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Sglv-8286-may-09 SGLV 8286, Servicemembers' Group Life Insurance Election and Certificate

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Directions To Personnel Clerks Of The Uniformed Services
1. Complete all appropriate items on this form. All entries except the signature and those
requested to be in the service member’s own handwriting, must be typed or printed in ink.
2. Include the name, address, and social security number (if available) of the beneficiary(ies),
and the relationship of the beneficiary(ies) to the service member (e.g. father, sister).
3. If a service member wants to designate a beneficiary other than would be normal under his
or her family circumstances, see “Unclear or Unusual Beneficiary Designations” (section
6.03) in the Servicemembers’ Group Life Insurance Handbook, Handbook 29-75-1
(www.insurance.va.gov).
4. A representative of the Uniformed Services must sign his or her name below that of the
service member to indicate that he/she received the form from the member (whether in
person, by mail or electronically) and should include the date he/she received it.
5. This form, properly completed, is authority to a payroll office to initiate or change the
deductions for insurance premiums if the amount of insurance is changed or cancelled.
6. If this form is being used to decline SGLI coverage, inform the service member that this
action will mean that he/she will no longer have Family SGLI coverage - both spousal
coverage and dependent child coverage – or Traumatic Injury Protection (TSGLI). Have
the service member complete SGLV 8286A and take action to end payment of Family
spousal premiums. No additional forms need to be completed to end payment of TSGLI
premiums.
7. Inform the service member that if he/she is married or gets married after completing this
form, his/her spouse is automatically covered under Family SGLI and premiums are due for
this coverage and will be deducted from his/her pay if his/her spouse is registered in
DEERS. If his/her spouse is not registered in DEERS, premiums cannot be deducted and
the member will owe a debt for unpaid premiums.
8. Inform the service member that if he/she has questions about this form, he/she may obtain
the advice of a military attorney at no expense to the service member.
9. After the form is completed in its entirety, you should:
• File a copy of pages 2 and 4 in the member’s official personnel file.
• Provide a copy of pages 2-5 to the service member.
• Provide a copy of pages 2 and 4 to the Active or Reserve component of the
Uniformed Services.
Remember: If this form is used to decline SGLI coverage and the service member has
Spousal Family SGLI coverage, you should take action to discontinue payment of spousal
Family SGLI premiums.
Note: Please do NOT send any of the forms or copies to the Office of Servicemembers’
Group Life Insurance or to the Department of Veterans Affairs.
SGLV 8286, May 2009 p. 1
Please read the instructions before completing this form.
Servicemembers’ Group Life Insurance Election and Certificate
Use this form to: (check all that apply)
Name or update your beneficiary
Reduce the amount of your insurance coverage
Decline insurance coverage
Important: This form is for use by Active Duty and Reserve members. This form does
not apply to and cannot be used for any other Government Life Insurance.
Last name First name Middle name
Rank, title or grade Social Security Number
Branch of Service (Do not
abbreviate)
Current Duty Location
Amount of Insurance
By law, you are automatically insured for $400,000. If you want $400,000 of insurance, skip to Beneficiary(ies) and Payment Options. If
you want less than $400,000 of insurance, please check the appropriate block below and write the amount desired and your initials.
Coverage is available in increments of $50,000. If you do not want any insurance*, check the appropriate block below and write (in your
own handwriting), “I do not want insurance at this time.”
Declining SGLI coverage also cancels all family coverage and traumatic injury protection under the SGLI program.
I want coverage in the amount of $_______________________ Your initials________________
_______________________________________________________________________________
(Write “I do not want Insurance at this time.”)
*Note: Reduced or refused insurance can only be restored by completing form SGLV 8285 with proof of good health and compliance with other requirements. Reduced or refused
insurance will also affect the amount of Veterans’ Group Life Insurance you can convert to upon separation from service.
Beneficiary(ies) and Payment Options
I designate the following beneficiary(ies) to receive payment of my insurance proceeds. I understand that the principal beneficiary(ies) will receive payment
upon my death. If all principal beneficiaries predecease me, the insurance will be paid to the contingent beneficiary(ies).
Complete Name (first, middle, last) and
Address of each beneficiary
Social Security
Number
(if known)
Relationship
to you
Share to each
beneficiary
(Use %, $ amounts or fractions)
Payment Option
(Lump sum or 36 equal monthly
payments)
Principal
1.
2.
3.
4.
Additional Principals on page 4 (check if
applicable)
Contingent
1.
2.
3.
4.
Additional Contingents on page 4 (check if
applicable)
I HAVE READ AND UNDERSTAND the instructions on pages 2 and 3 of this form. I ALSO UNDERSTAND that:
• This form cancels any prior beneficiary or payment instructions.
• The proceeds will be paid to beneficiaries as stated in #6 on page 3 of this form, unless otherwise stated above.
• If I have legal questions about this form, I may consult with a military attorney at no expense to me.
• I cannot have combined SGLI and VGLI coverages at the same time for more than $400,000.
• If I am married or If I get married after completing this form, my spouse is automatically covered under Family SGLI for which premiums will be
deducted from my pay, unless I decline Family SGLI coverage by completing SGLV 8286A. For Family SGLI premium deductions, my spouse MUST
be registered in DEERS. Failure to do so will result in debts owed for unpaid premiums.
SIGN HERE IN INK _______________________________________________ Date: ______________
(Your signature. Do not print.)
Do not write in space below. For official use only.
RECEIVED BY:
RANK, TITLE OR GRADE ORGANIZATION DATE RECEIVED
SGLV 8286, May 2009 Copy 1 = Member’s Official Personnel File p. 2
Copy 2 - To Member
Print Blank Form
Print completed Form
Clear Form
Print completed Form
Clear Form
Print Blank Form
Copy 3 - To Active or Reserve Component of Uniformed Service
ers' e provisions
s, and title 38 Code of Federal Regulations.
must ple re med Servic r for this designation to be valid.
overage
your spouse is automatically covered under Family SGLI and premiums will be
our pay, unless you decline Family SGLI coverage by completing SGLV 8286A. You must register your spouse in DEERS for
Family SGLI premiums to be deducted from your pay. use in DEERS, premiums cannot be deducted. This will
y may be required to perform active duty or active duty for training and each year will
ited
rance
within 120 days of by contacting
the Office of Ser
her giv names Mary ad of Mrs
c. A hanged automatic event occurring after you complete t marr age
beneficiary cannot be changed by, and is not affected by documents such as a divorce de
want to name more than four principal contingent beneficiaries, list the additional beneficiaries on the Beneficiary ntinuation Form
ocks on page 2, indicating that you have done so. The Benefic ry Continuation
Form (page 5) should then be attached to page 2 of the 8286.
. If you name minor children as beneficiaries, the insurance will be paid to the court-appointed guardian of the children's estat
You can establish a trust for the benefit of the children and name the trust as beneficiary. A trust names a trustee of your choice to be legally
responsible for administering the insurance proceeds for the children. Naming a trust as a beneficiary on this form does NOT create a trust. Before
ing a trust as beneficiary, you should consult a military attorney for assistance.
Social Security Number - Do not delay completing this form if you d not have a beneficiar s Social Security Number. The Social Security
, but is not required.
3. Shares to each Beneficiary - If you name more than one beneficiary, the sum of the shares must equal 100% or the full dollar amount of your
Directions To Service Member
What You Should Know
This insurance is granted under the Servicememb Group Life Insurance provisions of title 38, United States Code, and is subject to th
of that title and its amendment
This form be correctly com ted, signed and ceived by your Unifor e before your death in orde
Marriage and SGLI C
If you are married or you get married after completing this form,
deducted from y
If you do not register your spo
result you owing a debt for back premiums.
Periods of Coverage
SGLI is in effect throughout the period of full-time active duty or active duty for training. Coverage is also in effect on a full-time basis for
reservists who are assigned to a unit or position in which the
be scheduled to perform at least 12 periods of inactive duty training that is creditable for retirement purposes under Chapter 1223 of title 10, Un
States Code. SGLI coverage continues for 120 days following separation or release. You may convert your SGLI to Veterans’ Group Life Insu
of separation without proof of good health, or within one year and 120 days separation with proof of good health
vicemembers’ Group Life Insurance (see below).
Instructions On Completing This Form (Type or print in ink all items except where otherwise noted.)
1. Naming Beneficiaries
a. A new SGLV-8286 must be completed to change your beneficiary. You may name anyone as beneficiary without his/her consent. However, your
spouse will be notified if you reduce coverage or name a beneficiary other than your spouse.
b. If the beneficiary is a married woman, use
named beneficiary will NOT be c
en first and middle
ally by any
. For example, use Lisa Smith, inste . John Smith.
his form (e.g. i
cree or will.
, divorce, etc.). our Y
, any other
d. If you or Co
(page 5) and check the block under the principal or contingent bl ia
e
f.
e.
nam
2.
Number helps us to locate the beneficiary
o y'
insurance.
E
xample:
m
othe
r
200,000
5
0%
1
/2
f
athe
r
$
200,000 or
5
0% or
1
/2
T
otal
400,000
1
00%
1
4. Payment Option - You may choose whether you want the beneficiary to receive payment in one lump sum or in 36 equal monthly payments by
ment Option. If you choose 36 payments, the beneficiary cannot choose to receive a lump sum
payment. If you want the beneficiary to have a choice at the time of payment, write "lump sum" or leave the block blank.
Provisions For Payment Of Insurance
a. If you name more than one principal beneficiary and one or more predeceases you, the share(s) will be divided equally among the remaining
no surviving principal beneficiaries, the proceeds will be divided among the contingent
beneficiaries.
neficiaries, or if you indicate that payment should be made b
W
U
These claim
SGLV 8286, May 2009
To Member p. 3
writing "lump sum" or "36" in the column labeled Pay
5.
principal beneficiaries, unless otherwise stated. If there are
b. If you do not name a beneficiary, or if there are no surviving be
will be paid in the following order:
y law, the proceeds
1. Widow or widower
be distributed equally among the descendants of that child) 2. Children in equal shares (the share of any deceased child will
3. Parent(s) in equal shares or all to surviving parent
4. A duly appointed executor or administrator of your estate
5. Other next of kin
hat Your Beneficiaries Should Know
pon your death, the Casualty Assistance Office for your branch of service will assist your beneficiary in filing a claim for the insurance proceeds.
s are su ted to the Office of Servicemembers' Group Life Insurance, 80 Livingston Avenue, Roseland, NJ 07068-1733. Your bmit
beneficiary may also call 1-800-419-1473 for claim information.
Please read the instructions before completing this form.
Servicemembers’ Group Life Insurance Election and Certificate
Beneficiary Continuation
Instructions: ants to name more beneficiaries than the number of beneficiary spaces
p
This page is to be used ONLY when the service member w
rovided on page 2. If this page is completed, it should be copied and distributed together with page 2 of this form.
Member Information
L
ast name First name Middle name Rank, title or grade Social Security Number
Beneficiary(ies) and Payment Options
In of my
in
in
addition to the beneficiaries I have named on page 2 of this form (SGLV 8286), I also designate the following beneficiary(ies) to receive payment
surance proceeds. I understand that the principal beneficiary(ies) will receive payment upon my death. If all principal beneficiaries predecease me, the
surance will be paid to the contingent beneficiary(ies).
Complete Name (first, middle, last) and
Address of each beneficiary
Social Security
Number
(if known)
Relationship
to you
Share to each
beneficiary
(Use %, $ amounts or
Payment Option
(Lump sum or 36
equal monthly
payments)
fractions)
Principal
5.
6.
7.
8.
9.
10.
Contingent
5.
6.
7.
8.
9.
10.
I
This is a continuation of my beneficiary designation on page 2 of this form, Servicemembers’ Group Life Insurance Election and Certificate.
T pro eficiaries as stated in #6 on page 3 of the SGLV-8286, unless otherwise stated above.
S N _____________________ Date: ______________
int.)
HAVE READ AND UNDERSTAND the instructions on pages 2 and 3 of this form. I ALSO UNDERSTAND that:
he ceeds will be paid to ben
IG HERE IN INK
__________________________
(Your signature. Do not pr
Do not write in space below. For official use only.
R
ECEIVED BY: RANK, TITLE OR GRADE ORGANIZATION DATE RECEIVED
SGLV 8286, May 2009 Copy 1 - Member’s Official Personnel File
Copy 2 - To Member
Copy 3 - To Active or Reserve Component of
p. 4
Uniformed Service
Print completed Form
Clear Form
Print Blank Form
Print completed Form
Print Blank Form
Clear Form
TSGLI provides all service members wh have
SGLI with traumatic injury protection. TSGLI
provides for payment of up to $100,000 to
service members who incur a qualifying loss as
the result of a traumatic injury (on or off duty).
TSGLI payments are designed to help
traumatically injured service members d their
families with financial burdens associat with
recovering from a severe injury (such as travel,
mporary housing, and loss of income)
o
an
ed
te .
SGLI Traumatic In
j
ur
y
Protection Pro
g
ram
(
TSGLI
)
SGLI Disabilit
y
Extension
Veterans’ Grou
p
Life Insurance
(
VGLI
)
Service
-
Disabled Veterans Insurance
(S
-
DVI
)
Veterans’ Mort
g
a
g
e Life Insurance
(
VMLI
)
What Yo ts u Need To Know About Your Life Insurance Benefi
For More Information
For more info io u e fits, vi t in c ovrmat n abo t thes bene si www. suran e.va.g . You can also call us toll-free at
the following numbers:
SGLI
,
SGLI Disabilit
y
Extension
,
VGLI: 1-800-419-1473 S-DVI
,
VMLI: 1-800-669-8477
Famil
y
SGL
I
Servicemembers’ Grou
p
Life Insurance
(
SGLI
)
Keep This Paper With Your Records
to $90,000 to severely disabled veterans and
housing grant from VA. It is
designed to pay off some or all of the home
ce
You are eligible for a varie erving in the military and after
crem
$50, in effect for
days after discharge. Members who have S
tically have TSGLI.
Family SGLI provides automatic coverage to the
spouses and dependent children of service
members who have SGLI coverage. Spouses are
insured for $100,000 or the amount of the
member’s coverage, whichever is less.
Dependent children are automatically covered for
$10,000 at no cost to the service member.
Service members must register their spouse in
DEERS to ensure proper premiums are deducted.
VMLI provides mortgage life insurance of up
service members who have received a
specially adapted
mortgages of disabled veterans and servi
members in the event of their death.
ty of life insurance benefits while s
discharge. It is important that you understand these benefits so you can make informed
decisions about providing for the financial security of your loved ones.
Upon enlistment, service members automatically
have the maximum $400,000 of SGLI coverage.
Service members can decline or elect lesser
amounts of coverage in writing in in
000. SGLI coverage stays
ents of
120
GLI
automa
Members can decline or elect less coverage, but
not registering a spouse in DEERS is not the
quivalent of declining spousal coverage. e
T
he SGLI Disability Extension allows service
members who are totally disabled at time of
discharge to retain the SGLI coverage they
had in service up to
s. The servi r must ap
the Office of Servicemembers’ Group L
Insurance for this extension.
at no cost for two
year ce membe ply to
ife
VGLI allows service members to convert
their SGLI coverage to lifetime renewable
term insurance. The amount of VGLI
coverage cannot exceed the amount of
SGLI coverage the member has at
discharge. Members can apply within 120
days of discharge without proof of good
health, and for one year after that with
proof of good health.
S-DVI provi es up to $10,000 in overage to
disabled veterans who have received a new
VA disability rating. Veterans ha e two years
from the date VA notifies them of their rating
to apply for this coverage. Veterans who are
totally disabled can apply to have their
premiums waived. If approved for waiver,
the veteran can apply for an add onal
$20,000 in coverage.
SGLV 8286
To Member p. 5
d c
v
iti
W SEHILE IN RVICE AFTER DISCHARGE
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Completed 21 March 2020

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