Form FEGLI Implementation Questionnaire for Tribal Employers

Form approved:
OMB No. ________
Expires: _________
FEGLI Implementation Questionnaire for Tribal Employers
In addition to the FEGLI Fact Sheet, there are points of emphasis tribal employers should consider before
completing the questionnaire:
As the tribal employer, you would be responsible for paying a minimum of 1/3 the cost of
FEGLI Basic insurance premiums for tribal employees. (Under existing Federal law, the
Government pays 1/3 of the cost of Basic insurance for Federal employees; however OPM
will permit, but not require, the tribal employer contribution to be higher for tribal
employees). There is no Government or Tribal employer contribution for Optional
insurance.
In addition to your share of the Basic insurance premium cost, you will be responsible for an
administrative fee per enrollee. The administrative fee will be based on the number of
tribal enrollees and remains to be determined.
As the tribal employer, you will be responsible for ensuring that the correct premium
amounts are withheld and that all tribal employee coverage elections are accurately
captured and recorded.
In the event of premium underpayment, regardless of the reason for error, you will be
responsible for reimbursing the U.S. Treasury Employees’ Life Insurance Fund.
Both tribal employee coverage election records and premium withholdings may be subject
to periodic audits.
If you offer FEGLI you will not be able to offer any other group life insurance coverage to
your tribal employees (although tribal employees always have the right to purchase private
life insurance independent of FEGLI coverage you offer).
The FEGLI group life insurance benefit is only available to the tribal employee during the
employee’s active employment with you, for so long as you remain entitled to, and elect, to
offer the FEGLI coverage. If tribal employees choose to purchase FEGLI, they will not be able
to carry the group life insurance into retirement but may convert the FEGLI coverage to an
individual cash-value policy that they may retain after tribal employment ends or after you
stop offering FEGLI.

1. Please review the “Tribal Employer Responsibilities” on the FEGLI Fact Sheet to better
understand the full scope of your responsibilities. Do you currently offer group life insurance to
your employees?
□ Yes
□ No (If not, please explain why and proceed to question 3).
______________________________________________________________________________
______________________________________________________________________________
2. Please review the enclosed rates for the FEGLI program.
FEGLI rates are:
□ Lower than our current group life insurance program.
□ Higher than our current group life insurance program.
□ Comparable to our current group life insurance program.
Comments:
______________________________________________________________________________
______________________________________________________________________________
3. Please indicate your interest in offering FEGLI.
□ FEGLI is a benefit we are interested in offering.
Estimated number of tribal employees who would purchase FEGLI: ____________
What is the earliest date you would enter the Program? ______________ (MM/YY)

□ FEGLI is not a good fit (please tell us why):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
We welcome any other comments or input on implementation of the FEGLI Program for Tribal
employees.
Please submit your responses within 30 days. This questionnaire can be returned to us by fax at (202)
606-0633, by email to _____________, or by mail at the following address:
U.S. Office of Personnel Management
P.O. Box 791
Washington, DC 20044

Please provide us with your contact information:
Name _______________________________________________________
Tribe, tribal organization, or urban Indian organization______________________________________
Phone number ________________________________________________
FAX _________________________________________________________
E-mail _______________________________________________________
We look forward to a successful partnership. Thank you.
Public Burden Statement
The public reporting burden for this information collection is estimated to be ___ minutes. This burden estimate
includes time for reviewing instructions, researching existing data sources, gathering and maintaining the needed
data, and completing and submitting the information. Send comments regarding the accuracy of this burden
estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Planning and
Policy Analysis, Attn: OMB Number ______, 1900 E Street NW, Washington, DC 20415-7900. You are not required
to respond to this collection of information unless a valid OMB control number is displayed.

OMB No. ________
Expires: _________