SF 2817 November 2011 Markup

SF 2817 November 2011 Markup.pdf

Life Insurance Election

SF 2817 November 2011 Markup

OMB: 3206-0230

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0230 can be found here:

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Life Insurance Election

Federal Employees' Group Life Insurance Program

Federal Employees'
Group Life Insurance

1
2

General Instructions
By law, unless you waive all coverage or are ineligible, you are automatically
covered for Basic life insurance as an employee. When you first become
eligible for FEGLI, you may (1) do nothing and have Basic automatically,
(2) elect Basic and any or all of the options, or (3) waive all life insurance
coverage. If you are changing a previous election, see the back of Part 3 Employee Copy.

Read the back of Part 3 - Employee Copy carefully.
Assignees completing this form should read Items 5 and 6 on the
back of Part 3.
Give all parts of your completed form to your employing office.
Your employing office will complete Section 6 of this form (or its
electronic equivalent) and return your copy to you.

*This election supersedes all previous elections.*

Fill in identifying information concerning the employee.
Name (last, first, middle)

Date of birth (mm/dd/yyyy)
OWCP claim number,
if applicable

Social Security Number

Location of department or agency where you Daytime telephone number
work (city, state, ZIP code)
(including area code)

To elect or retain Basic, sign and date below. If you do not sign for Basic, you (or your assignee) may not elect or retain any form of optional
insurance. If you do not want any insurance at all, skip to Section 5.
I want Basic. I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)

Basic

..
.

See Privacy Act Statement on back of Part 3

Employing department or agency

Form Approved:
OMB No. 3206-0230

Optional

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of Date (mm/dd/yyyy)
attorney are not valid.)
If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS you have previously waived any or all
of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI Program Booklet). Sign the
box(es) below for any option(s) you are eligible for and wish to elect or retain. If you do not sign for an option, you have waived it and your future
opportunities to enroll in it are strictly limited.
You will not be covered for any option(s) for which you do not sign below, regardless of whether you previously elected the option(s).

Option A - Standard
I want Option A.
I authorize deductions to pay the full cost.

Option B - Additional

Option C - Family

I want Option B in the multiple of my annual basic pay I I want Option C in the multiple I indicate below.
indicate below. I authorize deductions to pay the full cost. I understand that each multiple is worth $5,000 upon
the death of my spouse, and $2,500 upon the death of an
eligible child. I authorize deductions to pay the full cost.
3 times my pay

3 multiples

1 times my pay

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

SIGNATURE (Do not print. Only you or your assignee
may sign. Signatures by guardians, conservators or
through a power of attorney are not valid.)

Date (mm/dd/yyyy)

If you want NO life insurance coverage, sign and date below.

Waiver of
all life
insurance
coverage

Agency
Use

I want NO life insurance coverage. I understand that any life insurance I have will stop at the end of the last day of the pay period in which my
employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form and submit
satisfactory medical information, or (2) I experience a life event, or (3) I have a break in Federal service of at least 180 days, or (4) I participate in an
open season, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand that my decision to
waive life insurance coverage now may affect my eligibility for coverage as a retiree.
SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through
Date (mm/dd/yyyy)
a power of attorney are not valid.)

Remarks:

Name and address of employing office

If new/newly eligible employee,
enter "0" for event.

Date received in employing office Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)

Number of event permitting
change
(See back of Part 2)

I followed the instructions on the back of Part 1.
Signature of authorized agency official

The employee's copy of this form, when completed by the employing office, together with the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees)
constitute the employee's Certificate (proof) of Insurance.
PART 1 - File in Official Personnel Folder
U.S. Office of Personnel Management
www.opm.gov/insure/life

Previous edition is not usable.

Standard Form 2817
Revised November 2011

Instructions for Agencies
1.

Who Should File This Form?
New employees eligible for life insurance who want
Y
optional insurance or no insurance. Note: New employees
who want only Basic do not have to file.
Y

Employees appointed to positions that allow life insurance
coverage following service in positions that did not allow
life insurance coverage.

Employees who want to change their life insurance.

Reinstated employees who filed a previous waiver of any
type of life insurance, were separated from service for at
least 180 days, and wish to elect coverage.
Assignees who want to decrease or cancel coverage.

Y
Y

Exception: If the employee assigned the insurance, only the
assignee(s) may waive or reduce some or all of the
employee's coverage. In that case, the assignee(s) must sign
the form (although the information in Section 2 must refer to
the employee). Please note that assignees cannot increase the
employee's coverage. Only the employee can do that.

Give a new employee a copy of the FEGLI Program Booklet
(FE 76-21 or FE 76-20 for U.S. Postal Service employees)
when he or she reports for duty and ask the employee to
return the completed SF 2817 as soon as possible (preferably
before the end of the first pay period), but no later than 60
days after his or her appointment.

What Should You Review After The Employee
Submits This Form?
Review all three parts of the SF 2817 to see that they are
legible and complete. If an employee signs the box for
Option A, Option B, or Option C, he or she must also sign
Section 3, Basic. If the employee uses a downloaded copy,
be sure all parts are completed. Contact the employee if any
part is unclear.
Only the employee may sign this form in Sections 3, 4, or 5,
with one exception (noted below). Signatures by guardians,
conservators, or through a power of attorney are NOT valid.

Department of Defense employees designated "emergency
essential" and civilian employees deployed in support of a
contingency operation per Public Law 110-417.

Employees with prior government service in non-excluded
positions who were separated after March 31, 1981, should
have an SF 2817 on file in their personnel folders, and that
election or waiver of coverage may still be in effect. Do not
accept a new SF 2817 unless the employee has a break in
Federal service of at least 180 days or is eligible to cancel a
previous waiver that has been in effect for at least one
year, or wishes to reduce coverage.

An employee who is already enrolled in Option B and/or
Option C may elect from 1 to 5 multiples (up to 5 total)
within 60 days based on the life event.

The employee is solely responsible for ensuring that the
SF 2817 accurately reflects his or her intentions.
If the employee is electing new coverage, always make sure
that the authorized agency official confirms that the
employee is eligible for the coverage, and that the official
signs the form in Section 6.
4.

When Did You Receive This?
Enter the date the employing office received this form.

Until you verify an employee's SF 2817 on file, make
deductions based on his or her statement about earlier
insurance coverage. Once coverage is confirmed, make any
necessary adjustments to correct the withholdings.

What Is The Event Permitting The Change?
Enter the number of the event permitting a change, if
applicable. See the Table of Effective Dates on the back of
Part 2 for event numbers.

An employee may at any time file an SF 2817 to waive or
reduce coverage, unless the employee has assigned his/her
insurance coverage. If the employee has assigned the
insurance, only the assignee(s) may waive or reduce the
coverage (except for Option C which cannot be assigned).

What Is The Effective Date Of The Coverage?
Enter the effective date of coverage. For new and newly
eligible employees: Basic is effective on the first day the
employee is in a pay and duty status; Optional coverage is
effective on the first day the employee is in a pay and duty
status on or after the day the employing office receives the
SF 2817. For changes in elections, see the Table of Effective
Dates on the back of Part 2. If there is more than one
effective date for this election, the 2nd effective date should
be notated in Part 6 under "Remarks."

What Do You Do With Parts 1, 2, and 3?
After completion, give Part 3 to the employee. File Part 1
in the employee's personnel folder. Destroy Part 2 after
payroll office use. Part 3, and the FEGLI Program Booklet
(FE 76-21, or FE 76-20 for U.S. Postal Service employees),
serve as the employee's certificate of insurance.

Where Can You Find More Information?
Consult the FEGLI Program Booklet (FE 76-21 or FE 76-20
for U.S. Postal Service employees) or the FEGLI Handbook,
which are available on the FEGLI web site at
www.opm.gov/insure/life.

How Else Can An Employee Elect More Coverage?
Y Provide Medical Information. An employee may elect
or increase Basic, Option A, or Option B insurance (but
not Option C), if a previously completed SF 2817
waiving coverage has been in effect for more than one
year, by submitting satisfactory evidence of insurability
via a Request for Insurance, SF 2822. If approved, the
employee should make the election on the SF 2817 and
submit to the employing agency. More details are
contained on the SF 2822.
Y

Experience A Qualifying Life Event. An employee may
elect Basic, Option A, Option B and/or Option C within
60 days following a FEGLI qualifying life event. These
events are: marriage, divorce, spouse's death, or the
acquisition of an eligible child.
For Option B and Option C, an employee may elect from
1 to 5 multiples (up to 5 total) based on the life event.

Back of Part 1

Standard Form 2817
Revised November 2011

Life Insurance Election

Federal Employees' Group Life Insurance Program

Federal Employees'
Group Life Insurance

1
2

INSURANCE
INELIGIBLE
0000
1000
1100
1001
1002
1003
1004

Form Approved:
OMB No. 3206-0230

SF 50
A0
B0
C0
D0
E1
E2
E3
E4

SF 50 Equivalents of Insurance Codes
1005
1101
1102
1103
1104
1105
1010
1110

E5
F1
F2
F3
F4
F5
G0
H0

1011
1012
1013
1014
1015
1111
1112
1113

I1
I2
I3
I4
I5
J1
J2
J3

1114
1115
1020
1120
1021
1022
1023
1024

1025
1121
1122
1123
1124
1125
1030
1130

J4
J5
K0
L0
M1
M2
M3
M4

M5
N1
N2
N3
N4
N5
90
P0

1031
1032
1033
1034
1035
1131
1132
1133

1134
1135
1040
1140
1041
1042
1043
1044

Q1
Q2
Q3
Q4
Q5
R1
R2
R3

1051
1052
1053
1054
1055
1151
1152
1153

1045 U5
1141 V1
1142 V2
1143 V3
1144 V4
1145 V5
1050 W0
1150 X0

R4
R5
S0
T0
U1
U2
U3
U4

1154
1155

Y1
Y2
Y3
Y4
Y5
Z1
Z2
Z3

Z4
Z5

Fill in identifying information concerning the employee.
Name (last, first, middle)

Date of birth (mm/dd/yyyy)
OWCP claim number,
if applicable

Employing department or agency

3
Basic

Social Security Number

Location of department or agency where you Daytime telephone number
(including area code)
work (City, state, ZIP Code)

In item 7: If this block is not signed, enter 0 in ALL FOUR boxes.
If this block is signed, enter 1 in box 1.
SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of Date (mm/dd/yyyy)
attorney are not valid.)

4
Option A - Standard

Option B - Additional

In item 7, box 2:
If this block is not signed, enter 0
If this block is signed, enter 1.

Option C - Family

In item 7, box 3:
If this block is not signed, enter 0
If this block is signed, enter the number marked "X"
below.

In item 7, box 4:
If this block is not signed, enter 0
If this block is signed, enter the number marked "X"
below.

3 times my pay

3 multiples

1 times my pay

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

SIGNATURE (Do not print. Only you or your assignee
may sign. Signatures by guardians, conservators or
through a power of attorney are not valid.)

Date (mm/dd/yyyy)

If you want NO life insurance coverage, sign and date below.
In item 7: If this block is signed, enter 0 in ALL FOUR boxes.

Waiver of
all life
insurance
coverage

Agency
Use

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a
power of attorney are not valid.)

Remarks:

Date (mm/dd/yyyy)

If new/newly eligible employee,
enter "0" for event.

Name and address of employing office

Number of event permitting
change

Date received in employing office Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)

(See back of Part 2)

I followed the instructions on the back of Part 1.
Signature of authorized agency official

INSTRUCTIONS: Enter codes in the boxes on the right as directed in items 3, 4 and 5 above.

U.S. Office of Personnel Management
www.opm.gov/insure/life

Insurance Code
1

SF 50
Equivalent

text added
PART 2 - For Agency Use
Previous edition is not usable.

Standard Form 2817
Revised November 2011

Table of Effective Dates: Changes in Life Insurance Coverage
Deductions: Begin, increase, stop or decrease in the same pay period in which coverage begins, increases, stops, or decreases.
Event Allowing Change

Change Permitted? (To elect any option, employee must elect or retain Basic)
Option A - Standard
Option B - Additional

Basic

Option C - Family

0. New/Newly Eligible
Employee:

Yes. See "Instructions to Agencies", #5, back of
Part 1.

Yes. Same as Basic.

1. PROVIDING
MEDICAL
INFORMATION:
Approval of Request for
Insurance (SF 2822) by
the Office of Federal
Employees' Group
Life Insurance (OFEGLI).

Yes. Coverage is automatically effective the first day
the employee is in a pay and duty status on or after
date of OFEGLI's approval.

Yes. Coverage is effective the first day the employee is in
a pay and duty status on or after the date of OFEGLI's
approval and the agency receives the SF 2817.

Yes. Same as Option A.

No. An employee may NOT elect Option C by
providing medical information.

Time Limit - on or after OFEGLI's date of approval.
If employee is not in a pay and duty status within 60
days, Basic does NOT become effective, and the
employee must start over.

Time Limit - Employee must submit the SF 2817 and be
in a pay and duty status within 60 days after date of
OFEGLI's approval. If employee is not in a pay and duty
status or doesn't submit the SF 2817 within those 60 days,
Option A does not become effective, and the employee
must start over.
Yes. Same as Basic.

Yes. Same as Basic.

Coverage - Same as Basic.

Employee may elect or increase multiples (up to 5 total).

Time Limit - Same as Basic.

Coverage - Same as Basic.

Yes. Employee may elect or increase multiples (up to 5
total). If the employee has Basic, Coverage is effective
the day the employing office receives the election, or the
date of the event, whichever is later. If Basic and Option
C are elected at the same time, Option C is effective
when Basic becomes effective.

2. LIFE EVENT:
Marriage, divorce, death
of spouse, or acquisition
of
an eligible child.

Yes. Coverage is effective the day of the event if the
SF 2817 is received before the event and the
employee is in pay and duty status on the day of the
event. Otherwise, Coverage is effective the first day
in pay and duty status after the event and after
receipt of the SF 2817.

Time Limit - Same as Basic.
Time Limit - Agency must receive the SF 2817 and
proof of the event within 60 days after the day of the
event.

Time Limit - Same as Basic.
(Note: If the employee already has Basic, there is no pay
and duty status requirement for Option C.)

3. REINSTATEMENT:
Employee is reinstated
after a break in service of
at least 180 days in a
position that is not
excluded from life
insurance by law or
regulation.

Yes. Coverage is effective on the first day the
Yes. Employee may elect Option A within 60 days after
employee is in a pay and duty status, unless waived by reinstatement. However, if employee does not submit
employee.
SF 2817 electing coverage within 60 days after

Same as Option A.

4. REINSTATEMENT:
Employee is reinstated
after
a break in service of at
least
180 days in a position that
is excluded from life
insurance by law or

No. However, if employee is later converted to a
non-excluded position, the coverage is effective on the
first day the employee is in a pay and duty status on or
after being converted to such a position.

No. However, if employee is later converted to a
Same as Option A.
non-excluded position, the coverage is effective on the first
day the employee is in a pay and duty status in the
converted position on or after the date the agency receives
the SF 2817 electing such coverage.

Same as Option A.

5A. CANCELING/
WAIVING
COVERAGE:
employee/assignee

reinstatement, s/he has the same Optional
insurance carried before the break in service
effective the beginning of the reinstatement.

Time Limit - Employee must submit the SF 2817 within 60
days after conversion to an eligible position.
Yes. If the coverage is canceled in the first pay
period, no premiums are due. Otherwise,
coverage stops at the end of the last day of the
pay period in which the agency receives the
SF 2817, with no 31-day extension of coverage.

A.Same as Basic.

A. Same as Basic.

Option C cannot be assigned.
If Option C is canceled because there no longer are
eligible family members, the effective date is
retroactive to the end of the pay period in which
there
no longer are any eligible family members.
The employing agency must refund Option C

Time Limit - None. Employee may cancel
coverage at any time. However, if the insurance
is assigned, only the assignee(s) may cancel

Not applicable.

A. Same as Basic.

5B. REDUCING
OPTION B and/or
OPTION C
MULTIPLES:
employee/assignee

6. Open Season.

If permitted under conditions specified by OPM.

7. CERTAIN DEPT. OF
DEFENSE AND
CIVILIAN
EMPLOYEES
AFFECTED
BY PUBLIC LAWS
106-398 AND 110-417:

Yes, if employing agency determines employee meets Same as Basic.
criteria to elect coverage. Coverage is effective the
first day the employee is in a pay and duty status on or
after the date the agency receives the SF 2817.

B. Not applicable.

Same as Basic.

B. Yes. Employee may at any time reduce the number
of multiples, unless the insurance has been assigned.
In that case, only the assignee(s) may reduce coverage
– the employee may not. This new coverage is
effective at the beginning of the pay period following
the one in which the employing office receives the
SF 2817.
Same as Basic.

B. Yes. Employee may at any time reduce the number
of multiples. This new coverage is effective at
the beginning of the pay period following the
one in which the employing office receives the
SF 2817. Assignee(s) cannot reduce Option C.

Same as Basic.

No. An employee may NOT elect Option C via these
provisions of law.

Same as Basic.

Employee may elect or increase multiples (up to 5
total).

Time Limit - Agency must receive the SF 2817
within 60 days of the date the employee receives
official notice of deployment in support of a
contingency operation or designation as an emergency
essential employee.

Back of Part 2

Standard Form 2817, Revised November 2011

Life Insurance Election

Federal Employees' Group Life Insurance Program

Federal Employees'
Group Life Insurance

1
2

*This election supersedes all previous elections.*

Fill in identifying information concerning the employee.
Name (last, first, middle)

Date of birth (mm/dd/yyyy)
OWCP claim number,
if applicable

Social Security Number

Location of department or agency where you Daytime telephone number
work (city, state, ZIP code)
(including area code)

Basic

..
.

See Privacy Act Statement on back of Part 3

Employing department or agency

Form Approved:
OMB No. 3206-0230

Optional

Option A - Standard
I want Option A.
I authorize deductions to pay the full cost.

Option B - Additional

Option C - Family

3 times my pay
1 times my pay

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

SIGNATURE (Do not print. Only you or your assignee
may sign. Signatures by guardians, conservators or
through a power of attorney are not valid.)

Date (mm/dd/yyyy)

If you want NO life insurance coverage, sign and date below.

Waiver of
all life
insurance
coverage

Agency
Use

Remarks:

Name and address of employing office

If new/newly eligible employee,
enter "0" for event.

Date received in employing office Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)

Number of event permitting
change
(See back of Part 2)

I followed the instructions on the back of Part 1.
Signature of authorized agency official

The employee's copy of this form, when completed by the employing office, together with the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees)
constitute the employee's Certificate (proof) of Insurance.
PART 3 - Employee Copy
U.S. Office of Personnel Management
www.opm.gov/insure/life

Previous edition is not usable.

Standard Form 2817
Revised November 2011

Instructions for Employees
1.

General Information
The major provisions of this program are described in the Federal
Employees' Group Life Insurance (FEGLI) Program Booklet (FE 76-21
or FE 76-20 for U.S. Postal Service employees). Please read the entire booklet
carefully. Your completed copy of this election form (SF 2817) and the
FEGLI Program Booklet constitute your certificate (proof) of insurance.
These publications, as well as comprehensive FEGLI information, are
available at www.opm.gov/insure/life.

signature. Return the completed form to the employee's employing office. If
the insured is an annuitant, return the completed form to OPM, Retirement
Operations Center, P.O. Box 45, Boyers, PA 16017-0045. See #11 for where
to return the completed form if the insured is a compensationer.
7.

I Am A New Employee or Newly Eligible for Life Insurance. What
Do I Need To Know?
You are automatically enrolled in Basic (even if you don't complete this form)
unless you waive it. If you waive Basic, you automatically waive all forms of
Optional insurance. You will not have any Optional insurance unless you elect it.

If you sign any block in Section 4, you elect (or retain) Optional Insurance.
You must also elect (or retain) Basic by signing Section 3.
If you sign Section 4 for Option B and/or Option C, you must also mark
one of the five boxes to show how many multiples you wish to elect (or
retain). Do not mark more than one box.

To elect Basic: You do not have to submit this form unless you also wish to
elect Optional insurance. text added
To waive Basic: Sign Section 5 of the form and give it to your employing
office. Your agency will withhold Basic premiums from your salary from
your first day at work in a pay status UNLESS you submit your waiver before
the end of your first pay period.

Be Sure You Sign For All Options You Want. This election supersedes all
previous ones. If you have optional coverage and wish to keep it, you must
sign the appropriate box(es). If you do not sign for it, you have waived it.
If you sign Section 5, you waive all FEGLI coverage.

To elect Optional: Sign Section 3 and one or more of the blocks in Section 4
of the form and give it to your employing office within 60 days after the date
you are appointed or first become eligible for life insurance.

Only you, the employee, may sign this form. Signatures by guardians,
conservators, or through a power of attorney are not acceptable.
Exception: If you have assigned your insurance, only the assignee(s) may
cancel some or all of your coverage. In that case, the assignee(s) must sign
the form (although the information in Section 2 must refer to you).

To waive Optional: If you do not sign for a particular type of Optional
coverage in Section 4, you automatically waive that coverage.
3.

I Am An Employee With Prior Government Service. What Do I
Need To Know?
When you return to work after a break in service of less than 180 days, your
human resources office will automatically enroll you in the same coverage
that you had before you left your prior position, if any. This coverage will be
effective on your first day in a pay and duty status in a FEGLI eligible
position. You will have to qualify to elect other coverage (open season,
providing medical information, or a life event). If you waived some coverage,
then the waiver of that coverage is still in effect.
When you return to work after a break in service of 180 days or more, your
human resources office will automatically enroll you in Basic and the same
Optional insurance that you had in your prior position. This coverage will be
effective on your first day in a pay and duty status in a FEGLI eligible
position. You may elect more insurance (if you don't already have the
maximum) within 60 days of your appointment to an eligible position. If you
previously waived coverage then that waiver is no longer in effect. You will
automatically be enrolled in Basic, unless you file a new waiver.
See the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal
Service Employees) for more details.

REMEMBER THAT YOU, NOT YOUR AGENCY, ARE
RESPONSIBLE FOR ENSURING THAT YOUR SF 2817 (OR ITS
ELECTRONIC EQUIVALENT) IS CORRECT AND ACCURATELY
REFLECTS YOUR INTENTIONS. IF YOU DO NOT SIGN FOR IT,
YOU HAVE CANCELED/WAIVED IT.
8.

Open Seasons
If you elected coverage during an Open Season, and that coverage has not yet
become effective, and you want to make a further change to your FEGLI
coverage on this SF 2817, you should check with your employing office.
That office can tell you about any special election procedures that may apply.

What If I Waive or Reduce My Coverage?
If you do not sign for a particular type of coverage, you have waived that
coverage. If you waive Basic or one or more of the options, your opportunities
to enroll in the coverage you waived are strictly limited. A waiver may
also affect your eligibility to continue coverage into retirement. See the
FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service
employees) for more details.

10. Where Do I Send The Completed Form?
After you have completed this form and verified that it accurately reflects your
intentions, send the entire form (without separating the parts) to your human
resources office. Do not send the form to OPM or OFEGLI.

I Am A Reemployed Annuitant. What Do I Need To Know?
If you waive your insurance when you return to Federal Service as a
reemployed annuitant, you also waive your insurance with your retirement
annuity. You will have no FEGLI life insurance. It is important that you
contact your human resources office and inform them that you are a
reemployed annuitant. More details can be found in OPM Form 1482,
Agency Certification of Status of Reemployed Annuitants.
What If I Assigned My Coverage?
If you have assigned your insurance by filing an RI 76-10, Assignment of
Federal Employees' Group Life Insurance, you may not cancel any of your
insurance coverage (except Option C). Only the assignee(s) may cancel your
coverage. However, you may elect new coverage if you otherwise meet the
requirements for electing such coverage. Any new coverage you elect will
automatically be subject to your existing assignment, except for Option C,
which you cannot assign. All assignments are automatically canceled after a
break in service of at least 31 days, or upon cancellation of all life insurance
coverage by the assignee(s).
I Am An Assignee. What Can I Do?
If you are completing this form in order to cancel some or all of the
employee's life insurance coverage, you must sign the form. The
information in Section 2 of the form refers to the employee, but you must
sign in Section 3, 4 or 5, as applicable. Indicate "assignee" after your

How Do I Complete The Form?
Follow the instructions for each item carefully. After you fill out the form,
review it to be sure it is complete and correct. The following checklist should
help.
If you sign Section 3, you elect (or retain) Basic.

11. What If I Receive Workers' Compensation?
If you are receiving compensation payments from the Office of Workers'
Compensation Programs (OWCP), provide your OWCP number in Section 2
of the form. If you are still employed, return the completed form to your
employing office. If you are not still employed or if you have been receiving
compensation payments for at least 12 months, see your human resources
office about your continued eligibility under the FEGLI Program.
12. How Do I Verify That My Agency Processed My Election?
After your employing office processes your election form, you will receive
an SF 50, Notification of Personnel Action. A two digit code appearing on
the SF 50 will explain your insurance coverage. These codes are explained
in Part 2 of the SF 2817. Also check your pay statement for the correct
withholdings. If you are insured as a compensationer, you will receive a notice
from OPM which will explain your insurance coverage.
13. Where Do I Get More Information About The FEGLI Program?
Consult the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal
Service employees) or the FEGLI Handbook (RI 76-26), which are available
on the FEGLI web site at www.opm.gov/insure/life.

Privacy Act and Public Burden Statements
Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance, authorizes solicitation of this information. The data you furnish will be used to determine your life insurance coverage. This
information may be shared and is subject to verification, via paper, electronic media, or through the use of the computer matching programs, with national, state, local or other charitable or social
security administrative agencies to determine and issue benefits under their programs or law enforcement agencies, when they are investigating a violation or potential violation of civil or criminal law.
Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number to distinguish between the applicant and people with similar names. Failure to furnish the requested
information may result in your agency's inability to determine your life insurance coverage.
We estimate this form takes an average of 15 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our
estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0230),
Washington, DC 20415-3430. The OMB Number, 3206-0230 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Back of Part 3

Standard Form 2817
Revised November 2011

File Type	application/pdf
File Title	Printing H:\FORMFLOW\SF2817.FRP
Author	csbenson
File Modified	2014-02-19
File Created	2011-10-04