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Sf2822 (U.S. Office of Personnel Management)

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Request For Insurance
Federal Employees' Group Life Insurance (FEGLI) Program
Federal Employees
Group Life Insurance
Instructions for Employees
When should I complete this form?
You should complete this form if:
�
you are in a position that makes you eligible for FEGLI
coverage (ask your human resources office if you don't
know), AND
�
at least one year has passed since the effective date of your
most recent waiver of Basic, Option A and/or Option B life
insurance, AND either:
�
you are not enrolled in the FEGLI Program, but would
like to be, OR
�
you are enrolled in the FEGLI Program, but you have
less than the maximum life insurance available and you
want more life insurance.
What is a waiver of life insurance coverage?
A waiver means you:
� did not elect life insurance coverage when it was available to
you, OR
� cancelled coverage you previously had, OR
� elected less than the maximum coverage.
Ask your human resources office if you don't know the effective
date of your last waiver, if any.
What coverage can I get by completing this form?
You can get Basic, Option A, and Option B, if the Office of
Federal Employees' Group Life Insurance (OFEGLI) approves
your physical.
You cannot get Option C by completing this form.
How do I complete this form?
� Ask your human resources office to complete Part A.
� You must complete Part C. Answer all of the questions, or
mark N/A (for not applicable). Do not leave an answer
blank.
� Bring this form to your physician or other healthcare
provider.
� Sign in Part C, in the presence of your physician or other
healthcare provider.
� Ask him/her to complete Part D.
� Ask him/her to mail the completed form directly to OFEGLI.
� OFEGLI must receive the form within 60 days of the date of
the physical.
Do I have to pay for this physical?
Yes, you must pay any fee for the physical. Your agency or
OFEGLI cannot pay for it.
Can I use results of a physical I had last year for another
reason?
No. OFEGLI cannot accept a previous physical. Your physician
or other healthcare provider must perform the physical for the
purposes of this request for life insurance. OFEGLI must receive
this form within 60 days of the date of the physical.
What is Basic insurance?
It is life insurance based on your annual salary, rounded up
to the nearest thousand dollars (if it is not already an even
thousand), plus $2,000. It includes accidental death and
dismemberment coverage (payment of more life insurance if
you die in an accident or lose a limb or eyesight.)
Basic also includes an Extra Benefit if you are under age 45 when
you die. The amount of Basic payable upon your death will be
double the regular amount if you are age 35 or under when you
die. Starting at age 36, the Extra Benefit reduces by 10 percent
per year, until at age 45 there is no Extra Benefit.
What is Option A?
It is life insurance equal to $10,000. It is also called Standard
Optional insurance. Option A also includes accidental death and
dismemberment coverage.
What is Option B?
It is life insurance equal to 1, 2, 3, 4 or 5 times your annual salary
(after rounding your salary up to the nearest thousand dollars, if it
is not already an even thousand). It is also called Additional
Optional insurance.
What is Option C?
It is life insurance for your family, available in 1 to 5 multiples.
Each multiple equals $5,000 for your spouse and $2,500 for each
eligible dependent child. It is also called Family Optional
insurance. You cannot elect Option C by completing this form.
You can only elect Option C during an open enrollment period or
if you have a life event (marriage, divorce, death of spouse, or
adding an eligible child to your family) and already have Basic.
When is coverage effective?
Basic will be effective on the first day you are in a pay and duty
status on or after OFEGLI's approval date.
Option A and/or Option B will be effective on the first day you
are in a pay and duty status on or after OFEGLI's approval date
and on or after the date your agency receives your SF 2817, Life
Insurance Election
.
However, if you are not in a pay and duty status within 31 days
after the approval date you will not have Basic insurance (unless
you already had it when you filled out this form), and you cannot
elect Option A or Option B. If you do not submit an SF 2817
within those 31 days, you cannot elect Option A or Option B.
What is pay and duty status?
This means you are on duty, receiving pay. You are not on annual
leave, sick leave, administrative leave or otherwise absent from
duty.
SF 2822
Instructions (page 1 of 2)
Revised January 2002
Instructions for Employees (continued)
How will I know if OFEGLI approves my physical?
Your human resources office will tell you. OFEGLI contacts your
human resources office as soon as it approves or denies your
request. You should contact your human resources office if it is
more than 2 weeks after the date your physician or other
healthcare provider performed the physical and you do not yet
know whether OFEGLI approved your physical.
My agency told me that OFEGLI approved my request.
What do I do?
If you just want Basic insurance, you do not have to do anything.
You will automatically have it on the first day you are in a pay
and duty status on or after the date of OFEGLI's approval (as long
as you are in a pay and duty status within 31 days of OFEGLI's
approval.)
If you want Option A and/or Option B, you must complete
SF 2817, Life Insurance Election. Your human resources office
must receive your form within 31 days after OFEGLI's approval.
Sign for Basic and for Option A and/or Option B. Be sure to
mark the number of Option B multiples you want to have.
Approval of your physical allows you to elect up to a total of 5
multiples of Option B.
Each SF 2817 you complete replaces the previous form. You
must sign for all coverage you currently have and wish to keep,
AND you must sign for all new coverage you wish to elect. If you
have coverage now and do not sign for that coverage, you have
cancelled that coverage.
My agency told me that OFEGLI denied my request.
Can I appeal?
OFEGLI's decision is final. There are no formal appeal
procedures. You or your physician or other healthcare provider
may call OFEGLI at 1-800-633-4542 and ask why it denied your
request for insurance. Depending on the reason for the denial,
you may be able to submit additional medical evidence. OFEGLI
may have denied your request because you didn't wait until at
least one year after the date of your last waiver of insurance. If
so, you can wait until that year has passed, complete another SF
2822, and have another physical. OFEGLI can discuss your
options.
Where can I get more information about the FEGLI
program?
You can find more information on the FEGLI website at
www.opm.gov/insure/life. Read the FEGLI Booklet (RI 76-21 or
RI 76-20 for Postal employees) and/or the FEGLI Handbook
(RI 76-26).
Privacy Act Statement
Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance, It may also be shared and verified with law enforcement agencies when they are
authorizes the solicitation of this information. The Office of Federal Employees' investigating a violation or potential violation of the civil or criminal law.
Group Life Insurance and your agency will use the data you furnish to determine Public Law 104-134 (April 26, 1996) requires that any person doing business
your eligibility to receive benefits under the FEGLI Program. This information with the Federal government furnish a Social Security number or tax
may be shared and is subject to verification, via paper, electronic media, or identification number. This is an amendment to title 31, Section 7701. If you
through the use of computer matching programs, with national, state, local or don't furnish the requested information, you may not have the level of insurance
other charitable or social security administrative agencies in order to determine protection you want.
benefits under their programs or to obtain information necessary for
determination or continuation of benefits under this program.
SF 2822
Instructions (page 2 of 2)
Revised January 2002
Request For Insurance
Federal Employees
Group Life Insurance
Federal Employees' Group Life Insurance (FEGLI) Program
Read instructions before
completing this form.
Employee's name (last, first, middle)1. Date of birth (mm/dd/yyyy)
2.
Social Security number3.
Part A — Employing Agency
Work location (city and state)
7.
Employing department/agency (including bureau or division)
5.
Has more than 1 year passed since the effective date of the employee's
last waiver or cancellation of FEGLI coverage?
8. Has the employee had any continuous absence of at least 3 weeks
because of sickness or injury during the past year?
Yes NoYes No
Name and mailing address of agency (type or print)13.
To:
9.
4.
Signature of certifying agency official
11. Title of certifying agency official
Date (mm/dd/yyyy)10.
Agency telephone number12.
FAX number, if you want OFEGLI
to fax its decision
14. Email address, if you want
OFEGLI to email its decision
15.
Part B — OFEGLI
Employee's daytime phone number6.
(
(
(
)
)
)
1. To the employing agency:
We approve this request. We deny this request.
2. OFEGLI Reviewer Date (mm/dd/yyyy)3.
Instructions for Agencies
When do we complete this form?
Complete Part A of this form whenever an employee asks you to, IF the employee
is eligible for life insurance (see below). Be sure to include a complete, legible
address where OFEGLI can send you its approval/denial. OFEGLI will not retype
this address. It will fold this form and put it in a window envelope if you do not
give an email address or fax number. That is why it is vital that your address is
clear and complete.
When is an employee eligible?
An employee is eligible if:
�
he/she is in a position that allows FEGLI coverage, AND
�
at least one year has passed since the effective date of his/her most recent
waiver or cancellation of life insurance coverage.
What do we do with the form after completing Part A?
Give the form to the employee. The employee and his/her physician or other
healthcare provider must complete the rest of the form and send it to OFEGLI.
OFEGLI will consider the results of the physical and either approve or deny the
request for insurance.
How will we receive OFEGLI's decision?
OFEGLI will send you its decision in one of three ways: by email, fax or regular
mail. If you give an email address in Block 14 above, OFEGLI will email its
decision to you. If you don't give an email address, but do give a fax number in
Block 15 above, OFEGLI will fax its decision to you. If you only give a mailing
address, OFEGLI will mail its decision to you.
When will we receive OFEGLI's decision?
You should receive OFEGLI's decision within 2 weeks after it receives the form
from the employee's physician or other healthcare provider. If you have any
questions about the status of the decision, please call OFEGLI at 1-800-633-4542.
U.S. Office of Personnel Management
What if OFEGLI approves the request?
� If the employee is not already enrolled in Basic, enroll the employee in
Basic, effective on his/her first day in pay and duty status on/after the date
of OFEGLI's approval.
� Void the approval if the employee is not in a pay and duty status within 31
days of OFEGLI's approval. The employee does not have Basic unless
he/she already had it before completing this form.
�
Notify the employee of OFEGLI's approval immediately and tell the
employee to submit an SF 2817 within 31 days of OFEGLI's approval, if
he/she wants to elect Option A and/or Option B. Coverage is effective on
his/her first day in pay and duty status on or after you receive the SF 2817.
If the employee is not in a pay and duty status or doesn't submit an SF 2817
within 31 days of OFEGLI's approval, OFEGLI's approval is void. The
employee will not have Option A or Option B unless he/she already had that
coverage before completing this form.
�
File the form in the employee's official personnel folder or its equivalent.
What if OFEGLI denies the request?
�
Immediately contact the employee. Tell the employee that he/she doesn't
have Basic (unless he/she already had it before completing this form) and
cannot elect Option A or Option B. The employee will only have the
coverage he/she had before completing this form (if any).
� File the form in the employee's official personnel folder or its equivalent.
SF 2822
FEGLI Handbook NSN 7540-01-231-5588 2822-103 Do NOT Use Previous Editions. Revised January 2002
Part C — Employee
1a.
Your address (number, street, city, state, ZIP code)
Daytime telephone number1b.
( )
2.
Have you had any change in health in the past 5 years?
Yes, give details: No
3.
Have you sought medical advice or been treated by a clinic, hospital, physician, or healer within the past 5 years?
Yes, give details:No
4.
Have you ever been denied life or health insurance, or offered it at higher than normal rates?
Yes, give details:No
5.
Chest pain, swollen ankles, or disease of heart or blood vessels?
High blood pressure? How high?
Asthma, emphysema, chronic bronchitis or other lung diseases?
Liver conditions, ulcers, or gastrointestinal (G.I.) conditions?
Disease of kidney, bladder, male or female organs, or albumin or sugar in the urine?
Unconsciousness, paralysis, epilepsy, or other nervous or mental disorder?
Cancer, tumor, polyp, or disease of the blood, spleen, or lymph glands?
Diabetes, tuberculosis, or drug habit?
Biopsy, surgical operation, or radiation treatment?
Yes No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Briefly state condition, dates,
duration, and kind of treatment.
Also state names and locations of
doctors and hospitals. (Use a blank
sheet if you need more room.)
5a.
Have you ever had or were you ever told you had the following? Check "Yes" or "No". If "Yes", explain in 5a.
Arthritis or any muscular weakness or disorder?
Yes No
In the last 5 years, has any physician or health professional diagnosed, treated you
for, you for, or given you medical advice on injuries or illnesses not shown
on this form? If "Yes", give details in 5a. Do not include colds or minor injuries/illnesses
that lasted less than 5 days.
Yes No
tested
I certify that my answers are true and complete to the best of my knowledge and belief.
6. Date (mm/dd/yyyy)7.Your signature (You must sign in the presence of the examining physician).
Part D — Examining Physician or Other Healthcare Provider
� This examination is for Federal Employees' Group Life Insurance
�
Fully complete, sign and date this part.
purposes. We cannot accept an earlier exam.
�
DO NOT RETURN THIS FORM TO THE EMPLOYEE.
�
The employee must pay any fee for this examination. Do not MAIL IT TO:
perform any special examinations or incur any unusual expense.
Office of Federal Employees' Group Life Insurance
�
Ask the employee to sign Item 6 in Part C in your presence. P.O. Box 2627
Jersey City, NJ 07303-2627
Print employee's full name (last, first, middle)1. Date of birth (mm/dd/yyyy)3.
Male Female
Gender2.
Height4.
centimeters feet and inchesor
Weight7.
kilograms poundsor
Blood pressure5.
Two readings, sitting
Diastolic at
5th phase
First reading
Systolic Diastolic
Second reading
6.
Pulse (at rest)
Fully describe abnormalities.
(Use a blank sheet if you need
more room.)
9.8. Does examination reveal abnormality of:
General movements, strength, stamina, responsiveness, coordination, etc.?
Eyes, ears, nose, throat?
Heart, arteries, or veins?
G.I. system?
Nervous systems and reflexes?
Extremities and skeletal or muscular system?
Yes No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes No
Respiratory system?
Yes No
G.U. system?
Yes No
Skin and glands?
If over 96, take pulse after
5 minutes
6a.
Yes No
Any murmurs present?
10. I certify that the employee signed Part C in my presence; that I have carefully examined the employee; and that I correctly recorded my complete
findings.
Signature of examining physician or other healthcare provider Date of examination (mm/dd/yyyy)
Name and address of examining physician or other healthcare provider11.
Telephone number
( )
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