Form Approved OMB No. 3206-0136 Designation of Beneficiary Federal Employees Group Life Insurance Federal Employees' Group Life Insurance (FEGLI) Program Important: Read instructions on the Back of Part 2 before completing this form. (DO NOT erase or cross-out. Use a new form.) A. Information About the Insured (not the Assignee, if there is one) (type or print) Name of Insured (Last, first, middle) The Insured is: Place an "X" in the appropriate box. Date of birth of Insured (mm/dd/yyyy) an employee Social Security Number of Insured If the Insured is retired or receiving Federal Employees' Compensation, give CSA, CSI, or OWCP claim number: a retiree a compensationer Department or agency where the Insured works (If retired, last department or agency where the Insured worked): Department or agency Location (city, state, and ZIP code) Bureau or division B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print) First name, middle initial, and last name of each beneficiary Address (Including ZIP code) Social Security Number Relationship Percent or fraction designated Total (Must equal 100% or 1.0) (Do not use dollar amounts) (Do not put a Total if you designated types of insurance. See example 4 on Back of Part 1.) C. Statement of Insured or Assignee (type or print) Your name and address (Including ZIP code) Please check one: I am: Please check all three: the Insured I have not assigned the insurance. an Assignee Two people who witnessed my signature signed below. I did not name either witness as a beneficiary. See Back of Part 2 for definitions I understand that if there is a valid assignment on file, only the assignee has the right to designate a beneficiary. If a valid assignment is not on file, but there is a valid court order on file with the agency or the U.S. Office of Personnel Management, as appropriate, any designation I complete for the same benefits is not valid. I understand that if this Designation is invalid for any reason, the Office of Federal Employees' Group Life Insurance will pay benefits according to the next most recent valid designation. If there isn't one, it will pay according to the order listed on the Back of Part 2. I understand that if this Designation is valid, it will stay in effect unless it is canceled. (See "When Is A Designation Canceled?" on the Back of Part 2). I am canceling any and all previous Designations of Beneficiary under the Federal Employees' Group Life Insurance Program and am now designating the beneficiary(ies) named above. Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box. Date (mm/dd/yyyy) D. Witnesses To Signature (A witness is not eligible to receive a payment as a beneficiary.) Signature of witness Address (Including ZIP code) Signature of witness Address (Including ZIP code) E. For Agency Use Only Receiving agency U.S. Office of Personnel Management FEGLI Handbook (RI 76-26) Date of receipt (mm/dd/yyyy) Signature of authorized agency official Title Part 1 - Original NSN 7540-01-231-6228 2823-103 Previous editions are not usable. SF 2823 Revised April 2001 American LegalNet, Inc. www.FormsWorkFlow.com Examples of Designations 1. How to designate one beneficiary First name, middle initial, and last name of each beneficiary Mary E. Brown Show beneficiary's full name. Do not write names as M.E. Brown or as Mrs. John H. Brown. If you want to designate your estate, enter "My estate" in the beneficiary column. Social Security Number 000-00-0000 Address (Including ZIP code) 214 Central Avenue Munice, IN 47303 Relationship Percent or fraction designated Niece 100% 2. How to designate more than one beneficiary Be sure that the shares to be paid to the several beneficiaries add up to 100 percent or 1.0. Read instructions on the Back of Part 2 if you need more room. First name, middle initial, and last name of each beneficiary Social Security Number Jose P. Lopez 111-11-1111 Rosa L. Rowe 222-22-2222 3. How to designate a contingent beneficiary First name, middle initial, and last name of each beneficiary Address (Including ZIP code) 360 Williams Street Red Band, NJ 07701 792 Broadway Whiting, IN 46392 Percent or fraction designated Nephew one-half Mother one-half (Someone to receive the benefits if the person you designate dies before the Insured dies) Social Security Number John M. Parrish, if living 333-33-3333 Otherwise to: Susan A. Parrish 444-44-4444 Address (Including ZIP code) 810 West 180th Street New York, NY 10033 810 West 180th Street New York, NY 10033 4. How to designate different beneficiaries for Basic and Optional insurance First name, middle initial, and last name of each beneficiary Relationship Social Security Number Leroy D. White 555-55-5555 Jane M. Smith 666-66-6666 Elizabeth J. Allen 777-77-7777 Ann J. Borden 888-88-8888 Relationship Percent or fraction designated Father 100% Sister 100% You cannot designate Option C - Family. Address (Including ZIP code) 124 Elm Street Dayton, OH 45420 421 Spring Avenue Portland, ME 04101 234 Fifth Avenue New York, NY 10029 678 Ninth Street Philadelphia, PA 19123 Relationship Father Sister Daughter Daughter Percent or fraction designated 100% Basic 100% Option A 50% Option B 50% Option B 5. How to designate an inter vivos trust (A trust that you set up during your lifetime) First name, middle initial, and last name of each beneficiary Social Security Number Address (Including ZIP code) Mary E. Brown 000-00-0000 214 Central Avenue Munice, IN 47303 Percent or fraction designated Trustee Trustee(s) or Successor Trustee(s) as provided in the John Q. Public Trust Agreement dated 12/18/1999, if valid. Otherwise to: Relationship 100% Niece 100% 6. How to designate a testamentary trust (A trust that is set up when you die, according to terms in your will) First name, middle initial, and last name of each beneficiary Social Security Number Address (Including ZIP code) Maria Sufuentes 999-99-9999 5909 Pacific Avenue, NW Washington, DC 20019 Percent or fraction designated Trustee Trustee(s) or Successor Trustee(s) as provided in my Last Will and Testament, if valid. Otherwise to: Relationship 100% Niece 100% Relationship Percent or fraction designated 7. How to cancel all designations of beneficiary First name, middle initial, and last name of each beneficiary Social Security Number Address (Including ZIP code) Cancel prior designations SF 2823 Revised April 2001 Back of Part 1 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 3206-0136 Designation of Beneficiary Federal Employees Group Life Insurance Federal Employees' Group Life Insurance (FEGLI) Program Important: Read instructions on the Back of Part 2 before completing this form. (DO NOT erase or cross-out. Use a new form.) A. Information About the Insured (not the Assignee, if there is one) (type or print) Name of Insured (Last, first, middle) The Insured is: Place an "X" in the appropriate box. Date of birth of Insured (mm/dd/yyyy) an employee Social Security Number of Insured If the Insured is retired or receiving Federal Employees' Compensation, give CSA, CSI, or OWCP claim number: a retiree a compensationer Department or agency where the Insured works (If retired, last department or agency where the Insured worked): Department or agency Location (City, state, and ZIP code) Bureau or division B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print) First name, middle initial, and last name of each beneficiary Address (Including ZIP code) Social Security Number Relationship Percent or fraction designated Total (Must equal 100% or 1.0) (Do not use dollar amounts) (Do not put a Total if you designated types of insurance. See example 4 on Back of Part 1.) C. Statement of Insured or Assignee (type or print) Your name and address (Including ZIP code) Please check one: I am: Please check all three: the Insured I have not assigned the insurance. an Assignee Two people who witnessed my signature signed below. I did not name either witness as a beneficiary. See Back of Part 2 for definitions I understand that if there is a valid assignment on file, only the assignee has the right to designate a beneficiary. If a valid assignment is not on file, but there is a valid court order on file with the agency or the U.S. Office of Personnel Management, as appropriate, any designation I complete for the same benefits is not valid. I understand that if this Designation is invalid for any reason, the Office of Federal Employees' Group Life Insurance will pay benefits according to the next most recent valid designation. If there isn't one, it will pay according to the order listed on the Back of Part 2. I understand that if this Designation is valid, it will stay in effect unless it is canceled. (See "When Is A Designation Canceled?" on the Back of Part 2). I am canceling any and all previous Designations of Beneficiary under the Federal Employees' Group Life Insurance Program and am now designating the beneficiary(ies) named above. Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box. Date (mm/dd/yyyy) D. Witnesses To Signature (A witness is not eligible to receive a payment as a beneficiary.) Signature of witness Address (Including ZIP code) Signature of witness Address (Including ZIP code) E. For Agency Use Only Receiving agency U.S. Office of Personnel Management FEGLI Handbook (RI 76-26) Date of receipt (mm/dd/yyyy) Signature of authorized agency official Part 2 - Duplicate NSN 7540-01-231-6228 2823-103 Title Previous editions are not usable. SF 2823 Revised April 2001 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS: The Insured or assignee must sign this form. Two people must witness the signature and sign as witnesses. The Insured's agency (or U.S. Office of Personnel Management [OPM], if the Insured is an annuitant or insured as a compensationer) must receive the designation before the Insured's death. A person with a power of attorney or other similar legal authority may not sign for the Insured or assignee. A witness cannot be a beneficiary. The agency or OPM, as appropriate, must receive certified court orders involving FEGLI on or after July 22, 1998, and before the Insured's death. Please read the additional instructions below before completing this form. "You" and "your" refer to the person completing this form (the Insured or an assignee). The "Insured" is the insured employee, annuitant or compensationer. The "Assignee" is a 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. Can I use a common disaster clause? Yes. A common disaster clause is a Who receives benefits when the Insured dies? By law, the Office of Federal statement that says that a designated beneficiary is entitled to the benefits only if Employees' Group Life Insurance (OFEGLI) pays benefits in this order: he/she survives the Insured by a specified minimum number of days. The number If the Insured assigned ownership of his/her insurance (usually by filing an of days cannot exceed 30. You can name a contingent beneficiary. If you don't RI 76-10, Assignment of Life Insurance), OFEGLI will pay: name a contingent and your beneficiary does not live long enough to qualify, First, to the beneficiary(ies) the assignee(s) validly designated; OFEGLI will pay according to the order listed in the first column. Second, if none, to the assignee(s). If the Insured did not assign ownership and there is a valid court order (see 5 Can I designate a trust? Yes. See examples 5 and 6 on the Back of Part 1. Those Code of Federal Regulations Part 870) on file with the agency or OPM, as examples name a contingent beneficiary in case the trust is not valid. You don't appropriate, OFEGLI will pay benefits according to the court order. have to name a contingent beneficiary unless you want to. If the trust is not valid, and you do not name a contingent, OFEGLI will pay according to the order listed If the Insured did not assign ownership and there is no valid court order on in the first column. file with the agency or OPM, as appropriate, then OFEGLI will pay: First, to the beneficiary(ies) the Insured validly designated; When is a designation canceled? A designation of beneficiary is automatically Second, if none, to the Insured's widow or widower; canceled 31 days after the Insured stops being insured. It is also canceled if either Third, if none of the above, to the Insured's child or children and the the Insured or assignee assigns the insurance or if the Insured or assignee submits descendants of any deceased children (a court will usually have to another valid designation. appoint a guardian to receive payment for a minor child); What if the Insured elected a full living benefit? Then there is no Basic left. Fourth, if none of the above, to the Insured's parents in equal shares, or So if you want to designate different types of insurance to different beneficiaries the entire amount to the surviving parent; (see example 4 on the Back of Part 1), you should only list Option A and Option Fifth, if none of the above, to the court-appointed executor or B. administrator of the Insured's estate; Who can sign this form? The Insured or Assignee (if applicable) must sign this Sixth, if none of the above, to the Insured's other next of kin entitled form. The signature of a guardian, conservator or other fiduciary (including, but under the laws of the State where the Insured lived. not limited to, those acting according to a Power of Attorney or a Durable Power of Attorney) is not acceptable. Do I have to designate a beneficiary? No. But if you want OFEGLI to pay differently than listed above and you have not assigned the life insurance and What if I erase or cross out something on this form? You should complete there is no valid court order on file with the agency or OPM, as appropriate, you another form. Erasures, cross-outs and alterations cause a delay in the payment of need to designate a beneficiary. benefits and may make the entire designation invalid. What if one of the beneficiaries dies or is disqualified for any reason? Unless What if I need more room? Write "See Attached" in Part B of the form. Use a you indicate otherwise on your designation of beneficiary, OFEGLI will distribute blank sheet. Print your name, date of birth and social security number at the top of that beneficiary's share equally among the surviving beneficiaries, or entirely to the attachment. List the information required in Part B for each beneficiary. Sign the sole survivor. the form and attachment. Have the same two people witness both of your What if none of the beneficiaries is living when the Insured dies? OFEGLI signatures and sign the form and attachment. will pay the benefits according to the order of precedence listed above. Where can I get more information? The FEGLI Handbook (RI 76-26) and FEGLI Booklet (RI 76-21 or RI 76-20 for Postal employees) contain more Can I cancel or change this designation at any time? Yes, you may cancel or information. You can read them at www.opm.gov/insure/life . change your designation at any time, without the knowledge of or consent of the beneficiary(ies), unless you assigned the insurance or there is a valid court order Where should I send this form? Send it to the Insured's employing agency if the on file with the agency or OPM, as appropriate. Insured: is an employee; or Is a change or cancellation of beneficiary in my last will or testament valid? has been receiving compensation payments from the Office of Workers' It is valid only if you sign your will, two people who witnessed your signature Compensation Programs for less than 12 months and is still on the agency's sign your will, and your agency (or OPM, for retirees or insured compensationers) rolls as an employee. receives your will before the Insured's death. What if I don't know a beneficiary's social security number? If you don't know the number, leave it blank. But having the number helps speed up the payment of benefits. Can a witness receive benefits as a designated beneficiary? No. Who can I name as a beneficiary? You may name any person, firm, corporation or legal entity (except an agency of the Federal or District of Columbia government). Send it to the Office of Personnel Management, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045 if the Insured: is a retiree; or is receiving compensation payments from the Office of Workers' Compensation Programs and is not still employed or has been receiving compensation payments for at least 12 months. The agency or OPM will note receipt in section E of the form and return a copy to you as evidence that it received and filed the original. Properly completed designations are not valid unless the appropriate office listed above receives them before the Insured's death. Privacy Act and Public Burden Statements Title 5, U.S. Code, chapter 87, Life Insurance, authorizes solicitation of this information. The Office of Federal Employees' Group Life Insurance (OFEGLI) will use the information you furnish to determine your beneficiary(ies) for benefits under the Federal Employees' Group Life Insurance Program. OFEGLI is not a Federal agency. It is staffed by employees of the contracted life insurance carrier. It may share this information with the Office of Personnel Management (OPM). Agencies and/or OPM will place this information in the Insured's Official Personnel Folder or retirement file. OPM or OFEGLI may disclose this information to other Federal agencies or Congressional offices which may have a need to know it in connection with your application for a job, license, grant or other benefit. It may also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social security administrative agencies to determine and issue benefits under their programs. In addition, to the extent this information indicates possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law enforcement agency. We also ask for the Insured's Social Security Number to use it as an individual identifier in the Federal Employees' Group Life Insurance Program. Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a social security number or tax identification number. This is an amendment to title 31, Section 7701. While the law does not require you to supply all the information requested on this form, doing so will help in the prompt processing of your designation. Agencies other than the Office of Personnel Management may have further routine uses for disclosure of information from the records systems in which they file copies of this form. If this is the case, they should provide you with any such uses which are applicable at the time you complete this form. We think this form takes an average of 15 minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management, Reports and Forms Coordinator, (3206-0136), Washington, D.C. 20415-7900. The OMB number, 3206-0136, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. Keep Your Designation Current. Submit a New One If the Address of One of Your Beneficiaries Changes or If Your Intentions Change SF 2823 (for example, due to a change in family status, such as marriage, divorce, death, birth, etc.). Revised April 2001 Back of Part 2 American LegalNet, Inc. www.FormsWorkFlow.com