OMB Supporting Statement

RI 76-10 Jun 2015.pdf

RI 76-10 Assignment, Federal Employees' Group Life Insurance (FEGLI) Program

OMB Supporting Statement

OMB: 3206-0270

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0270 can be found here:

2019-11-30 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

(Do Not Erase or Cross
Out. Use a New Form.)

Assignment
Federal Employees' Group Life Insurance (FEGLI) Program
*This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries.
A.

Note: Read instructions on
the back of Part 2 before
completing this form.

Information About the Insured (not the Assignee) (type or print)

Name of Insured (Last, first, middle)

Date of birth of Insured (mm/dd/yyyy)

The Insured is:

If the Insured is retired or receiving Federal Employees' Compensation, give "CSA",
"CSI", or OWCP claim number:

An employee
A retiree
A compensationer

Place an "X" in the
appropriate box.

Social Security Number of Insured

Department or agency in which the Insured is presently employed (If retired, last department or agency where the Insured worked):
Department or agency
Bureau or Division

Location (City, state, and ZIP code)

Information About the Assignee(s) (type or print)
First name, middle initial, and last name of
each assignee

Social Security Number

Address (Including ZIP code)

Relationship

Percent or fraction
assigned

Total (Must equal 100% or 1.0) (Do not use dollar amounts or types of insurance)
C.

Statement of Insured or Assignee (type or print)

Your name and address (Including ZIP code)

Please check one:
I am:
the Insured

Please check both of these:
an Assignee

I have signed this form in the presence of the
two witnesses who have signed below.
I did not name either witness as an assignee.

See back of Part 2 for definitions.
I understand that the Insured retains responsibility for paying life insurance
I understand that upon the Insured's death, the Office of Federal Employees'
premiums, even after the assignment.
Group Life Insurance (OFEGLI) will pay the share of any living assignee to the
assignee's designated beneficiary, if there is one. If the assignee did not designate a
I understand the Insured cannot cancel insurance after this assignment, and that
beneficiary, OFEGLI will pay the assignee, if living. If the assignee dies before the
an assignment is irrevocable.
Insured dies, and he/she did not designate a beneficiary, or all of the
I assign all present and future right, title, interest, and incidents of ownership in
beneficiary(ies) die(s) before the Insured dies, OFEGLI will pay the assignee's
the Insured's FEGLI coverage (except Option C -- Family) to the Assignee(s) listed
estate.
above.
Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney Date (mm/dd/yyyy)
are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box.



Witnesses To Signature (A witness cannot be an assignee)
Address (Including ZIP code)

Signature of witness




Signature of witness

Address (Including ZIP code)

For Agency Use Only

Receiving agency

Date of receipt (mm/dd/yyyy)

Signature of authorized agency official

Title

See back of Part 2 for instructions on where to send this form. Do not send it to the Office of Federal Employees' Group Life Insurance.
U.S. Office of Personnel Management
FEGLI Handbook (RI 76-26)

Part 1 - Original

RI 76-10
Revised June 2015
Previous editions are not usable.

Examples of Assignments
NOTE: If you need more space when completing this form, see "What If I Need More Room?" in the instructions on the back of Part 2.

1. How to assign to one individual
First name, middle initial, and last name of
each assignee

Mary E. Brown

Show assignee's full name. Do not write names as M.E. Brown or as Mrs. John H. Brown.
Social Security Number

000-00-0000

2. How to assign to more than one individual
First name, middle initial, and last name of
each assignee

Address (Including ZIP code)

214 Central Avenue
Muncie, IN 47303

Relationship Percent or fraction
assigned
Ex-spouse

100%

Be sure that the shares add up to 100 percent or 1.0.

Social Security Number

Address (Including ZIP code)

Jose P. Lopez

111-11-1111

360 Williams Street
Red Bank, NJ 07701

Rosa L. Rowe

222-22-2222

792 Broadway
Whiting, IN 46394

Relationship Percent or fraction
assigned
Domestic
Partner

one-half

Mother

one-half

3. How to assign to a trust
First name, middle initial, and last name of
each assignee
Trustee(s) or Successor Trustee(s) as
provided in the John Q. Public Trust
Agreement dated 02/18/2000

4. How to assign to a firm

Not Applicable

Address (Including ZIP code)

Not Applicable

Relationship Percent or fraction
assigned
Trustee

100%

Show the firm's Taxpayer Identification Number instead of a Social Security Number.

First name, middle initial, and last name of
each assignee
XYZ Corporation
Attn: John Smith

Social Security Number

TIN 999-99-9999

Address (Including ZIP code)

5909 Pacific Avenue, NW
Washington, DC 20019

Back of Part 1

Relationship Percent or fraction
assigned
Corporation

100%

(Do Not Erase or Cross
Out. Use a New Form.)

Assignment
Federal Employees' Group Life Insurance (FEGLI) Program
*This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries.
A.

Note: Read instructions on
the back of Part 2 before
completing this form.

Information About the Insured (not the Assignee) (type or print)

Name of Insured (Last, first, middle)

Date of birth of Insured (mm/dd/yyyy)

Social Security Number of Insured

If the Insured is retired or receiving Federal Employees' Compensation, give "CSA",
An employee
"CSI", or OWCP claim number:
A retiree
A compensationer
Department or agency in which the Insured is presently employed (If retired, last department or agency where the Insured worked):
The Insured is:

Place an "X" in the
appropriate box.

Department or agency

Bureau or Division

Location (City, state, and ZIP code)

Information About the Assignee(s) (type or print)
First name, middle initial, and last name of
each assignee

Social Security Number

Address (Including ZIP code)

Relationship

Percent or fraction
assigned

Total (Must equal 100% or 1.0) (Do not use dollar amounts or types of insurance)
C.

Statement of Insured or Assignee (type or print)

Your name and address (Including ZIP code)

Please check one:
I am:
the Insured

Please check both of these:
an Assignee

I have signed this form in the presence of the
two witnesses who have signed below.
I did not name either witness as an assignee.

See back of Part 2 for definitions.
I understand that upon the Insured's death, the Office of Federal Employees'
Group Life Insurance (OFEGLI) will pay the share of any living assignee to the
assignee's designated beneficiary, if there is one. If the assignee did not designate a
beneficiary, OFEGLI will pay the assignee, if living. If the assignee dies before the
Insured dies, and he/she did not designate a beneficiary, or all of the
beneficiary(ies) die(s) before the Insured dies, OFEGLI will pay the assignee's
estate.

I understand that the Insured retains responsibility for paying life insurance
premiums, even after the assignment.

I understand the Insured cannot cancel insurance after this assignment, and that
an assignment is irrevocable.
I assign all present and future right, title, interest, and incidents of ownership in
the Insured's FEGLI coverage (except Option C -- Family) to the Assignee(s) listed
above.
Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney Date (mm/dd/yyyy)
are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box.



Witnesses To Signature (A witness cannot be an assignee)

Signature of witness

Address (Including ZIP code)

Signature of witness

Address (Including ZIP code)




For Agency Use Only

Receiving agency

Date of receipt (mm/dd/yyyy)

Signature of authorized agency official

Title

See back of Part 2 for instructions on where to send this form. Do not send it to the Office of Federal Employees' Group Life Insurance.
U.S. Office of Personnel Management
FEGLI Handbook (RI 76-26)

Part 2 - Insured/Assignee Reassigning

RI 76-10
Revised June 2015
Previous editions are not usable.

Information for the Person Completing This Form

(Either the Insured or an Assignee Who Is Reassigning Coverage)
The "Insured" is the employee, annuitant or compensationer.
The "Assignee" is the person(s), firm(s), or trust(s) (usually named on an Assignment form, RI 76-10) who owns and controls the Insured's life insurance
coverage. An assignment is not the same as a designation of beneficiary.
General
Is There Anything I Cannot Assign? Yes. You cannot assign: (1) Family optional
What Is An Assignment? An assignment of life insurance is the transfer of ownership
and control of life insurance coverage from the Insured person to one or more persons,
firms or trusts. The assignee receives the death benefits when the Insured dies, or may
designate someone else to receive those benefits.
How Does An Assignment Differ From A Designation Of Beneficiary (SF 2823)?
An assignment transfers ownership and control of life insurance coverage. A
designation does not. An assignee has the right to reassign the coverage to someone
else. A designated beneficiary does not. The Insured can cancel a designation of
beneficiary at any time, but cannot cancel an assignment. You should only use this
form (RI 76-10) to make an assignment, and only use SF 2823 to make a designation.
How Does This Assignment Affect My Rights? By assigning the insurance, you give
up:
1. The right to cancel the insurance coverage.
2. The right to designate and change beneficiaries.
3. The right to convert to a private insurance policy when the FEGLI coverage
terminates for any reason other than cancellation.
4. The right to change the post-65 reduction schedule for Basic insurance after the
Insured makes the original election when he/she retires or begins to receive
payments from the Office of Workers' Compensation Programs. If the Insured
chose No Reduction or 50% Reduction, the Assignee(s) can change it to 75%
Reduction (unless the Insured received a Living Benefit). No one can change an
election of No Reduction to 50% Reduction. See the SF 2818, Continuation of
Life Insurance Coverage as a Retiree or Compensationer, for more information.
5. The right to change the post-65 reduction schedule for Option B insurance after
the Insured makes the original election when he/she retires or begins to receive
payments from the Office of Workers' Compensation Programs, under certain
circumstances. If the Insured chose No Reduction, the assignee(s) can change it
to Full Reduction. If the Insured chose Full Reduction, the assignee cannot
change it. See the SF 2818, Continuation of Life Insurance Coverage as a
Retiree or Compensationer, for more information.
What Reduction Elections Can The Insured Make At Retirement? The Insured has
the right to make the original election for how much Basic and Option B coverage
he/she wishes to retain after he/she is age 65 and retired.
The Insured can elect either 75% Reduction, 50% Reduction or No Reduction for Basic
(see the SF 2818 for more information about these choices).
The Insured can elect either Full Reduction or No Reduction for Option B (see the SF
2818 for more information about these choices). The Insured can change an election of
Full Reduction to No Reduction, as applicable.
What Reduction Elections Can The Assignee(s) Make? The assignee(s) can change
the Insured's Basic election to 75% Reduction (if the Insured did not already elect 75%
Reduction). The assignee(s) can change the Insured's Option B election to Full
Reduction (if the Insured did not already elect Full Reduction).
Can The Insured Cancel This Assignment? No. This is an irrevocable assignment of
life insurance coverage. For example, the Insured should not make an assignment as
collateral for a bank loan which he/she intends to repay in full. Even though he/she
repays the loan, that assignment will remain in effect.
When Is An Assignment Cancelled? An assignment is void 31 days after the
Insured's FEGLI coverage ends.
Should I Consult A Tax Attorney Or Other Professional Before Making This
Assignment? You may want to. It is possible that assignment to a trust may not
exclude FEGLI benefits from your estate. It is also possible that you could inherit the
FEGLI coverage through designation or death of your assignee(s).

insurance coverage (Option C). However, if the assignee(s) cancel(s) Basic insurance,
such cancellation automatically cancels all other FEGLI coverage, including Option C.
(2) The right to elect more insurance coverage. The Insured retains this right. However,
all of the insurance (except for Option C) that the Insured elects will automatically be
subject to the existing assignment. (This applies to employees only; annuitants and
compensationers cannot elect more insurance coverage.)
Who Can Cancel The Premiums? The assignee(s) can cancel the coverage. If they
do so, the premiums also stop. The Insured cannot cancel the premiums or the
coverage.

Completing the Form
Can I Name A Contingent Assignee? No. You cannot name a contingent assignee
(for example, you cannot assign to Maria if she is living; otherwise to Jose.)
What If I Make A Mistake? If you erase or change anything on the form, you should
start again with a new form. Do not submit a form with erasures or cross-outs.
What If I Need More Room? Write "See Attached" in Part B of the form. Use a blank
sheet. Print your name, date of birth and social security number at the top of the
attachment. List the information required in Part B for each assignee. Sign the form and
attachment. Have the same two people witness both of your signatures and sign the
form and attachment.
What If I (or the Insured) Has Several Types Of FEGLI (Like Basic And Option
A)? You must assign all of the insurance, although you do not have to assign it all to
the same person. You must assign percentages or fractions of the total insurance that
add up to 100% or 1.0, respectively.
Can I Assign Basic To Someone And Optional To Someone Else? No. You cannot
assign types of coverage.
Can I Assign Dollar Amounts? No.
Can I Assign Coverage To Myself? No.
What If I Don't Have An Assignee's Social Security Number? If you don't know
the number, leave it blank. We ask for the number because having it sometimes helps
to identify and locate the proper assignee.

Other Information
Where Should I Send This Form? If the Insured:
• is an employee; or
• has been receiving compensation payments from the Office of Workers'
Compensation Programs for LESS THAN 12 months and is still on the agency's
rolls as an employee, then
send it to the Insured's employing agency.
If the Insured:
•
•

is a retiree; or
is receiving compensation payments from the Office of Workers' Compensation
Programs and is not still employed or has been receiving compensation payments
for AT LEAST 12 months; then

send it to:

Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

When Is The Assignment Effective? The assignment is effective on the date that the
Insured's employing office or retirement system, as appropriate, receives the properly
completed, signed and witnessed form.

You cannot cancel this assignment.
The Insured cannot cancel life insurance premium withholdings for assigned FEGLI coverage.
No one can assign Option C.
Privacy Act and Public Burden Statements
Title 5, U.S. Code, chapter 87, Life Insurance, authorizes solicitation of this information. The data you furnish will be used to determine ownership of the Insured's Federal Employees' Group Life
Insurance. This information will be shared with the Office of Federal Employees' Group Life Insurance in the event of the Insured's death. It will also be shared with the Office of Personnel Management
and be placed in the Insured's Official Personnel Folder or retirement file. This information may be disclosed to other Federal agencies or Congressional offices which may have a need to know it in
connection with your application for a job, license, grant or other benefit. It may also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching
programs, with national, state, local or other charitable or social security administrative agencies to determine and issue benefits under their programs. In addition, to the extent this information indicates
possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law enforcement agency.
We also request that you provide the Insured's Social Security Number so that it may be used as an individual identifier in the Federal Employees' Group Life Insurance Program. Public Law 104-134
(April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section 7701.
While the law does not require you to supply all the information requested on this form, doing so will assist in the prompt processing of your assignment.
Agencies other than the Office of Personnel Management may have further routine uses for disclosure of information from the records systems in which they file copies of this form. If this is the case, they
should provide you with any such uses which are applicable at the time you complete this form.
We estimate this form takes an average of XX minutes to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our
estimate or any other aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management, Retirement Services Publications Team (3206-XXXX),
Washington, DC 20415-3430. The OMB number, 3206-XXXX, is currently valid. OPM may not collect this information, and you are not required to respond, unless the number is displayed.

Back of Part 2

(Do Not Erase or Cross
Out. Use a New Form.)

Assignment
Federal Employees' Group Life Insurance (FEGLI) Program
*This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries.
A.

Note: Read instructions on
the back of Part 2 before
completing this form.

Information About the Insured (not the Assignee) (type or print)

Name of Insured (Last, first, middle)

Date of birth of Insured (mm/dd/yyyy)

Social Security Number of Insured

Place an "X" in the
appropriate box.

Department or agency

Bureau or Division

Location (City, state, and ZIP code)

Information About the Assignee(s) (type or print)
First name, middle initial, and last name of
each assignee

Social Security Number

Address (Including ZIP code)

Relationship

Percent or fraction
assigned

Total (Must equal 100% or 1.0) (Do not use dollar amounts or types of insurance)
C.

Statement of Insured or Assignee (type or print)

Your name and address (Including ZIP code)

Please check one:
I am:
the Insured

Please check both of these:
an Assignee

I have signed this form in the presence of the
two witnesses who have signed below.
I did not name either witness as an assignee.

See back of Part 2 for definitions.
I understand that the Insured retains responsibility for paying life insurance
premiums, even after the assignment.

I understand that upon the Insured's death, the Office of Federal Employees'
Group Life Insurance (OFEGLI) will pay the share of any living assignee to the
assignee's designated beneficiary, if there is one. If the assignee did not designate a
beneficiary, OFEGLI will pay the assignee, if living. If the assignee dies before the
Insured dies, and he/she did not designate a beneficiary, or all of the
beneficiary(ies) die(s) before the Insured dies, OFEGLI will pay the assignee's
estate.



Witnesses To Signature (A witness cannot be an assignee)

Signature of witness

Address (Including ZIP code)

Signature of witness

Address (Including ZIP code)




For Agency Use Only

Receiving agency

Date of receipt (mm/dd/yyyy)

Signature of authorized agency official

Title

See back of Part 2 for instructions on where to send this form. Do not send it to the Office of Federal Employees' Group Life Insurance.
U.S. Office of Personnel Management
FEGLI Handbook (RI 76-26)

Part 3 - Assignee

RI 76-10
Revised June 2015
Previous editions are not usable.

Information for Agencies and Retirement Systems
To process an Assignment:
1.

If the Insured signed the form in Item C, check to see whether the
Insured already has a current, valid assignment on file. If so, write
VOID across the front of this form and return it to the Insured. The
Insured cannot assign coverage twice.

If an assignee signed the form in Item C, check to see whether
he/she is a current assignee of the Insured's life insurance. If not,
write VOID across the front of this form and return it to the person
who signed the form. Only a current assignee can reassign life
insurance coverage.

Verify that the Insured/assignee properly completed the form and
that two witnesses signed the form. The form must be free of
erasures or cross-outs. If the assignment is to two or more
individuals, make sure specified percentages or fractions add
up to 100 percent or 1.0, respectively. Dollar amounts or types of
insurance are not acceptable.

Certify receipt of the assignment form in Item E.

Separate the form. Give the person filing the form Part 2. Give
each assignee named in Item B a copy of Part 3, along with a blank
SF 2823, Designation of Beneficiary, and RI 76-21, FEGLI Booklet
(or RI 76-20 if the Insured is a Postal employee) or RI 76-12,
FEGLI pamphlet, if the Insured is an annuitant or compensationer.
Give each assignee the name and address of the employing office
or retirement system where he/she should return the completed
SF 2823.

File Part 1 of the assignment form with the Insured's other FEGLI
forms. Attach the original to the SF 2821, Agency Certification of
Insurance Status, when the Insured separates, dies, retires, or ends
12 months in nonpay status.

Information for Assignees
General
You are responsible for keeping your current address on file with the
office where the assignment is filed. As the owner of the Insured's
Federal Employees' Group Life Insurance (FEGLI) coverage, you have
the right to:
1.

Designate and change the beneficiary(ies) for the assigned
insurance. Unless you submit a designation of beneficiary,
you will be the beneficiary of the Insured's coverage. If you
do designate a beneficiary and the beneficiary survives the Insured,
the beneficiary will receive the insurance benefit.

Change the Insured's original election of No Reduction or
50% Reduction for Basic insurance to 75% Reduction (unless the
Insured received a Living Benefit).

Change the Insured's original election of No Reduction for Option
B insurance to Full Reduction.

Convert your share of the insurance to an individual policy on the
Insured's life when the Insured's FEGLI coverage terminates other
than by voluntary cancellation.
If there is more than one assignee, each assignee has the right to
convert all or part of his or her share of the insurance.

Cancel the insurance. When the insurance is assigned to two or
more people, these assignees must all agree to the cancellation. A
cancellation of Basic insurance cancels all insurance.

Assign your share of the insurance to another person(s), firm(s) or
trust(s).

You cannot cancel this assignment of FEGLI coverage.
You may, however, cancel the Insured's FEGLI coverage or reassign the Insured's FEGLI coverage.

Designation of Beneficiary
1.

You may wish to designate a beneficiary as soon as you
are notified that the Insured has assigned his/her insurance
to you. You should use an SF 2823, Designation of Beneficiary.
You may obtain a blank SF 2823 from the Insured's employing
office or retirement system or on our web site,
www.opm.gov/healthcare-insurance/life-insurance.

If you die before the Insured and you did not designate a
contingent beneficiary, your estate will receive benefits when the
Insured dies.
3.

When insurance is assigned to more than one assignee, an
assignee's designation only applies to his/her share of the Insured's
coverage.

You may want to designate yourself, if living, and then someone
else (a contingent beneficiary) to receive the death benefits if you
die before the Insured.

More Information
You can read more information in the RI 76-21, FEGLI Program Booklet for Federal Employees (or RI 76-20 for Postal employees) and the
RI 76-26, FEGLI Handbook available on-line only at www.opm.gov/healthcare-insurance/life-insurance.
Back of Part 3

File Type	application/pdf
File Title	Printing P:\RSSP\ASB\FORMS\FORMSF~1\RI_76-10.FRP
Author	PRPINKNE
File Modified	2014-05-08
File Created	2014-02-03