Form Approved: OMB No. 3206-0230 Life Insurance Election Federal Employees' Group Life Insurance Program . . . See Privacy Act Statement on back of Part 3 General Instructions By law, unless you waive all coverage or are ineligible, you are Read the back of Part 3 - Employee Copy carefully. automatically covered for Basic life insurance as an employee. When Assignees completing this form should read Items 5 and 6 on you first become eligible for FEGLI, you may (1) elect Basic and any the back of Part 3. or all of the options, (2) elect Basic but waive all of the options, or (3) Do not separate the parts. Give this form to your employing waive all life insurance coverage. If you are changing a previous office which will complete the form and return your copy to election, see the back of Part 3 - Employee Copy. you. 1 This election supersedes all previous elections. 2 Fill in identifying information concerning the employee. Name (Last) (First) (Middle) Employing department or agency 3 Social Security Number Location of department or agency where Daytime telephone number employee works (City, state, ZIP Code) (including area code) To elect or retain Basic, sign and date below. If you do not sign for Basic, you may not elect or retain any form of optional insurance. If you do not want any insurance at all, skip to Section 5. Basic 4 OWCP claim number, if applicable Date of birth (mm/dd/yyyy) Optional I want Basic. I authorize deductions to pay my share of the cost. (Basic may be provided without cost to Postal Service employees.) Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or Date (mm/dd/yyyy) through a power of attorney are not acceptable.) If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS you have previously waived any or all of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI booklet). Sign the box(es) below for any option(s) you are eligible for and wish to elect or retain. If you do not sign for an option, you have waived it and your future opportunities to enroll in it are strictly limited. You will not be covered for any option(s) for which you do not sign below, regardless of whether you previously elected the option(s). Option A - Standard I want Option A. I authorize deductions to pay the full cost. Option B - Additional Option C - Family I want Option B in the multiple of my annual basic I want Option C in the multiple I indicate below. I pay I indicate below. I authorize deductions to pay understand that each multiple is worth $5,000 upon the death of my spouse, and $2,500 upon the death the full cost. of an eligible child. I authorize deductions to pay the full cost. 3 multiples 3 times my pay 1 times my pay 4 times my pay 2 times my pay 5 times my pay 1 multiple 4 multiples 2 multiples 5 multiples Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Date (mm/dd/yyyy) Date (mm/dd/yyyy) Date (mm/dd/yyyy) 5 If you want NO life insurance coverage, sign and date below. Waiver of all life insurance coverage 6 I want no life insurance coverage. I understand that any life insurance I have will stop at the end of the last day of the pay period in which my employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form and submit satisfactory results of a physical, or (2) I have a break in Federal service of at least 180 days, or (3) I participate in an open enrollment period, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand that my decision to waive life insurance coverage now may affect my eligibility for coverage as a retiree. Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or Date (mm/dd/yyyy) through a power of attorney are not acceptable.) Number of event permitting change (See back of Part 2) Agency Remarks: Use Name and address of employing office Date received in employing office (mm/dd/yyyy) Effective date of coverage (mm/dd/yyyy) I followed the instructions on the back of Part 1. Signature of authorized agency official The employee's copy of this form, when completed by the employing office, together with the FEGLI booklet (RI 76-21 or RI 76-20 for Postal Service employees) constitute the employee's Certificate of Insurance. PART 1 - File in Official Personnel Folder U.S. Office of Personnel Management Federal Employees' Group Life Insurance Handbook (RI 76-26) NSN 7540-01-231-4280 2817-105 April 1999 edition is usable. All other editions are obsolete and unusable. Standard Form 2817 Rev. June 2000 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Agencies 1. Who Should File This Form • New employees eligible for life insurance. • Employees appointed to positions that allow life insurance coverage following service in positions that did not allow life insurance coverage. • Employees who want to change their insurance. • Reinstated employees who filed a previous waiver of any type of life insurance and who were separated from service for at least 180 days. Give a new employee a copy of the FEGLI booklet (RI 76-21 or RI 76-20 for Postal Service employees), when he or she reports for duty and ask the employee to return the completed SF 2817 as soon as possible (preferably before the end of the first pay period), but no later than 31 days after his or her appointment. Employees with prior service in nonexcluded positions who were separated after March 31, 1981, will have an SF 2817 on file in their personnel folders, and that election or waiver of coverage may still be in effect. Do not accept a new SF 2817 unless the employee has a break in Federal service of at least 180 days or is eligible to cancel a previous waiver that has been in effect for at least one year or wishes to reduce coverage. Until you verify an employee's SF 2817 on file, make deductions based on his or her statement about earlier insurance coverage in the employee's Declaration for Federal Employment, OF 306, if completed. 2. Review of Completed Form Review the original and both copies of the SF 2817 to see that they are legible and complete. If an employee signs the box for Option A, Option B, or Option C, he or she must also sign item 3, Basic. Only the employee may sign this form in items 3, 4, or 5, with one exception (noted below). Signatures by guardians, conservators, or through a power of attorney are not acceptable. Exception: If the employee assigned his or her insurance, only the assignee(s) may waive some or all of the employee's coverage. In that case, the assignee(s) must sign the form (although the information in Section 2 must refer to the employee). Please note that assignees cannot increase the employee's coverage. Only the employee can do that. Instruct the employee that, while the agency will make sure that the SF 2817 is complete, he or she is solely responsible for ensuring that the SF 2817 accurately reflects his or her intentions. 3. Completion of Form The Personnel Officer or his or her designated representative must confirm that the employee is eligible for the coverage that he or she has elected and sign the form in item 6. 4. Date Received Enter the date the employing office received this form. An employee may at any time file an SF 2817 to waive or reduce coverage, unless the employee has assigned his/her insurance coverage. If the employee has assigned the insurance, only the assignee(s) may waive or reduce the coverage (except for Option C which cannot be assigned). 5. Number of Event Permitting Change An employee may elect or increase Basic, Option A, or Option B insurance (but not Option C), if a signed waiver has been in effect for more than one year, by submitting a Request for Insurance, SF 2822. If approved, ask the employee to submit an SF 2817 showing his or her election. More details are contained on the SF 2822. 6. Effective Date of Coverage An employee who is already enrolled in Basic may elect Option B and/or Option C within 60 days following marriage, divorce, spouse's death, or the acquisition of an eligible child. Exception: Acquiring a foster child does not count as a life event for Option B purposes. • For Option B, the number of multiples he or she may elect (up to 5 total) is limited to the following: (a) for marriage or acquisition of a child, the number of additional family members; (b) for divorce or death of spouse, the total number of the employee's dependent children. • For Option C, he or she may elect from 1 to 5 multiples (up to 5 total) no matter how many family members he/she has or acquires with the event. An employee who is already enrolled in Option B and/or Option C for at least one multiple may change to a higher multiple within 60 days following marriage, divorce, spouse's death, or the acquisition of an eligible child. The number of multiples is limited as listed above. Enter the number of the event permitting a change, if applicable. See the Table of Effective Dates on the back of Part 2 for event numbers. Enter the effective date of coverage. For new and newly eligible employees: Basic is effective on the first day the employee is at work in a pay status; Optional coverage is effective on the first day the employee is at work in a pay status on or after the day the employing office receives the SF 2817. For changes in elections, see the Table of Effective Dates on the back of Part 2. If the employee elected more than one type of coverage and there is more than one effective date, write in both dates and provide details in the Remarks section. 7. Disposition of SF 2817 After completion, remove Part 3 and return it to the employee. File Part 1 in the employee's personnel folder. Destroy Part 2 after payroll office use. 8. Further Information For further information, consult the FEGLI Handbook (RI 76-26) or the FEGLI Booklet (RI 76-21 or RI 76-20 for Postal Service employees), which are available on the FEGLI web site at www.opm.gov/insure/life. American LegalNet, Inc. www.FormsWorkFlow.com Form Approved: OMB No. 3206-0230 Life Insurance Election Federal Employees' Group Life Insurance Program 1 2 SF 50 Equivalents of Insurance Codes INSURANCE INELIGIBLE 0000 1000 1100 1001 1002 1003 1004 SF 50 A0 B0 C0 D0 E1 E2 E3 E4 1005 1101 1102 1103 1104 1105 1010 1110 E5 F1 F2 F3 F4 F5 G0 H0 1011 1012 1013 1014 1015 1111 1112 1113 I1 I2 I3 I4 I5 J1 J2 J3 1114 1115 1020 1120 1021 1022 1023 1024 J4 J5 K0 L0 M1 M2 M3 M4 1025 1121 1122 1123 1124 1125 1030 1130 M5 N1 N2 N3 N4 N5 90 P0 1031 1032 1033 1034 1035 1131 1132 Q1 Q2 Q3 Q4 Q5 R1 R2 1134 1135 1040 1140 1041 1042 1043 1044 R4 R5 S0 T0 U1 U2 U3 U4 1045 1141 1142 1143 1144 1145 1050 1150 U5 V1 V2 V3 V4 V5 W0 X0 1051 1052 1053 1054 1055 1151 1152 1153 Y1 Y2 Y3 Y4 Y5 Z1 Z2 Z3 1154 1155 Z4 Z5 Fill in identifying information concerning the employee. Name (Last) (First) (Middle) Employing department or agency 3 OWCP claim number, if applicable Date of birth (mm/dd/yyyy) Social Security Number Location of department or agency where Daytime telephone number employee works (City, state, ZIP Code) (including area code) In item 7: If this block is not signed, enter 0 in ALL FOUR boxes. If this block is signed, enter 1 in box 1. Basic Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Date (mm/dd/yyyy) 4 Option A - Standard In item 7, box 2: If this block is not signed, enter 0 If this block is signed, enter 1 Option B - Additional Option C - Family In item 7, box 4: If this block is not signed, enter 0 If this block is signed, enter the number marked "X" below In item 7, box 3: If this block is not signed, enter 0 If this block is signed, enter the number marked "X" below 3 times my pay 1 times my pay 4 times my pay 2 times my pay 5 times my pay 3 multiples 1 multiple 4 multiples 2 multiples 5 multiples Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Date (mm/dd/yyyy) Date (mm/dd/yyyy) Date (mm/dd/yyyy) 5 If you want NO life insurance coverage at all, sign and date below. Waiver of all life insurance coverage 6 In item 7: If this block is signed, enter 0 in ALL FOUR boxes. Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Number of event permitting change (See back of Part 2) Agency Remarks: Use Name and address of employing office Date (mm/dd/yyyy) Date received in employing office (mm/dd/yyyy) Effective date of coverage (mm/dd/yyyy) I followed the instructions on the back of Part 1. Signature of authorized agency official 7 INSTRUCTIONS: Enter codes in the boxes on the right as directed in items 3, 4 and 5 above. U.S. Office of Personnel Management Federal Employees' Group Life Insurance Handbook (RI 76-26) PART 2 - For Agency Use NSN 7540-01-231-4280 2817-105 Insurance Code 1 2 3 SF 50 Equivalent 4 April 1999 edition is usable. All other editions are obsolete and unusable. Standard Form 2817 Rev. June 2000 American LegalNet, Inc. www.FormsWorkFlow.com Table of Effective Dates: Changes in Life Insurance Election Deductions: Begin, increase, stop or decrease with the pay period in which coverage begins, increases, stops or decreases. Change Permitted? (To enroll in any option, employee must enroll or be enrolled in Basic) Event Allowing Change Basic Option A - Standard 1. Physical: Approval of Request for Insurance (SF 2822) by the Office of Federal Employees' Group Life Insurance (OFEGLI). Yes. Coverage is effective on the first day the employee is at work in a pay status after date of OFEGLI's approval. Time Limit - OFEGLI's approval expires after 31 days. If employee is not at work in a pay status within those 31 days, Basic does not become effective. Employee must obtain a new physical. Yes. Coverage is effective on the first day the employee is at work in a pay status on or after date of OFEGLI's approval and agency receives the SF 2817. Time Limit - Employee must submit SF 2817 and be at work in a pay status within 31 days after date of OFEGLI's approval. If employee is not at work in a pay status or doesn't submit the SF 2817 within those 31 days, Option A does not become effective. Employee must obtain a new physical. Same as Option A. 2. Life Event: Marriage, divorce, death of spouse or acquisition of an eligible child. No change permitted for this event. No change permitted for this event. Yes. Employee may elect or increase multiples (limited Yes. Employee may elect or increase multiples (limited 3. Employee is reinstated after a break in service of at least 180 days in a position that is not excluded from life insurance by law or regulation. Yes. Coverage is effective on the first day the employee is at work in a pay status, if no new waiver is filed. 4. Employee returns to Federal Service after a break in service of at least 180 days in a position that is excluded from life insurance by law or regulation. No. However, if employee is later converted to a non-excluded position, the coverage is effective on the first day the employee is at work in a pay status on or after being converted to such a position. 5A. Employee initially waives or subsequently cancels life insurance coverage. or 5B. Employee (or if applicable, assignee(s)) elects to decrease optional coverage. 6. Open Enrollment Period. Option B - Additional Option C - Family No change permitted for this event. to 5 total) up to (a) for marriage or children, the number of additional family members; (b) for divorce or death of spouse, the total number of dependent children. Exception: Acquiring a foster child does not count as a life event for Option B purposes. Coverage is effective the day of the event (IF employee is at work in a pay status on that day), if employee submits the SF 2817 before the event. Coverage is effective the first day the employee is at work in a pay status on or after the date of the event, if employee submits the SF 2817 within 60 days after the event (or is not at work in a pay status on the day of the event). Time Limit - Agency must receive SF 2817 and proof of the event within 60 days after date of event. (Time limit may be extended if event occurs when employee was separated from Federal service or if it occurs 60 days or less before separation.) to 5 total) no matter how many family members he/she has or acquires with the event. Coverage is effective the day of the event, if employee submits the SF 2817 before the event. Coverage is effective the day the agency receives the SF 2817, if employee submits it within 60 days after the event. Time Limit - Agency must receive SF 2817 and proof of the event within 60 days after date of event. (Time limit may be extended if event occurs when employee was separated from Federal service, 60 days or less before separation, or during the year following waiver of Basic.) Yes. Employee may elect any or all optional insurance within 31 days after reinstatement. Coverage is the same as with new employees. However, if employee does not submit SF 2817 electing such coverage to his/her agency within 31 days after reinstatement, he/she has the same Optional insurance carried immediately before his/her break in service. No. However, if employee is later converted to a non-excluded position, the coverage is effective on the first day the employee is converted to such a position wherein he or she is at work in a pay status on or after the date the agency receives the SF 2817 electing such coverage. Time Limit - Employee must submit SF 2817 electing such coverage to his or her agency within 31 days after conversion. Same as Option A. Same as Option A. Same as Option A. Same as Option A. A.Yes. Coverage stops at the end of the last day of the pay period in which the agency receives the SF 2817, with no 31-day extension of coverage. Time Limit None. Employee may cancel coverage at any time. However, if the insurance is assigned, only the assignee(s) may cancel coverage – the employee may not. A.Same as Basic. A. Same as Basic. A. Same as Basic, except information on assignment is not applicable. B. Not applicable. B. Not applicable. B. Yes. Employee may at any time reduce the number of multiples, unless the insurance has been assigned. In that case, only the assignee(s) may reduce coverage – the employee may not. Coverage reduces effective on the last day of the pay period in which the agency receives the SF 2817. B. Yes. Employee may at any time reduce the number of multiples. Coverage reduces effective on the last day of the pay period in which the agency receives the SF 2817. If permitted under conditions specified by OPM. Same as Basic. Same as Basic. Same as Basic. American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Employees 1. General Information 7. How to Complete and Review Your Election Form The major provisions of this program are described in the Federal Employees' Group Life Insurance (FEGLI) booklet (RI 76-21 or RI 76-20 for Postal Service employees, available from your employing office). Please read the entire booklet carefully. Your completed copy of this election form and the FEGLI booklet constitute your certification of coverage. Follow the instructions for each item carefully. After you fill out the form, review it to be sure it is complete and correct. The following checklist should help. 2. New Employees and Employees Newly Eligible for Life Insurance You are automatically enrolled in Basic unless you waive it. If you waive Basic, you automatically waive all forms of Optional insurance. You will not have any Optional insurance unless you elect it. To elect Basic: You do not need to submit this form unless you also wish to elect Optional insurance. If you do not submit this form, you will have Basic, but no Optional coverage. If you sign item 3, you elect (or retain) Basic. Do not also sign item 5. (You cannot elect (or retain) and waive coverage.) If you sign any block in item 4, you must also sign item 3. (To elect (or retain) an option, you must also elect (or retain) Basic.) If you sign item 4 for Option B and/or Option C, you must also mark one of the five boxes to show how many multiples you wish to elect (or retain). Do not mark more than one. Be sure you sign for all options you want. This election supersedes all previous ones. If you have optional coverage and wish to keep it, you must sign the appropriate box(es). If you do not sign for it, you have waived it. To waive Basic: Sign Section 5 of the form and give it to your employing office. Your agency will withhold Basic premiums from your salary from your first day at work in a pay status UNLESS you submit your waiver before the end of your first pay period. If you sign item 5, you waive Basic. Do not sign item 3 or any block in item 4. (You cannot waive and elect coverage.) To elect Optional: Sign Section 3 and one or more of the blocks in Section 4 of the form and give it to your employing office within 31 days after the date you are appointed or first become eligible for life insurance. Only you, the employee, may sign this form. Signatures by guardians, conservators, or through a power of attorney are not acceptable. Exception: If you have assigned your insurance, only the assignee(s) may cancel some or all of your coverage. In that case, the assignee(s) must sign the form (although the information in Section 2 must refer to you). To waive Optional: If you do not sign for a particular type of Optional coverage in Section 4, you automatically waive that coverage. If you do not submit the form at all, you will have Basic, but no Optional coverage. REMEMBER THAT YOU, NOT YOUR AGENCY, ARE RESPONSIBLE FOR ENSURING THAT YOUR SF 2817 IS CORRECT AND ACCURATELY REFLECTS YOUR INTENTIONS. 3. Employees With Prior Government Service 8. 1999 Open Enrollment Period A life insurance election or waiver on SF 2817 filed during a prior period of Federal employment stays in effect unless you change coverage or have a break in service of at least 180 days. A break in service of at least 180 days cancels any previous waiver of insurance. Unless you file a new waiver, Basic becomes effective on the first day you actually enter on duty in a pay status in a position in which you are eligible for coverage. You can elect any amount of Optional insurance within 31 days of returning to service, regardless of the coverage you had during previous employment. If you fail to elect any Optional insurance, you will automatically get the Optional insurance you carried immediately before your break in service. If you had a break in service of less than 180 days and were eligible in your last period of Federal employment, your life insurance in your new employment will be the same as you had then and if you waived coverage then, the waiver is still in effect. Your opportunities to cancel your waiver are strictly limited. See the FEGLI booklet. 4. Reemployed Annuitants If you waive your insurance as a reemployed annuitant, you also waive your insurance as an annuitant, and you will have no Federal life insurance. 5. Assignment If you have assigned your insurance by filing an RI 76-10, Assignment of Federal Employees' Group Life Insurance, you may not cancel any of your current insurance coverage. Only the assignee(s) may cancel your coverage. However, you may elect new coverage if you otherwise meet the requirements for electing such coverage. Any new coverage you elect will automatically be subject to your existing assignment, except for Option C, which you cannot assign. All assignments are automatically canceled after a break in service of at least 31 days, or upon cancellation of all life insurance coverage by the assignee(s). 6. Attention Assignees If you are completing this form in order to cancel some or all of the employee's life insurance coverage, you must sign the form. The information in Section 2 of the form refers to the employee, but you must sign in Section 3, 4 or 5, as applicable. Indicate "assignee" after your signature. Return the completed form to the employee's employing office. If the insured is an annuitant, return the completed form to OPM, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045. See #11 for where to return the completed form if the insured is a compensationer. If you elected coverage during the 1999 Open Enrollment Period, and that coverage has not yet become effective, and you want to make a further change to your FEGLI coverage on this SF 2817, you should check with your employing office. That office can tell you about any special election procedures that may apply. 9. Waiving or Changing Your Insurance Coverage If you do not sign for a particular type of coverage, you have waived that coverage. If you waive Basic or one or more of the options, your opportunities to enroll in the coverage you waived are strictly limited. A waiver may also affect your eligibility to continue coverage into retirement. See the FEGLI booklet. 10. Where to Send Completed Form After you have completed this form and verified that it accurately reflects your intentions, send the entire form (without separating the parts) to your employing office. 11. Compensationers If you are receiving compensation payments from the Office of Workers' Compensation Programs (OWCP), provide your OWCP number in Section 2 of the form. If you are still employed, return the completed form to your employing office. If you are not still employed or if you have been receiving compensation payments for at least 12 months, return the completed form to OPM, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045. 12. How to Verify that Your Agency Processed Your Election After your employing office processes your election form, you will receive an SF 50, Notice of Personnel Action. A two digit code appearing on the SF 50 will explain your insurance coverage. These codes are explained on Part 2 of the SF 2817. Also check your pay statement for the correct withholdings. If you are insured as a compensationer, you will receive a notice from OPM which will explain your insurance coverage. 13. Further Information For further information, consult the FEGLI Handbook (RI 76-26) or the FEGLI Booklet (RI 76-21 or RI 76-20 for Postal Service employees), which are available on the FEGLI web site at www.opm.gov/insure/life. Privacy Act and Public Burden Statements Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance, authorizes solicitation of this information. The data you furnish will be used to determine your life insurance coverage. This information may be shared and is subject to verification, via paper, electronic media, or through the use of the computer matching programs, with national, state, local or other charitable or social security administrative agencies to determine and issue benefits under their programs or law enforcement agencies, when they are investigating a violation or potential violation of the civil or criminal law. 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. Failure to furnish the requested information may result in OPM's inability to determine your life insurance coverage. We think this form takes an average of 15 minutes to complete including the time for getting the needed data and reviewing both the instructions and 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 (OPM), Reports and Forms Manager, Paperwork Reduction Project (3206-0230), Washington, DC 20415-7900. The OMB Number, 3206-0230 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. American LegalNet, Inc. www.FormsWorkFlow.com