Claim for Dismemberment Benefits
Federal Employees’ Group Life Insurance (FEGLI) Program
Instructions
Form FE-7
Do NOT use previous Revised December 2013
OFEGLI Form in Adobe Acrobat PDF ( 12/13)
“You”, “your” and “I” refer to the insured employee.
Who completes this form?
Employees enrolled in the FEGLI Program who lose a limb or eyesight
complete this form.
How do I complete this form?
Complete Part A and ask your physician or other healthcare provider to
complete Part C. Then give the form to your human resources of fice.
Should I attach anything to this form?
Yes. Attach copies of all medical reports from treatment you received for this
accident. Also attach any police, traffic or other reports about this accident.
How can I get help completing this form?
Contact your human resources office or call the Office of Federal
Employees’ Group Life Insurance (OFEGLI) at 1-800-633-4542.
Can someone complete this form on my behalf?
Yes. If you are physically or mentally unable to complete this claim
form, someone else can complete it for you and attach a short explana-
tion of the reason you are unable to complete this form. Items 1-8 of
Part A and all of Parts B and C should be about you, but the person
completing this form should sign his/her name and give his/her address
and telephone number.
Part A - Employee’s Statement
1. Your name (Last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security number
4. Your department or agency, including bureau or division
5. Location of employment (City, state and ZIP code)
6. Date of accident (mm/dd/yyyy)
7. Place of accident (City and State)
8. Give a brief description of the accident.
All statements I made on this claim form are true. I have not knowingly left out anything related to this claim. I authorize my physician or other healthcare provider to release any
information requested about this claim.
Your Signature Address
Telephone number Date (mm/dd/yyyy)
(day)
(evening)
Employing Agency’s Instructions
Please help the employee complete this claim form, if necessary. The employee should return this form after the physician or ot her health care provider com-
pletes Part C. Complete Part B and send this form to:
Office of Federal Employees’ Group Life Insurance
PO Box 6080
Scranton, PA 18505-6080
Part B - Agency’s Certification
1. Annual rate of basic pay for Basic Life insurance purposes on the date of the accident $
2. Was the employee covered by Option A on the date of the accident? NO YES If “YES,”
I certify that this information correctly reflects of ficial records and that the employee was covered by Federal Employees’ Group Life Insurance on the date of the accident.
Signature of authorized agency official Name of agency
Name of authorized agency official (type or print) Mailing address of agency, including ZIP code
Title
Date (mm/dd/yyyy) Telephone number Fax number
() ()
Area code Area code
Date of election (mm/dd/yyyy)
