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Fe6dep (U.S. Office of Personnel Management)

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Do NOT use previous editions Page 1
Form FE-6 DEP
Revised 'HFHPEHU 2013
OFEGLI Form in Adobe Acrobat PDF (12/13)
Statement of Claim — Option C
Family Life Insurance
Federal Employees’ Group Life Insurance Program
Instructions
General
The Metropolitan Life Insurance Company (MetLife) pays claims for the Federal Employees’ Group Life Insurance (FEGLI)
Program through its administrative ofce, the Ofce of Federal Employees’ Group Life Insurance (OFEGLI). “I” and “you” refer
to the individual completing this form.
How do I complete this form?
• Read the instructions carefully.
• Please type or print legibly in ink.
• Complete parts A, B, C, and page 3.
What else do I have to submit?
In addition to this claim form, you must send a certied copy of the deceased’s death certicate that contains the cause and manner
of death. You can get the certicate from your city or state’s Bureau of Vital Statistics or equivalent agency. MetLife cannot process
your claim until it receives the certied death certicate. MetLife will let you know if it needs anything else.
What should I do if I need help completing this form?
If you need help in completing this form, you may contact MetLife/OFEGLI’s customer service representatives, toll-free, at
1-800-OFE-GLIA (1-800-633-4542).
Where do I send this form and other documents?
Please do not send your claim form and other documents directly to MetLife/OFEGLI.
• If you are an active employee, send everything to your employing ofce.
• If you are retired or receiving Federal Workers’ Compensation benets, send everything to:
Ofce of Personnel Management (OPM)
Retirement Operations Center
Attention: FE6-DEP
Boyers, PA 16017
How will I receive benets?
If your claim is for less than $5,000, MetLife will mail you a check.
If your claim is for $5,000 or more, you must choose one of two payment options: (1) a check, or (2) a MetLife Total Control
Account (TCA), an interest bearing account set up in your name and administered by MetLife. This account is not insured by the
Federal Deposit Insurance Company (FDIC). The choice is yours. See Page 2 for details. See Page 3 to make your selection.
What should I do if I no longer want Option C-Family Life Insurance?
• If you are an active employee, contact your employing ofce’s servicing human resources ofce.
• If you are retired or receiving Federal Workers’ Compensation benets, write to:
Ofce of Personnel Management (OPM)
Retirement Operations Center
Attention: Annuity Adjustment Section
Boyers, PA 16017
Please include your retirement or compensation claim number and be sure to sign your letter.
Instructions to the employing agency/retirement system
• Complete Part D of this claim form.
• If the claim requires that you determine eligibility for foster children or disabled children older than age 22, rst review
the denitions on page 5 and then complete Part D of this claim form. Please note that MetLife does not need the background
documentation.
• Send the completed claim form and certied death certicate to:
MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080
Do NOT use previous editions Page 2
Form FE-6 DEP
Revised December 2013
MetLife OFEGLI Form in Adobe Acrobat PDF (12/13)
Claim for Death Benets
Federal Employees’ Group Life Insurance Program
Understanding Your Life Insurance Payment Options
If your claim is for less than $5,000, Metropolitan Life Insurance Company (MetLife) will mail you a check.
If your claim is for $5,000 or more, you have an important choice to make regarding how you wish to receive
the payment. On Page 3, you must select one of two ways to receive your payment:
• Check (mailed to you through the U.S. Postal Service)
• MetLife Total Control Account (TCA) - an interest bearing account set up in your name and
administered by MetLife.
The MetLife TCA is a settlement option offered by MetLife for the payment of claims. A MetLife TCA is
not a checking, savings, or money market bank account. Since your MetLife TCA is not a bank account,
it is not insured by the FDIC or any government agency. Instead, MetLife guarantees the full amount in
your MetLife TCA, including all interest earned. MetLife’s guarantee is further backed by your respective
state insurance guaranty association. Maximum guarantee limits vary from state to state and may change
over time. If you choose a MetLife TCA, the relationship is between you and MetLife, not with the federal
government or any of its agencies.
The MetLife TCA offers you a minimum guaranteed annual effective interest rate, meaning that MetLife
commits to pay you at least that specied rate of interest on the money in the account. You begin earning
interest the day the MetLife TCA is created. Interest is earned daily, but is not credited until the last day of
the month. The interest rate offered on the MetLife TCA may be better or worse than the prevailing market
rates. The MetLife TCA is a product offered by MetLife on which the company may make a prot. You pay
no monthly maintenance fees on a MetLife TCA.
You have complete control of, and access to, the entire amount of your insurance proceeds. You can
withdraw the full amount from the MetLife TCA at any time. The information packet you receive will
include a draft book (similar to a checkbook). At any time and at no cost, you can write drafts (similar
to checks) from a minimum of $250 up to the full balance of your account. In addition, you will receive
periodic activity statements, and you can designate a beneciary for your account. If you choose the MetLife
TCA settlement option, you will receive more detailed information when the account is opened.
Please keep pages 1 and 2 for your records
Do NOT use previous editions Page 3
Form FE-6 DEP
Revised December 2013
MetLife OFEGLI Form in Adobe Acrobat PDF (12/13)
Claim for Death Benets
Federal Employees’ Group Life Insurance (FEGLI) Program
Part 1: Select Method to Receive Your Payment
Please SELECT ONE method of settlement in order to receive your payment. By selecting below, you conrm that you have read
the enclosed materials on both FEGLI payment options (Check and MetLife Total Control Account).
M
Check
Your payment will be sent via the U.S. Postal Service to the address you enter below.
M
MetLife Total Control Account (TCA)
You are eligible for a MetLife TCA if your payment is for $5,000 or more. MetLife TCA is not a bank account and is not
FDIC-insured. See Page 2 for more details.
Part 2: Enter the Following Information to Receive Payment
Please complete, in ink, the information below. This information is needed to send you a check or to open your MetLife Total Control
Account. Even if this information is provided elsewhere on this form, you must also provide it here.
lf no box is checked above (and your payment is $5,000 or more), a MetLife Total Control Account will be established in your name
and your payment will be deposited on your behalf.
Your signature
Your name (please print)
Address (number, street, apartment number)
City, State, ZIP Code
Your Social Security Number
or
Estate/Trust/Tax ID Number
Date (mm/dd/yyyy)
Daytime telephone number
( )
Area Code
Evening telephone number
( )
Area Code
Please return pages 3 through 5 to OFEGLI
Do NOT use previous editions Page 4
Form FE-6 DEP
Revised December 2013
OFEGLI Form in Adobe Acrobat PDF (12/13)
Statement of Claim — Option C
Family Life Insurance
Federal Employees’ Group Life Insurance (FEGLI)
Part A. Information about You
1. Your name (Last) (First) (Middle) 2. Date of birth (mm/dd/yyyy)
3. Social Security Number
4. Department or agency in which last employed, including bureau or division
5. Location of last employment (City, state, ZIP code)
6. Are you retired and receiving a monthly annuity under any Federal civilian retirement system?
Yes No If “Yes”, provide the Claim number (CSA, CSF, CSI)____________________________________
*Special Note: Social Security monthly payments are not Federal civilian retirement annuities.
If “Yes”, provide the effective date of Retirement ______________________________________
(mm/dd/yyyy)
Part B. Information about the Deceased Family Member
1. Deceased’s full name (Last) (First) (Middle) 2. Date of birth (mm/dd/yyyy) 3. Date of death (mm/dd/yyyy)
Complete Items 4 through 9 if this claim is for your spouse
4. Date of marriage (mm/dd/yyyy) 5. Place of marriage (City and state)
6. Marriage was performed by:
Clergy or Justice of the Peace
Other (specify) ________________________
7. Were you living with the
deceased at the time of death?
Yes No
8. Were you divorced from the deceased
at the time of death?
Yes No
9. If you were divorced from the deceased, give the date (mm/dd/yyyy)
and place of the divorce. (City and state)
Complete Items 10 through 13 if this claim is for your child
10. Child’s marital status
Single
Married
11. Child’s relationship to you
Legitimate child
Foster child
Stepchild Disabled dependent child 22 yrs. or over
Adopted child Recognized natural child Other (Specify) ____________________
12. If the deceased was a stepchild, recognized natural child, or foster child
was the child living with you at the time of death?
Yes No (Explain on separate sheet)
13. If the deceased was a recognized natural child and was not living with
you at the time of death, did you provide nancial support for the child?
Yes No (Explain on separate sheet)
- - -
Part C. Your Certication
If your claim is for less than $5,000, MetLife will mail you a check.
If your claim is for $5,000 or more, you must choose one of two
payment options. See Page 2 for details. See Page 3 to make your
selection.
FEGLI death benets are not subject to Federal income tax, but the
interest that MetLife pays on those benets is subject to such tax.
MetLife will report all interest payments to the Internal Revenue
Service.
Your name (Please print)
________________________________________________________________
Address (Number, street, apt. no.)
________________________________________________________________
City, State, ZIP code
________________________________________________________________
Your Social Security Number or Estate / Trust / Tax ID Number
Under penalty of perjury, I certify:
1. That the number shown on this form is my correct taxpayer identication number; and
2. That I am NOT subject to backup withholding because: (a) I have not been notied by the Internal Revenue Service (IRS) that I am
subject to backup withholding as a result of a failure to report all interest or dividends; or (b) the IRS has notied me that I am no longer
subject to backup withholding.
If you are currently subject to backup withholding, check this box:
3. I am a U.S. citizen or a U.S. resident for tax purposes. Check one: Yes No
If you are not a U.S. citizen or resident for tax purposes, we will send you a W-8BEN that you are required to complete to certify your
foreign status.
The IRS does not require your consent to any provision of this document other than the certications required to avoid backup
withholding.
_____________________________________________________
My signature (Do not print)
( ______ ) ___________________
Area Code Daytime telephone no.
( ______ ) ___________________
Area Code Evening telephone no.
Warning – If you knowingly and willfully make any materially false, ctitious or fraudulent statement or representation on this form, or conceal a material fact related
to the requests for information on this form, you may be subject to a monetary ne or imprisonment for not more than ve years, or both, under 18 U.S.C. 1001.
Do NOT use previous editions Page 5
Form FE-6 DEP
Revised December 2013
OFEGLI Form in Adobe Acrobat PDF (12/13)
Part D. Employing Agency/OPM Certication of Insurance Status
• Employing agency completes items 1, 2 and 4 through 8 for Active Employees
• OPM completes all items 1 through 8 for Retirees and Compensationers
1. Did the insured have Option C on the date of death of the family member?
No Yes If “Yes” provide effective date of election _____________
(mm/dd/yyyy)
If “Yes” mark the box to show the number of multiples
1 2 3 4 5
2. Did the insured indicate in Part B - Item 11 that the deceased was a foster
child or disabled dependent child?
No Yes
If “Yes” do you certify that the child qualies for Option C coverage?
No Yes
If the insured is retired or receiving compensation, complete items 3a. through 3c.
3a. What is the effective date of the insured’s retirement or receipt of
compensation? ____________________
(mm/dd/yyyy)
3b. What is the insured’s date of birth? _____________________
(mm/dd/yyyy)
3c. What was the insured’s Option C election?
Number of multiples for full reduction 1 2 3 4 5
Number of multiples for no reduction 1 2 3 4 5
4. Agency Name
_______________________________________________
_______________________________________________
Agency Telephone Number
(
________ ) ____________________
Area Code
5. Agency Mailing Address
_______________________________________________
_______________________________________________
Number, Street
_______________________________________________
City, State, ZIP code
I certify that the information I gave in Part D of this form is correct and that I obtained it from the employee’s/retiree’s/compensationer’s ofcial records.
6. Name of authorized agency ofcial
(Please print)
__________________________________________
7. Signature of authorized agency ofcial
(Do not print)
__________________________________________
8. Date signed
___________________________________________
(mm/dd/yyyy)
Send this completed claim form and certied death certicate to: MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080
Denition of Terms
Disabled dependent child age 22 years or over means a child who was incapable of self-support because of a mental or physical
disability that existed before the child became 22 years of age.
Foster child means a child living with you in a regular parent-child relationship where you are the primary source of nancial
support for the child and expect to raise the child to adulthood. A child placed in your home by a welfare or social service agency
under an agreement where the agency retains control of the child or pays for maintenance does not qualify as a foster child.
Grandchildren, as such, are not eligible family members. However, grandchildren can qualify as foster children if they meet all of
the requirements.
Recognized natural child means a child born out of wedlock whom you recognized as your child during the child’s lifetime.
In addition, at the time of the child’s death, he/she must have either lived with you in a regular parent-child relationship or been
dependent on you nancially.
Regular parent-child relationship means that you exercise parental authority, responsibility, and control over the child by caring
for, supporting, disciplining, and guiding the child, including making decisions about the child’s education and health care.
If you have any questions concerning your child’s eligibility for coverage, you must contact your employing agency or retirement
system, and not MetLife/OFEGLI.
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Do NOT use previous editions
Form TCA-FEATURES
Revised February 2011
MetLife OFEGLI Form in Adobe Acrobat PDF (02/11)
MetLife’s TCA (“Total Control Account”) is a settlement option for the payment of claims. The TCA is not a checking, savings
or money market account from a bank. If you receive your life insurance proceeds by TCA, your customer relationship is with
MetLife, not the Federal government or any of its agencies.
The Total Control Account
®
Settlement Option Features
INTEREST
• TCA eams interest from the date it is established. The rate credited to your TCA will never fall below the annual effective
interest rate guaranteed in your Customer Agreement issued to you when proceeds are paid through a TCA, and will equal
or exceed the rate established by one of the following indices: the prior week’s Money Fund Report Averages
TM
/Government
7-Day Simple Yield or the Bank Rate Monitor
TM
National Money Market Rate Index.
• Interest is compounded daily and credited monthly to your TCA. (Generally, the interest you are paid will be subject to income
tax. You should consult your own tax advisor about your particular circumstances.)
METLIFE TCA FINANCIAL SECURlTY
• The assets backing the TCA are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears
the investment risk of the assets backing the TCA, and expects to receive a prot. Regardless of the investment experience of
such assets, the interest credited to your TCA will never fall below the rate guaranteed in your Customer Agreement. Call
1-800-METSAVE (1-800-638-7283) for your guaranteed annual effective interest rate.
• The TCA is not insured by the FDIC (“Federal Deposit Insurance Corporation”) or any government agency. However, the entire
amount of your TCA, including all interest paid to you, is fully guaranteed by the nancial strength and claims paying ability of
MetLife. MetLife’s guarantee is further backed by your respective state insurance guaranty association. Maximum limits vary
from state to state and may change over time. MetLife’s obligation to pay the total policy proceeds is satised by depositing such
proceeds in your TCA.
IMMEDIATE ACCESS TO FUNDS AND FLEXIBILITY
• You can withdraw all or part of your TCA balance immediately or at any time thereafter, without penalty or loss of interest.
• There are no limits on the number of drafts you can write each month.
• You can name a beneciary to receive your TCA balance, in case something happens to you.
NO MONTHLY MAINTENANCE FEES
• There are no monthly maintenance fees for the TCA, and no charges for withdrawals, drafts or reordering drafts.
• You can write drafts from a minimum amount of $250 up to the full amount in your TCA at any time.
• Please note: automatic electronic fund transfers, electronic bill payments, and phone payments are not available from the TCA.
• You may be charged a fee for special services. The current special servicing fees are:
• Draft Copy: $2.00
• Stop Payment: $10.00
• Wire Transfer: $10.00
• Overdrawn TCA: $15.00
These fees may be subject to change in accordance with the terms of the TCA Customer Agreement.
METLIFE TCA FEATURES AND RELATED SERVICES
• When a claim is paid through a TCA, you’ll receive a TCA Starter Kit with information about TCA, a draftbook, and a Customer
Agreement specifying your guaranteed annual effective interest rate.
• MetLife sends each account holder a quarterly statement regarding account balances and activity. Statements are also sent
monthly if there has been withdrawal activity in the account.
• Dedicated customer service representatives are within easy reach to answer any questions you may have about your TCA. You
will be provided with a toll-free customer service number with your starter kit materials.
TIME TO DECIDE
• TCA provides you with interest on your funds while you take the time to decide how to best use your proceeds.
• Your rights to elect other MetLife settlement options are preserved. You may, at any time, place some or all of your TCA balance
in any other available option.
You will receive information on settlement options which are available to you along with your TCA Starter Kit.
If the proceeds payable to you are less than $5,000, or you reside in a foreign country, or the claimant is a corporation
or similar entity, payment is usually made by a single, lump-sum check. Proceeds payable to minors will either be paid to the
appropriate guardian or held by MetLife until age of majority.
Total Control Account
®
is a registered service mark of Metropolitan Life Insurance Company
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Completed 26 July 2020

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