Fillable Form FE-6 fegli claim for death benefits

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Form FE-6 fegli claim for death benefits

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Claim for Death Benefits
Federal Employees’ Group Life Insurance (FEGLI) Program
(To file an Option C-Family Benefits claim, use form FE-6 DEP)
Form FE-6
Revised December 2016
Do NOT use previous editions
Who receives the FEGLI life insurance benefits?
The law states that FEGLI benefits will be paid in the following manner:
If the deceased did not assign ownership and there is no valid court order on file with the employing agency or the Office of
Personnel Management (OPM) (if retired), then the Office of Federal Employees' Group Life Insurance (OFEGLI) (an
administrative office of MetLife) will pay:
•
First, to the beneficiary(ies) the insured validly designated
•
Second, if none, to the insured's widow or widower
•
Third, if none of the above, to the insured's child or children and descendants of any deceased children (a court will usually
appoint a guardian to receive payment for a minor child)
•
Fourth, if none of the above, to the insured's parents in equal shares, or the entire amount to the surviving parent
•
Fifth, if none of the above, to the court-appointed executor or administrator of the insured's estate
•
Sixth, if none of the above, to the insured's other next of kin, entitled under the laws of the state where the insured lived
If the insured did not assign ownership and there is a valid court order on file with the agency or the U.S. Office
of Personnel Management (OPM), as appropriate, OFEGLI will pay benefits according to the court order.
If the insured assigned ownership of his/her life insurance to someone else (generally by filing an RI 76-10, Assignment form),
then OFEGLI will pay:
•
First, to the beneficiary(ies) the assignee(s) validly designated
•
Second, if none, to the assignee(s)
Completing this form
Please complete this Claim for Death Benefits form by following the instructions on the form. Only use this form for the death of
a Federal employee, annuitant, or compensationer. If you are filing a claim for a dependent, use form FE-6 DEP. Each claimant/
beneficiary is required to complete their own form. Provide all of the information requested, so OFEGLI may process your claim
as quickly as possible. If you have questions, or need help completing this form, call OFEGLI at 1-800-633-4542. Our Customer
Service Center is open Monday through Friday, 8:30 a.m. to 4:00 p.m. EST.
If you have not previously notified the employing agency or OPM (if retired) of the death, please contact the appropriate office.
The easiest way to report the death of a Federal retiree is online at:
www.opm.gov/reportdeath
or you can report the death by calling OPM at 1-888-767-6738 .
Decide
You have the following options to receive your life insurance proceeds:
•
A Total Control Account
®
in your name (you may select this option if your benefits are $5,000 or greater), or
•
A check that we mail to you
Please read About the Total Control Account (Page 2) for details. Indicate your choice on Page 5 when completing the claim
form. If you do not choose an option and your benefits are $5,000 or greater, a MetLife Total Control Account will be established
in your name and your payment will be deposited on your behalf.
Return
A.
Check off the items you’re sending with this claim form
Death Certificate. We require a certified copy of the death certificate with the cause and manner of death. The funeral
director taking care of the funeral arrangements or your state bureau of vital statistics can usually provide a copy of the
death certificate. We only require one death certificate - if you're aware of another claimant who's sending one, you don't
have to send it.
If you signed a document with a funeral home that authorizes us to make a payment directly to them, a copy of that
document.
If the insured was an active employee and died in an accident, and you’re making an accidental death benefit claim, proof of
the accident - police reports and other supporting documents.
If you are filing this claim on behalf of the estate, a copy of the appointment papers issued by the court.
If a trust is designated, a statement that the trust is still in effect and you are authorized to act under the trust, and a copy of
the trust document. If you are not the original trustee, a copy of the page naming you as successor trustee.
If you have a Power of Attorney, a copy of the appointment papers naming you as the attorney-in-fact for the beneficiary.
B.
Submission instructions
Return this claim form and the necessary documents to:
OFEGLI
PO Box 6080
Scranton, PA 18505-6080
Overnight Address: OFEGLI
10 E.D. Preate Drive
Moosic, PA 18507
If a certified death certificate has
already been submitted, you may
fax your claim form to OFEGLI at:
570-558-8659
Page 1
Claim for Death Benefits
Federal Employees’ Group Life Insurance Program
About the Total Control Account
A convenient place for you to hold the proceeds from your claim while you decide what to do with the money.
How the account works
The Total Control Account (TCA) is a draft account that works like a checking account:
•
When your account is open, MetLife
1
will send you a package which includes additional details about the
TCA. We pay the full amount owed to you by placing your proceeds into the TCA and providing you a book
of drafts. You can use the drafts like you would use checks.
•
You can use a single draft to access the entire proceeds or you may write several drafts for smaller
amounts (minimum amount $250). There are no limits on the number of drafts you may write, up to the full
available balance in your account. Processing time is similar to check processing. If there is no activity on
your account for a period of time (typically three years, but this may vary by state), state regulations may
require that we contact you at the address we have on file. If we aren't able to reach you, we may be
required to close your account and transfer the funds to the state.
•
You earn interest on the money in your account from the date your account is open.
•
We’ll send you an account statement each month when there is activity in your account. If you have no
activity, we’ll send you a statement once every three months.
•
You can name a beneficiary for your account. We’ll include a beneficiary form in the package we send you
when we open your account.
Interest rates and guarantees
The interest rate on your account is set weekly, and will never fall below the minimum guaranteed rate stated in
your TCA package, or the rate established by one of the following indices: the prior week’s Money Fund Report
Averages™/Government 7-Day Simple Yield, or the Bank Rate Monitor™ National Money Market Index. We
calculate interest daily and compound it, so you earn interest on your interest. The interest is added to your
account monthly. The interest earnings generally are taxable so you should speak with your tax advisor. MetLife
will report all interest payments to the Internal Revenue Service (IRS).
No monthly maintenance fees
There are no monthly maintenance or service fees on your TCA, no charges for making withdrawals or writing
drafts, and no cost for ordering additional drafts. You may be charged for special services or an overdrawn TCA,
and the current fees (subject to change) for those are: draft copy $2; stop payment $10; wire transfer $10;
overdrawn TCA $15; overnight delivery service $25.
Other important information
•
Your Total Control Account is backed by the financial strength of MetLife. The assets backing the funds are
held in MetLife’s general account and are subject to MetLife’s creditors. In addition, while the funds in your
account are not insured by the FDIC, they are guaranteed by your state insurance guarantee association.
The coverage limits vary by state. Please contact the National Organization of Life and Health Insurance
Guaranty Associations (
www.NOLHGA.com
or 703-481-5206) to learn more. FOR FURTHER
INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE.
•
We may limit or suspend your access to the funds in your account if we suspect fraud or if there was an
error in opening your account.
•
We use the services of The Bank of New York Mellon, 701 Market Street, Philadelphia, PA 19106, for Total
Control Account recordkeeping and draft clearing.
•
A TCA generally is not available if your claim is less than $5,000, you reside in a foreign country, or if the
claimant is a corporation or similar entity.
•
MetLife may receive investment earnings from operating the Total Control Account. The performance
results of any investments we make do not affect the interest rate we pay you.
•
To learn more about TCA, please call us at 800-638-7283 or write us at Metropolitan Life Insurance
Company, OFEGLI, PO Box 6080, Scranton, PA 18505-6080, Attention: TCA.
Total Control Account
®
is a registered service mark of Metropolitan Life Insurance Company.
1
“MetLife” means Metropolitan Life Insurance Company
Do NOT use previous editions
Page 2
Form FE-6
Revised December 2016
Claim for Death Benefits
Federal Employees’ Group Life Insurance Program
Part A. Information about the insured
1. Insured's full name
(Last) (First) (Middle)
2. Date of birth (mm/dd/yyyy) 3. Date of death (mm/dd/yyyy)
4. Social Security number or FEGLI Claim number
5. Legal Residence at time of death (City and State)
6. Department or agency in which last employed, including bureau or division
7. Location of last employment (City, State, ZIP Code)
8. At the time of death, was the insured retired under any Federal civilian retirement system?
Yes
No Unknown
If “Yes”, provide the Claim number
(CSA/CSF/CSI)
9. At the time of death, was the insured receiving Federal Worker’s Compensation benefits?
Yes
No Unknown
If “Yes”, provide the effective
date of Federal Worker’s
Compensation Benefits
Part B. Information about the insured's marriages
1. How many times was the
insured married? Include
yourself if you were
married to the insured at
the time of death.
2. Give the name of each spouse
(include ALL marriages)
3. How did the marriage end?
(Check one in each case)
4. When did the marriage end?
(mm/dd/yyyy)
Death Divorce
No data needed
Death Divorce
No data needed
Death Divorce
No data needed
Death Divorce
Part C. Information about your marriages
(Complete only if you are the insured's widow or widower)
1. Date of marriage (mm/dd/yyyy) 2. Place of marriage (City and State)
3. Marriage was performed by:
Clergy or Justice of the Peace
Other (specify)
4. Were you divorced from the insured
at the time of death?
Yes
No
5. If you were divorced from the insured, give the date (mm/dd/yyyy) and place of divorce
6. How many times were you
married? Include the
insured if you were
married at the time of
death.
7. Give the name of each spouse
(include ALL marriages)
8. How did the marriage end?
(Check one in each case)
9. When did the marriage end?
(mm/dd/yyyy)
Death Divorce
No data needed
Death Divorce
No data needed
Death Divorce
No data needed
Death Divorce
Do NOT use previous editions
Page 3
Form FE-6
Revised December 2016
Part D. Information about the insured's next of kin
(Everyone must complete Part D unless you are the insured's widow or widower)
1. Did the insured have any living children on the date of his/her death?
Yes
No*
If Yes, how many
Please list the insured's living children below. Note that step-children are not eligible.
*(a) If the insured has no children, list the insured's parents; if one or both parents died before the insured, provide their name(s) and date(s)
of death.
(b) If the insured has no children, and both parents died before the insured, list the next of kin who may be capable of inheriting from the
insured (brothers, sisters, descendants of deceased brothers, sisters,etc.). Additional sheets can be used if needed.
Name Age
Relationship to the
insured
Full address
2. Did the insured have any children who died before his/her date of death?
Yes
No
If Yes, how many
Please list any children who died before the insured. If any of the children who died before also have children (descendants), list them below
as well and indicate the parent who was the insured's child. Additional sheets can be used if needed.
Name Age
Relationship to the
insured
Full address
Descendant
Child
Descendant
Child
Descendant
Child
Descendant
Child
Descendant
Child
Descendant
Child
Complete item 3 only if any of the persons listed above are under age 18
3. If the court appointed a guardian for the estate of any minor children
above, give the name and address of the guardian and attach a copy of
the court appointment papers. Natural parentage or custody as a result
of a divorce do not constitute guardianship.
Name
Address (number, street, apt. no.)
City State ZIP Code
Part E. Information about the insured's estate (Complete if the insured's estate is entitled)
If the court appointed an executor or administrator to settle the insured's
estate, give his/her name and address and attach a copy of the court
appointment papers.
Name
Address (number, street, apt. no.)
City State ZIP Code
Part F. Additional information
Have you signed a document with a funeral home that authorizes us to make a payment directly to them?
This document is usually referred to as a funeral home assignment. (If yes, please send us a copy of the document with this claim form.)
Yes No
Are you claiming accidental death benefits (did the insured die solely through violent, external, and accidental means)? If “Yes”, submit
coroner's and police reports, news clippings, and any other available reports concerning the accident. OFEGLI cannot consider a claim
for such benefits if the insured separated or retired before the accident.
Yes No
Do NOT use previous editions
Page 4
Form FE-6
Revised December 2016
Claim for Death Benefits
Federal Employees’ Group Life Insurance Program
Part G: Select a method to receive your payment
Please SELECT ONE method of settlement in order to receive your payment. By selecting below, you confirm that
you have read the enclosed materials on both FEGLI payment options.
Total Control Account (TCA)
Check
FEGLI death benefits are not subject to Federal income tax, but the interest that OFEGLI pays on those benefits is subject to
such tax. OFEGLI will report all interest payments to the Internal Revenue Service (IRS).
Part H - Information about you
Please note: If you are completing this claim on behalf of someone else (such as a minor), complete all of Part H with that
person's information, and not yours. Sign your own name "on behalf of" the other person.
Name (please print)
Relationship to the insured Date of birth
Address (number, street, apartment number)
City State ZIP
Social Security number
or
Estate/Trust/Tax ID Number
Daytime Telephone number Email address
Under penalties of perjury, I certify:
1. That the number shown as my Social Security Number in "Part H: Information about you" is my correct taxpayer identification
number, and
2. That I am NOT subject to backup withholding because: (a) I have not been notified by the Internal Revenue Service (IRS) that I am
subject to backup withholding as a result of a failure to report all interest and dividends, or (b) I am exempt from backup
withholding, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen, resident alien, or other U.S. person*, and
4. I am not subject to Foreign Account Tax Compliance Act (FATCA) reporting because I am a U.S. person* and the account is
located within the United States.
(Please note: You must cross out Item 2 above if the IRS has notified you that you are currently subject to backup withholding because you
failed to report all interest or dividend income on your tax return.)
* If you are not a U.S. Citizen, a U.S. resident alien or other U.S. person for tax purposes, please cross out Item 3 above, and complete form
W-8BEN (individuals) or W-8BEN-E (entities).
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid
backup withholding.
Signature If you are completing this claim on behalf of someone else sign your own name "on behalf of" the other person.
Today's Date
Warning - If you knowingly and willfully make any materially false, fictitious, 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 fine or imprisonment for not more than five years, or both under 18 U.S.C. 100
Please return pages 3 through 5 to OFEGLI
Do NOT use previous editions
Page 5
Form F-6
Revised December 2016
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