Life Insurance Election

Forms and Documents

Document Name	Status
Form SF 2817 Life Insurance Election Form and Instruction	Modified
30-Day FRN.pdf Supplementary Document	2009-04-22
60 Day FRN.pdf Supplementary Document	2009-04-22
SF 2817 SS.doc Supporting Statement A	2009-04-22

IC Document Collections

IC ID	Document Title	Status
33739	Life Insurance Election Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0230	ICR Reference No: 200904-3206-008
Status: Historical Active	Previous ICR Reference No: 200508-3206-005
Agency/Subagency: OPM	Agency Tracking No:
Title: Life Insurance Election
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/02/2009
	Date Received in OIRA: 04/30/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2012	36 Months From Approved
Responses	150	0	0
Time Burden (Hours)	25	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: SF 2817, Life Insurance Election – is the form that eligible individuals use to enroll or change enrollment status under the FEGLI Program. The SF 2817 is used by Federal employees and assignees (those who have acquired control of an employee/annuitant’s coverage through an assignment or “transfer” of the ownership of the life insurance).

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Authorizing Statute(s): US Code: 5 USC Chapter 87 Name of Law: Life Insurance
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 66277	11/07/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 14170	03/30/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Life Insurance Election	SF 2817	Life Insurance Election (Federal Employees' Group Life Insurance Program)

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	150	0	0	0	0	150
Annual Time Burden (Hours)	25	0	0	0	0	25
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/30/2009

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