee's Group Life Insurance on the date in item 8. 15a. Signature of certifying official (Facsimile not acceptable) 15e. Name and address of agency (Including ZIP Code) 15b. Typed name of certifying official 15c. Title 15f. Telephone number (Including area code) 15d. Date 16. Payroll records certification (This form will not be accepted without dual certification.) I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree. Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code (Insurance code and SF 50 equivalent) on the date in the item 8. 16a. Signature of certifying official (Facsimile not acceptable) Alpha code 16f. Name and address of payroll office (If different from that given in item 15e) 16b. Typed name of certifying official 16c. Title 16d. Date 16e. Telephone number (Including area code) Remarks (For agency use only) U.S. Office of Personnel Management The FEGLI Handbook for Personnel and Payroll Offices 16g. Payroll office number OPM use only NSN 7540-01-231-5587 Previous editions are not usable Standard Form 2821 Revised May 1995 American LegalNet, Inc. www.FormsWorkFlow.com Instructions To Employing Agencies Completion of Certification 1. 2. 2. This certification must be completed in triplicate whenever an employee's insurance terminates or is scheduled to terminate due to: a. Death b. Retirement c. Completion of 12 months in non-pay status including those cases where the employee will be continuing all or some of his or her insurance while in receipt of workers' compensation. d. Any other reason, except under the following circumstances: (1) Employee waived or declined all insurance on his or her most recent SF 2817. (2) If it is known that, within 3 calendar days after the insurance terminates, the employee will return to Government service in the same position or another position and he or she will be eligible to reacquire insurance coverage. In item 4b, indicate the retirement system under which the employee is covered. If other than those shown, please specify. In item 4c, indicate the insured Office of Workers' Compensation Programs case file number, if applicable. 3. b. c. A retiring employee who will continue Basic Life insurance, but cancel (and therefore NOT CONVERT) one or more of the options for which he or she would otherwise be eligible, must complete SF 2817, Life Insurance Election, declining those options. However, if the employee has assigned his/her insurance, he/she may not cancel any insurance. Only the assignee(s) may do so. If the effective date of the change in coverage comes before the separation for retirement, process the SF 2817 as usual and attach the original, with all other life insurance elections, to the Application for Retirement. However, if the effective date of the change in coverage falls after the date of separation for retirement, indicate as such in item 6 of the SF 2817 designated Agency Remarks, give the employee his or her copy, and attach both the original and Part 2 to the SF 2821. In either event, OPM must have the executed SF 2817. The SF 2821 should be completed to reflect the retiring employee's insurance status at the time of separation for retirement and attached to the Application for Retirement. d. If the retiring employee will continue Basic Life insurance, but convert (and therefore NOT CANCEL) one or more of the options, complete the SF 2821 and submit the original (Part 1) with the Application for Retirement, as indicated in item 2a, above. However, if the employee has assigned his/her insurance, he/she may not convert any insurance. Only the assignee(s) may do so. The employee or assignee(s), if applicable, should submit the duplicate SF 2821 (Part 2) with a completed SF 2819, indicating which options he or she wishes to convert, to OFEGLI. Do Not have the employee or assignee(s), if applicable, complete an SF 2817, Life Insurance Election, declining the options being converted. e. If the retiring employee or assignee(s), if applicable, prefers to convert (and therefore NOT CANCEL) both Basic Life and all optional insurance(s) to an individual policy, give him or her the original and duplicate (Parts 1 and 2) of the SF 2821 and an SF 2819. Retain designations of beneficiary (SF 54 or SF 2823), if any. Do Not have the employee or assignee(s), if applicable, complete an SF 2817, Life Insurance Election, declining the options being converted. f. In item 11, "effective date of continuous coverage under the FEGLI Program" means the date the employee began FEGLI coverage without a break for any reason, except separation from the Federal service or exclusion by law or regulation. In addition to the effective date of continuous FEGLI coverage, indicate the dates of any break in service. If the employee is continuing Basic Life insurance into retirement, have him or her complete SF 2818, Continuation of Life Insurance Coverage. Attach the complete SF 2818 to the original (Part 1) SF 2821. If the retiring employee is not eligible to continue life insurance coverage into retirement, give him or her or assignee(s), if applicable, the original and duplicate (Parts 1 and 2) of the SF 2821 and an SF 2819. Retain designations of beneficiary (SF 54 or SF 2823), if any. In item 9, give the date of the Notice of Conversion Privilege (SF 2819). In case of death in service, where employee had no Option C coverage, leave this item blank. 6. If the retiring employee is applying for an immediate annuity and is eligible and will be continuing all life insurance into retirement, attach the original SF 2821 (Part 1), all designations of beneficiary (SF 54 or SF 2823), if any, and all life insurance elections (SF 176 or SF 2817), to the Application for Retirement and send these documents to OPM. Give the duplicate (Part 2) of the SF 2821 to the employee. (Note: In a disability retirement case where the retirement application has already been sent to OPM, attach the original SF 2821 and the other insurance forms to the "final" Individual Retirement Record [SF 2806/SF 3100 or equivalent].) If the retiring employee has an Assignment of Federal Employees' Group Life Insurance (RI 76-10) on file, you must attach it to the original SF 2821. If the retiring employee elected Living Benefits, attach the Explanation of Benefits (EOB) which was returned to the personnel office by OFEGLI. In item 7, indicate whether the employee elected living benefits. If yes, attach the Explanation of Benefits (EOB) which was returned to the personnel office by OFEGLI, and indicate whether full or partial benefits were elected. If partial, indicate the dollar amount. 5. a. In item 6, indicate whether the employee completed an Assignment of Federal Employees' Group Life Insurance form (RI 76-10). If yes, attach the form. If the assignee(s) subsequently reassigned the insurance, attach the applicable RI 76-10 form(s). 4. Retirement of Employee 7. In item 12, indicate the dollar amount of Option A. In most cases, this will be $10,000. However, the amount may exceed $10,000 if the combined total of the maximum basic insurance amount and the $10,000 for this option is less than the employee's annual basic rate of pay (the rate actually payable). 8. In item 12, 13, and 14, "effective date of election" means the date the employee began the optional FEGLI coverage without a break for any reason, except separation from the Federal service or exclusion by law or regulation. 9. Appropriate officials must certify that the employee's personnel and payroll records are consistent with the information reported on this form. The two certifications (in items 15 and 16) may not be made by the same official; however, a payroll certification may be made by a personnel officer who has access to payroll records. 10. If this certification is prepared for reasons other than separation for retirement, death, or end of 12 months in non-pay status, Do Not send the SF 2821 to OPM. Give or mail the original (Part 1) and duplicate (Part 2) to the employee or assignee(s), if applicable, with the SF 2819, for conversion purposes. However, if the employee is receiving compensation benefits, and employment terminates prior to the end of 12 months in non-pay status, check Other in item 4a and forward the original (Part 1) of the SF 2821 to the Office of Personnel Management, Retirement Operations Center, Boyers, PA 16017. 11. 3. Death of Employee a. Send duplicate (Part 2) of the SF 2821 to the Office of Federal Employees' Group Life Insurance (OFEGLI), 200 Park Avenue, New York, NY 10166-0188. b. Keep the original (preferably in the Official Personnel Folder or its equivalent) for attachment to a claim for death benefits (Form FE-6) when received. c. If no claim is received, send the original (Part 1) SF 2821, upon request, to OFEGLI. d. If the deceased employee has any designation of beneficiary forms (SF 54 or SF 2823) on file, you must attach them to the original SF 2821 when it is sent to OFEGLI. e. If the deceased employee has an Assignment of Federal Employees' Group Life Insurance form (RI 76-10) on file, you must attach it to the original SF 2821 when it is sent to OFEGLI. If the employee elected Living Benefits, attach the Explanation of Benefits (EOB) which was returned to the personnel office by OFEGLI. Before completing items 12 through 14, contact the district Office of Workers' Compensation, if necessary, to confirm whether the employee still has any optional insurance. b. Disposition of Certification 1. Employee is Receiving Compensation Benefits a. Important: When a duplicate SF 2821 is issued to replace one which is lost, it must be clearly marked "DUPLICATE". A compensationer is considered a retired employee for purposes of life insurance. Therefore, follow items 2a - 2f above. 4. All Other Cases Give or mail the original and duplicate (Parts 1 and 2 of the SF 2821) to the employee and/or assignee(s), as applicable. 5. In All Cases Retain the file copy (Part 3) of the SF 2821 in the employee's Official Personnel Folder or its equivalent. Prompt Certification Required The time in which an employee or assignee(s), if applicable, may convert group life insurance to an individual policy is limited. This SF 2821 must be completed and delivered or mailed promptly. American LegalNet, Inc. www.FormsWorkFlow.com