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Fe6dep (U.S. Office of Personnel Management)

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ACTIVE Employees — Employing agency must complete. FORMER Employees who are RETIREES or COMPENSATIONERS — Office of Personnel Management must complete.
1a. Did the insured have Option C on the date 1b. Effective date of election
of death of the family member?
Yes ❑ No ❑
I certify that the information I gave in Part D is correct and that I obtained it
from the employee’s/annuitant’s official records.
4. Signature of authorized agency official
5. Name of authorized agency official
(Type or print)
6. Title
7. Name of agency
8.
Mailing address of agency, including ZIP Code
9. Telephone number 10. Date signed
(mm/dd/yyyy)
( ) —
Part A—General Information About the Insured
Part D—Certification of Insurance Status
Part C—Certification By the Insured
Part B—Information About Deceased Family Member
1. Backup Withholding Has the IRS notified you that you are subject to 2. Signature of insured
(Do not print)
backup withholding as a result of a failure to report all interest or
dividends?
Yes No
3. Full name of insured
(Type or print)
I hereby certify that all statements made in this claim are true to the best of
my knowledge, information, and belief, and that no evidence necessary to a
settlement of this claim is suppressed or withheld.
4. Mailing address
(Number, street, apt. no.)
5. City, State and Zip code
6. Date
(mm/dd/yyyy)
7. Telephone number
(incl. area code)
Office of Federal Employees’ Group
Life Insurance
200 Park Avenue
New York, NY 10166-0188
Read instructions on the
reverse side of this form
before completing form.
Statement of Claim
Option C—Family Life Insurance
Federal Employees’ Group Life Insurance
1. Name of Insured
(Employee or Annuitant) (Last, first, middle)
2. Date of birth
(mm/dd/yyyy)
3. Social Security Number
4. Department or agency in which employed (include bureau or division) 5. Location of employment
(City, State, Zip Code)
6. Are you retired and receiving annuity under any Federal civilian retirement system?
6a. Retirement claim number 6b. Date of retirement
Yes, Give
No
1. Full name of deceased 2. Date of birth
(mm/dd/yyyy)
3. Date of death
(mm/dd/yyyy)
4. Date of marriage
(mm/dd/yyyy)
5. Place of marriage
(City, State)
6. Marriage was performed by
Clergy or Justice of the Peace
Other
(Specify)
7. Was this marriage ended by divorce?
7a. Date of divorce
(mm/dd/yyyy)
7b. Place of divorce
(City, State)
Complete blanks 4-7 if deceased is your SPOUSE
Complete blanks 8-11 if deceased is your CHILD
8. Child’s marital status 9. Child’s relationship to you Foster child
Single Legitimate child Stepchild
Disabled dependent child 22 yrs. or over
Married Adopted child Recognized natural child Other
(Specify)
10. If the deceased was a stepchild, recognized natural child, or foster child, 11. If the deceased was a recognized natural child and was not living with
was the child living with you at the time of death? you at the time of death, did you provide financial support for the child?
Yes No
(Explain on separate sheet)
Yes No
(Explain on separate sheet)
Previous editions are not usable Form FE-6 DEP Revised June 1999
OFEGLI Form in Adobe Acrobat PDF (0699)
Yes, Give
No
3a. If the insured is retired or receiving compensation, complete Boxes 3b,
3c and 3d below.
3d. Option C election
Number of Multiples for Full Reduction:
Number of Multiples for No Reduction:
2b. If the insured indicated in Item 9 of Part B that the deceased was a foster
child or disabled dependent child, do you certify that the child qualifies for
Option C coverage ? Yes ❑ No ❑
2a. Number of multiples:
1
1
2
2
3
3
4
4
5
5
1 2 3
4
5
Warning—Any materially false, fictitious or fraudulent statement or
representation which is knowingly and willfully made or any concealment
of a material fact which is related to the requests for information required
herein is punishable under 18 U.S.C. Statute 1001 by a monetary fine or
imprisonment for not more than five years, or both.
3b. Date of retirement or receipt of compensation
(mm/dd/yyyy)
3c. Date of birth
(
mm/dd/yyyy)
Instructions
1. To Avoid Delay
(a) Read these instructions carefully.
(b) Type or print in ink.
2. Completion of Claim
Complete parts A, B and C.
3. Evidence Required
You must submit a certified death certificate
showing the cause and manner of death with this
claim (a photocopy is not acceptable). You may
obtain this record from the Bureau of Vital
Statistics or equivalent agency. Failure to submit a
certified death certificate will delay settlement of
this claim. We may need additional evidence and
will let you know.
4. If You Need Assistance
If you need assistance in completing this claim,
contact your employing office if you are an
employee or the Office of Personnel Management
if you are a retiree or compensationer.
If you need further assistance, you may write the
Office of Federal Employees’ Group Life Insurance,
200 Park Avenue, New York, NY 10166-0188 or
call the OFEGLI Service Representative, toll-free,
at 1-800-OFE-GLIA (1-800-633-4542).
5. Where to Send Claim
If you are an active employee, send the completed
claim form and the certified death certificate to your
employing office. If you are retired or receiving
Federal Workers’ Compensation benefits, send the
completed claim form and the certified death
certificate to: Office of Personnel Management,
Retirement Operations Center, Attention: FE-6 DEP
Boyers, PA 16017.
Your employing office or OPM will verify your family
insurance status and forward the certified claim and
death certificate to the Office of Federal Employees’
Group Life Insurance for payment or further action.
DO NOT SEND YOUR CLAIM DIRECTLY
TO OFEGLI
6. To Cancel Option C
If you no longer have any eligible family members
you may wish to cancel your Option C coverage.
Active Employees - Contact your employing office.
Retirees or Compensationers - Write:
Office of Personnel Management
Retirement Operations Center,
Attention: Annuity Adjustment Section
Boyers, PA 16017
Be sure to include your retirement or compensation
claim number.
Instructions to Agency/Retirement System
When you receive a claim form and certified death
certificate from an employee or annuitant, complete
Part D of the claim form. You are responsible for
determining eligibility for foster children and disabled
children age 22 and over. See the definitions below.
Do not send the background documentation to
OFEGLI. Simply indicate your certification in Part D of
the claim form.
After you complete Part D, mail the form and death
certificate to the Office of Federal Employees’ Group
Life Insurance, 200 Park Avenue, New York, NY
10166-0188.
Definition of Terms
Disabled dependent child 22 yrs. 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 financial 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 financially.
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 OFEGLI.
Previous editions are not usable Form FE-6 DEP Revised June 1999
OFEGLI Form in Adobe Acrobat PDF (0699)
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Completed 26 July 2020

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