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Fe2004 (U.S. Office of Personnel Management)

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FEGLI 2004 Open Season
Election Form
Federal Employees' Group Life Insurance Program
This is your Golden Opportunity!
September 1 - September 30, 2004
Most agencies (including agencies who use Employee Express) require paper
forms for FEGLI elections. A few agencies process FEGLI elections
electronically, and do NOT use paper FEGLI election forms. If you're
unsure about what your agency does, contact them for more information.
• Use this form for FEGLI 2004 Open Season elections to enroll in the FEGLI
Program, or to change/increase your current FEGLI coverage.
• Open Season elections have a DELAYED effective date. New coverage you elect
on this form will be effective on the first day of your first pay period that begins on
or after September 1, 2005, and that immediately follows one in which you meet
the pay and duty status requirements discussed on the back of Part 3 of this form.
• Benefits WILL NOT be paid based on new coverage you elect until that new coverage
is effective. For some employees, their new coverage will never become effective
because they will never meet the pay and duty status requirements.
• You CANNOT continue new coverage elected on this form if you retire or begin
receiving compensation fewer than FIVE years after the coverage becomes
effective. So that means the very earliest most employees can retire or start receiving
compensation and carry that new coverage into retirement or compensation is
September 4, 2010 (September 3, 2010, for U.S. Postal Service employees.)
• If you want to cancel coverage effective right away, do NOT use this form.
Use the SF 2817, Life Insurance Election.
• If you are satisfied with your current coverage (or lack of coverage), do NOT
complete this form. Your current coverage will remain unchanged.
• Be sure to sign for EACH type of coverage you wish to have, even if you have
that coverage now. Anything you do NOT sign for will be cancelled/waived on
the effective date of this election.
FE-2004
September 2004
1
FEGLI 2004 Open Season
September 1-30, 2004
Election Form
Federal Employees' Group Life Insurance Program
Instructions
Use this form ONLY for FEGLI 2004 Open Season elections. Use SF 2817,
Life Insurance Election, for all non-Open Season elections.
Read the back of Part 3 - Employee Copy carefully.
Give all parts of your completed form to your employing office.
Your employing office will complete Part 6 of this form and return a copy
(or its electronic equivalent) to you.
2
Effective date
New coverage you elect during this Open Season will be effective on the
first day of your first pay period that begins on or after September 1, 2005,
and that immediately follows one in which you were in a pay and
duty status
for at least 32 hours for full-time employees. See the back of Part 3 for the
pay and duty status requirements for part-time and intermittent employees.
Benefits will NOT be paid based on new coverage you elect until that
new coverage is effective.
Be sure you sign for ALL coverage you wish to have not just the new coverage you wish to elect during Open Season.
This election supersedes all previous elections.
Fill in identifying information about yourself
3
Name
(Last) (First) (Middle) Date of birth (mm/dd/yyyy) Social Security Number
Employing department or agency
Department or agency location where you work
(City, state, ZIP Code)
Daytime telephone number
(Including area code)
4
Basic
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.
I want Basic.
I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)
Signature (Do not print. Only you may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.)
Date (mm/dd/yyyy)
5
Optional
If you signed for Basic in Item 4 on this form, you may elect or retain any or all of the following options. Sign the box(es) below
for any option(s) you wish to elect or retain.
As of the effective date of this election, you will NOT have any
option(s) that you do not sign for below, even if you currently have that option.
Option A - Standard
I want Option A.
I authorize deductions to pay the full cost.
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Date (mm/dd/yyyy)
Option B - Additional
I want Option B in the multiple of my annual rate of
basic pay I indicate below. I authorize deductions to
pay the full cost.
1 times my pay
2 times my pay
3 times my pay
4 times my pay
5 times my pay
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Date
(mm/dd/yyyy)
Option C - Family
I want Option C in the multiple I indicate below.
I understand that each multiple is worth $5,000
upon the death of my spouse, and $2,500 upon
the death of an eligible child. I authorize deductions
to pay the full cost.
1 multiple
2 multiples
3 multiples
4 multiples
5 multiples
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
(mm/dd/yyyy) Date
6
Agency
Use
Remarks:
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
Once the coverage is effective, Part 3 of this form (the Employee Copy or its electronic equivalent) and the FEGLI Program Booklet
(FE 76-21 or RI 76-21) (FE 76-20 or RI 76-20 for U.S. Postal Service employees) constitute your Certificate of Insurance.
FE-2004
PART 1 - File in Official Personnel Folder
September 2004
Print Form
Save Form
Clear Form
Instructions for Agencies
1. Who should file this form
Eligible employees (including reemployed annuitants) who
wish to make a FEGLI 2004 Open Season election.
2. Who should NOT file this form
•
Employees making non-Open Season elections (for
example, new employees electing coverage within
31 days of their appointment, life event elections, etc.)
They must use SF 2817, Life Insurance Election.
•
Employees who want to cancel all of their FEGLI coverage.
They must use SF 2817, Life Insurance Election.
•
Assignees
•
Annuitants and compensationers
3. Review of completed form
Agencies should review the original and all copies of this form
to see that they are legible and complete. If an employee signs the
box for Option A, Option B, or Option C in item 5, he or she must
also sign item 4, Basic.
Only the employee may sign this form. Signatures by guardians,
conservators, or through a power of attorney are not acceptable.
Please note that while the agency should make sure that the form is
complete, the employee is solely responsible for ensuring that this
form accurately reflects his or her intentions.
4. Completion of form
An authorized agency official must sign the form in item 6.
5. Date received
In item 6, enter the date the employing office received this form.
6. Effective date of coverage
FEGLI 2004 Open Season elections are effective on the first day of
the first pay period that begins on or after September 1, 2005, and
that immediately follows one in which the employee was in a pay
and duty status for at least 32 hours for full-time employees.
Part-time employees must have been in a pay and duty status for
one-half of their regularly scheduled tour of duty. Employees on an
intermittent schedule or without a regularly scheduled tour of duty
must have been in a pay and duty status for one-half of the hours
customarily worked. An employee on annual leave, sick leave,
donated leave, or any other type of leave is not in a pay and duty
status.
Benefits WILL NOT be paid based on new coverage until that
new coverage becomes effective. Thus, if an employee who made
an Open Season election dies (or his/her covered family member
dies) BEFORE that new coverage is effective, life insurance
benefits will NOT be paid based on that new coverage.
7. Disposition of this form
•
Part 1 -- File this in the employee's Official Personnel
Folder (OPF) or its equivalent.
•
Part 2 -- Forward this to the employee's payroll office. It can be
destroyed after payroll office use in 2005 or beyond, depending
on the effective date of the election.
•
Part 3 -- Give this (or its electronic equivalent) to the employee
AFTER the coverage becomes effective.
•
Part 4 -- Give this (or its electronic equivalent) to the employee
at the time of election, after the agency has signed and dated
the form.
8. Flagging the OPF
Agencies must develop a system for holding Parts 1, 2 and 3 until
they can be processed in 2005 or beyond, when the coverage
becomes effective. Whether you put them in the OPF or its
equivalent, or maintain them separately from the OPF, you must flag
the OPF or its equivalent in some way to indicate that the employee
has a pending Open Season election.
9. Continuation into retirement or compensation
If employees retire or begin receiving compensation payments
from the Department of Labor fewer than five years after the
effective date of this Open Season election (see #6), they
CANNOT carry the new coverage into retirement or
compensation. So this means the very earliest most employees
can retire or start receiving compensation and carry new
coverage into retirement or compensation is September 4, 2010
(September 3, 2010, for U.S. Postal Service employees.)
10. Further information
For further information about the FEGLI 2004 Open Season,
consult your agency headquarters insurance officer or visit
www.fegli2004.opm.gov.
FE-2004
Back of Part 1
September 2004
FEGLI 2004 Open Season
September 1-30, 2004
Election Form
Federal Employees' Group Life Insurance Program
SF 50 Equivalents of Insurance Codes
INSURANCE SF 50
1004 E4 1110 H0 1113 J3 1024 M4 1130 P0 1133 R3 1044 U4 1150 X0 1153 Z3
INELIGIBLE A0 1005 E5 1011 I1 1114 J4 1025 M5 1031 Q1 1134 R4 1045 U5 1051 Y1 1154 Z4
0000 B0 1101 F1 1012 I2 1115 J5 1121 N1 1032 Q2 1135 R5 1141 V1 1052 Y2 1155 Z5
1000 C0 1102 F2 1013 I3 1020 K0 1122 N2 1033 Q3 1040 S0 1142 V2 1053 Y3
1100 D0 1103 F3 1014 I4 1120 L0 1123 N3 1034 Q4 1140 T0 1143 V3 1054 Y4
1001 E1 1104 F4 1015 I5 1021 M1 1124 N4 1035 Q5 1041 U1 1144 V4 1055 Y5
1002 E2 1105 F5 1111 J1 1022 M2 1125 N5 1131 R1 1042 U2 1145 V5 1151 Z1
1003 E3 1010 G0 1112 J2 1023 M3 1030 90 1132 R2 1043 U3 1050 W0 1152 Z2
3
Fill in identifying information about yourself
Name
(Last) (First) (Middle) Date of birth (mm/dd/yyyy) Social Security Number
Employing department or agency
Department or agency location where you work
(City, state, ZIP Code)
Daytime telephone number
(Including area code)
4
Basic
In item 7: If this block is not signed, have employee sign it otherwise all coverage is waived.
If this box is signed enter 1 in box 1.�
Date (mm/dd/yyyy)
Signature (Do not print. Only you may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.)�
5
Optional
If you signed for Basic in Item 4 on this form, you may elect or retain any or all of the following options. Sign the box(es) below
for any option(s) you wish to elect or retain.
As of the effective date of this election, you will NOT have any
option(s) that you do not sign for below, even if you currently have that option.
Option A - Standard
In item 7, box 2:
If this block is not signed, enter
0
If this block is signed, enter
1
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)�
Date (mm/dd/yyyy)
Option B - Additional
In item 7, box 3:
If this block is not signed, enter
0
If this block is signed, enter the number
marked "X" below
1 times my pay
2 times my pay
3 times my pay
4 times my pay
5 times my pay
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Date
(mm/dd/yyyy)
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
1 multiple
2 multiples
3 multiples
4 multiples
5 multiples
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a�
power of attorney are not acceptable.)
Date (mm/dd/yyyy)
6
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
7
INSTRUCTIONS:
Enter codes in the boxes on the right.
Insurance Code
1 2
3
4
SF 50
Equivalent
FE-2004
September 2004
PART 2 - For Agency Use
Print Form
Save Form
Clear Form
This page was left blank intentionally.
FE-2004
Back of Part 2
September 2004
1
FEGLI 2004 Open Season
September 1-30, 2004
Election Form
Federal Employees' Group Life Insurance Program
Instructions
Use SF 2817, Use this form ONLY for FEGLI 2004 Open Season elections.
Life Insurance Election, for all non-Open Season elections.
Read the back of Part 3 - Employee Copy carefully.
Give all parts of your completed form to your employing office.
Your employing office will complete Part 6 of this form and return a copy
pay and duty status requirements for part-time and intermittent employees.
(or its electronic equivalent) to you.
2
Effective date
New coverage you elect during this Open Season will be effective on the
first day of your first pay period that begins on or after September 1, 2005,
and that immediately follows one in which you were in a pay and
duty status
for at least 32 hours for full-time employees. See the back of Part 3 for the
Benefits will NOT be paid based on new coverage you elect until that
new coverage is effective.
Be sure you sign for ALL coverage you wish to have not just the new coverage you wish to elect during Open Season.
This election supersedes all previous elections.
3
Fill in identifying information about yourself
Name
(Last) (First) (Middle) Date of birth (mm/dd/yyyy) Social Security Number
Employing department or agency
Department or agency location where you work
(City, state, ZIP Code)
Daytime telephone number
(Including area code)
4
Basic
To elect or retain Basic, If you do not sign for Basic, you may not elect or retain any form of Optional insurance.
I want Basic.
I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)
Signature (Do not print. Only you may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.)
Date (mm/dd/yyyy)
Sign the box(es) below
5
Optional
If you signed for Basic in Item 4 on this form, you may elect or retain any or all of the following options.
for any option(s) you wish to elect or retain. As of the effective date of this election, you will NOT have any
Option A - Standard
option(s) that you do not sign for below, even if you currently have that option.
I want Option A.
I authorize deductions to pay the full cost.
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Date (mm/dd/yyyy)
Option B - Additional
I want Option B in the multiple of my annual rate of
basic pay I indicate below. I authorize deductions to
pay the full cost.
1 times my pay
2 times my pay
3 times my pay
4 times my pay
5 times my pay
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Date
(mm/dd/yyyy)
Option C - Family
I want Option C in the multiple I indicate below.
I understand that each multiple is worth $5,000
upon the death of my spouse, and $2,500 upon
the death of an eligible child. I authorize deductions
to pay the full cost.
1 multiple
2 multiples
3 multiples
4 multiples
5 multiples
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Date (mm/dd/yyyy)
sign and date below.
6
Agency
Use
Remarks:
Name and address of employing office
(mm/dd/yyyy)
Date received in employing office
Effective date of coverage
(mm/dd/yyyy)
I followed the instructions on the back of Part 1.
Signature of authorized agency official
Once the coverage is effective, Part 3 of this form (the Employee Copy or its electronic equivalent) and the FEGLI Program Booklet
(FE 76-21 or RI 76-21) (FE 76-20 or RI 76-20 for U.S. Postal Service employees) constitute your Certificate of Insurance.
FE-2004
September 2004
PART 3 - Employee Copy (After Coverage is Effective)
Print Form
Save Form
Clear Form
Instructions for Employees
1. General information
Use this form (or its electronic equivalent) for FEGLI 2004
Open Season elections to enroll in the FEGLI Program, or to
change/increase your current FEGLI coverage. Most agencies
(including agencies who use Employee Express) require paper
forms for FEGLI elections. A few agencies process FEGLI
elections electronically, and do NOT use paper FEGLI election
forms. If you're unsure about what your agency does, contact
them for more information.
If you want to cancel ALL of your current coverage or make a
non-Open Season election (for example, if you're a new
employee electing coverage within 31 days of your appointment,
or you're electing coverage based on a life event, etc.), you must
use SF 2817, Life Insurance Election.
Be sure that you sign for ALL coverage you now have and
wish to keep. Also sign for any NEW coverage you wish to
elect. If you do not sign for a particular type of coverage,
even if you have it now, it will cancel on the effective date of
this election (see #2, below.)
2. Effective date
FEGLI 2004 Open Season elections will be effective on the first
day of your first pay period that begins on or after September 1,
2005, and that immediately follows one in which you were in a
pay and duty status for at least 32 hours for full-time employees.
If you are a part-time employee, you must have been in a pay and
duty status for one-half of the regularly scheduled tour of duty
shown on your current SF 50, Notification of Personnel Action.
If you are on an intermittent schedule or do not have a regularly
scheduled tour of duty, you must have been in a pay and duty
status for one-half of the hours you customarily work.
For some employees, their new coverage will never become
effective because they will never meet the pay and duty status
requirements.
If you are on annual leave, sick leave, donated leave, or any other
type of leave, you are not in a pay and duty status.
Benefits WILL NOT be paid based on any new coverage
until that new coverage becomes effective. That means that if
you make a FEGLI 2004 Open Season election and you or a
covered family member die BEFORE that new coverage is
effective, life insurance benefits will NOT be paid based on that
new coverage.
3. Continuing coverage into retirement or compensation
If you retire or begin receiving compensation payments from the
Department of Labor fewer than five years after the effective
date of this Open Season election (see #2, above), you CANNOT
carry new coverage into retirement or compensation. So this
means the very earliest most employees can retire or start
receiving compensation and carry that new coverage into
retirement or compensation is September 4, 2010 (September 3,
2010, for U.S. Postal Service employees.)
4. How to complete and review your election form
Follow the instructions for each item carefully. After you fill out
this form (or its electronic equivalent), review it to be sure it is
complete and correct, and accurately reflects your intentions.
Give the completed form to your employing office.
The following list should help you complete the form:
If you sign Item 4, you elect Basic.
If you sign any block in Item 5, you must also sign
Item 4. (To elect an option, you must also elect Basic.)
If you sign Item 5 for Option B and/or Option C,
you must also mark one of the 5 boxes to show how
many multiples you wish to elect. Do not mark more
than 1 box for each option.
Be sure you sign for every option you want, EVEN IF
you already have that coverage. Anything you do not
sign for will be cancelled/waived on the effective date
of this election.
This election supersedes all previous elections.
Only you, the employee, may sign this form (or its electronic
equivalent.) Signatures by guardians, conservators, or through
a power of attorney are not acceptable.
YOU ARE RESPONSIBLE FOR ENSURING THAT YOUR
ELECTION IS CORRECT AND ACCURATELY
REFLECTS YOUR INTENTIONS. IF YOU DO NOT SIGN
FOR IT, YOU HAVE CANCELLED/WAIVED IT.
5. Assignment
If you have assigned your coverage by filing an RI 76-10,
Assignment of Federal Employees' Group Life Insurance, any
new coverage you elect during the FEGLI 2004 Open Season
(except Option C) will be subject to that assignment. Your
assignee(s) may not make an Open Season election.
6. Further information
For further information about the FEGLI 2004 Open Season,
consult your employing office or visit
www.fegli2004.opm.gov.
FE-2004
Back of Part 3
September 2004
FEGLI 2004 Open Season
September 1-30, 2004
Election Form
Federal Employees' Group Life Insurance Program
Instructions
Life Insurance Election, for all non-Open Season elections.
Read the back of Part 3 - Employee Copy carefully.
Give all parts of your completed form to your employing office.
Your employing office will complete Part 6 of this form and return a copy
1
(or its electronic equivalent) to you.
Effective date
2
New coverage you elect during this Open Season will be effective on the
first day of your first pay period that begins on or after September 1, 2005,
and that immediately follows one in which you were in a pay and
duty status
for at least 32 hours for full-time employees. See the back of Part 3 for the
pay and duty status requirements for part-time and intermittent employees.
Benefits will NOT be paid based on new coverage you elect until that
new coverage is effective.
Be sure you sign for ALL coverage you wish to have not just the new coverage you wish to elect during Open Season.
This election supersedes all previous elections.
3
Fill in identifying information about yourself
Name
(Last) (First) (Middle) Date of birth (mm/dd/yyyy) Social Security Number
Employing department or agency
Department or agency location where you work
Daytime telephone number
(City, state, ZIP Code)
(Including area code)
To elect or retain Basic,
4
Basic
I want Basic.
Signature
Date (mm/dd/yyyy)
If you signed for Basic in Item 4 on this form, you may elect or retain any or all of the following options. Sign the box(es) below
5
Optional
for any option(s) you wish to elect or retain. As of the effective date of this election, you will NOT have any
option(s) that you do not sign for below, even if you currently have that option.
Option A - Standard Option B - Additional Option C - Family
I want Option A.
I want Option B in the multiple of my annual rate of
I want Option C in the multiple I indicate below.
I authorize deductions to pay the full cost.
I understand that each multiple is worth $5,000
pay the full cost.
upon the death of my spouse, and $2,500 upon
to pay the full cost.
3 times my pay
3 multiples
1 times my pay 4 times my pay
1 multiple 4 multiples
2 times my pay 5 times my pay
2 multiples 5 multiples
Signature (Do not print. Only you may sign.
Signature (Do not print. Only you may sign.
Signature (Do not print. Only you may sign.
Signatures by guardians, conservators or through a
Signatures by guardians, conservators or through a
Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
power of attorney are not acceptable.)
power of attorney are not acceptable.)
Date (mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date (mm/dd/yyyy)
6
Agency Remarks:
Use
Name and address of employing office
Date received in employing office
Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)
I followed the instructions on the back of Part 1.
Signature of authorized agency official
Use this form ONLY for FEGLI 2004 Open Season elections. Use SF 2817,
sign and date below. If you do not sign for Basic, you may not elect or retain any form of Optional insurance.
I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)
(Do not print. Only you may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.)
basic pay I indicate below. I authorize deductions to
the death of an eligible child. I authorize deductions
Once the coverage is effective, Part 3 of this form (the Employee Copy or its electronic equivalent) and the FEGLI Program Booklet
(FE 76-21 or RI 76-21) (FE 76-20 or RI 76-20 for U.S. Postal Service employees) constitute your Certificate of Insurance.
FE-2004
Part 4 - Acknowledgment Copy
September 2004
Print Form
Save Form
Clear Form
Acknowledgement Copy
This form (or its electronic equivalent)
is only an acknowledgement of your FEGLI 2004
Open Season election. Your new coverage is
NOT
yet effective.
Please note that the new coverage you elected will be effective on the first day of your first
pay period that begins on or after
September 1, 2005
, and that immediately follows one in
which you are in a pay and duty status for at least 32 hours for full-time employees.
If you are a part-time employee, you must be in a pay and duty status for one-half of the
regularly scheduled tour of duty shown on your current SF 50,
Notification of Personnel
Action
. If you are on an intermittent schedule or do not have a regularly scheduled tour of
duty, you must be in a pay and duty status for one-half of the hours you customarily work. If
you are on annual leave, sick leave, donated leave, or any other type of leave, you are not in a
pay and duty status.
BENEFITS WILL NOT BE PAID BASED ON NEW COVERAGE YOU ELECTED
UNTIL THAT NEW COVERAGE IS EFFECTIVE.
Please keep a copy of this form (or its electronic equivalent) until you receive confirmation
from your employing office that your FEGLI 2004 Open Season election is effective. You
should also check your pay statement after the coverage is effective to make sure the correct
premiums are being deducted.
You should receive confirmation shortly after the effective date of your election.
If you retire or begin receiving compensation payments from the Department of Labor fewer
than five years after the effective date of this Open Season election, you
CANNOT
carry the
new coverage into retirement or compensation. So this means the very earliest most
employees can retire or start receiving compensation and carry that new coverage into
retirement or compensation is September 4, 2010 (September 3, 2010, for U.S. Postal Service
employees.)
Double-check to be sure you
signed for EACH type
of coverage you wish to have,
even if
you have that coverage now. Anything you do not sign for will be cancelled/waived on the
effective date of this election. If you made a mistake, contact your employing office
immediately.
FE-2004
Back of Part 4
September 2004
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