Form SF 2823 SF 2823 Designation of Beneficiary, Federal Employees' Group Lif

Form Approved
OMB No. 3206-0136

Designation of Beneficiary
Federal Employees
Group Life Insurance

Federal Employees' Group Life Insurance (FEGLI) Program
(DO NOT erase or cross-out. Use a new form.)

Important:
Read instructions on the
Back of Part 2 before completing this form.

A. Information About the Insured (not the Assignee, if there is one) (type or print)
Name of Insured (Last, first, middle)

The Insured is:
Place an "X" in the
appropriate box.

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

an employee

Social Security Number of Insured

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

a retiree
a compensationer

Department or agency where the Insured works (If retired, last department or agency where the Insured worked):
Department or agency

Bureau or division

Location (city, state, and ZIP code)

B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print)
First name, middle initial, and last name of
each beneficiary

Social Security Number

Address (Including ZIP code)

Relationship

Percent or fraction
designated

Total (Must equal 100% or 1.0) (Do not use dollar amounts)
(Do not put a Total if you designated types of insurance. See example 4 on Back of Part 1.)

C. Statement of Insured or Assignee (type or print)
Your name and address (Including ZIP code)

Please check one:
I am:

Please check all three:

I have not assigned the insurance.

the Insured
an Assignee
See Back of Part 2 for definitions
I understand that if there is a valid assignment on file, only the assignee has the
right to designate a beneficiary. If a valid assignment is not on file, but there is a
valid court order on file with the agency or the U.S. Office of Personnel
Management, as appropriate, any designation I complete for the same benefits is
not valid.
I understand that if this Designation is valid, it will stay in effect unless it is
canceled. (See "When Is A Designation Canceled?" on the Back of Part 2).

Two people who witnessed my
signature signed below.
I did not name either witness as a
beneficiary.

I understand that if this Designation is invalid for any reason, the Office of
Federal Employees' Group Life Insurance will pay benefits according to the
next most recent valid designation. If there isn't one, it will pay according to the
order listed on the Back of Part 2.
I am canceling any and all previous Designations of Beneficiary under the
Federal Employees' Group Life Insurance Program and am now designating the
beneficiary(ies) named above.

Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power
of attorney are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box.

Date (mm/dd/yyyy)

Â
D. Witnesses To Signature (A witness is not eligible to receive a payment as a beneficiary.)
Signature of witness

Address (Including ZIP code)

Â
Signature of witness

Address (Including ZIP code)

Â
E. For Agency Use Only (or OPM, as appropriate)
Receiving agency

U.S. Office of Personnel Management
FEGLI Handbook (RI 76-26)

Date of receipt (mm/dd/yyyy)

Signature of authorized official

Title

Part 1 - Original
Previous editions are not usable.

SF 2823
Revised January 2014

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.

Examples of Designations
1. How to designate one beneficiary Show beneficiary's full name. Do not write names as M.E. Brown or as Mrs. John H. Brown.
If you want to designate your estate, enter "My estate" in the beneficiary column.
First name, middle initial, and last name of
each beneficiary

Mary E. Brown

Social Security Number

000-00-0000

Address (Including ZIP code)

214 Central Avenue
Munice, IN 47303

Relationship

Percent or fraction
designated

Niece

100%

2. How to designate more than one beneficiary Be sure that the shares to be paid to the several beneficiaries add up to 100 percent
or 1.0. Read instructions on the Back of Part 2 if you need more room.
First name, middle initial, and last name of
each beneficiary

Social Security Number

Jose P. Lopez

111-11-1111

Rosa L. Rowe

222-22-2222

3. How to designate a contingent beneficiary
First name, middle initial, and last name of
each beneficiary

Address (Including ZIP code)

360 Williams Street
Red Band, NJ 07701
792 Broadway
Whiting, IN 46392

Percent or fraction
designated

Domestic
Partner

one-half

Mother

one-half

(Someone to receive the benefits if the person you designate dies before the Insured
dies)

Social Security Number

John M. Parrish, if living

333-33-3333

Otherwise to: Susan A. Parrish

444-44-4444

Address (Including ZIP code)

810 West 180th Street
New York, NY 10033
810 West 180th Street
New York, NY 10033

4. How to designate different beneficiaries for Basic and Optional
First name, middle initial, and last name of
each beneficiary

Relationship

Social Security Number

Leroy D. White

555-55-5555

Jane M. Smith

666-66-6666

Elizabeth J. Allen

777-77-7777

Ann J. Borden

888-88-8888

Relationship

Percent or fraction
designated

Spouse

100%

Sister

100%

You cannot designate Option C - Family.
Address (Including ZIP code)

124 Elm Street
Dayton, OH 45420
421 Spring Avenue
Portland, ME 04101
234 Fifth Avenue
New York, NY 10029
678 Ninth Street
Philadelphia, PA 19123

Relationship

Father
Sister
Daughter
Daughter

Percent or fraction
designated

100%
Basic
100%
Option A
50%
Option B
50%
Option B

5. How to designate an inter vivos trust (A trust that you set up during your lifetime)
First name, middle initial, and last name of
each beneficiary

Social Security Number

Address (Including ZIP code)

Trustee(s) or Successor Trustee(s) as
provided in the John Q. Public Trust
Agreement dated 10/15/2013, if valid.
Otherwise to:
Mary E. Brown

000-00-0000

214 Central Avenue
Munice, IN 47303

Relationship

Percent or fraction
designated

Trustee

100%

Niece

100%

6. How to designate a testamentary trust (A trust that is set up when you die, according to terms in your will)
First name, middle initial, and last name of
each beneficiary

Social Security Number

Address (Including ZIP code)

Trustee(s) or Successor Trustee(s) as
provided in my Last Will and
Testament, if valid. Otherwise to:
Maria Sufuentes

999-99-9999

5909 Pacific Avenue, NW
Washington, DC 20019

Relationship

Percent or fraction
designated

Trustee

100%

Niece

100%

Relationship

Percent or fraction
designated

7. How to cancel all designations of beneficiary
First name, middle initial, and last name of
each beneficiary

Social Security Number

Address (Including ZIP code)

Cancel prior designations
Back of Part 1

SF 2823
Revised January 2014

Form Approved
OMB No. 3206-0136

Designation of Beneficiary
Federal Employees
Group Life Insurance

Federal Employees' Group Life Insurance (FEGLI) Program
(DO NOT erase or cross-out. Use a new form.)

Important:
Read instructions on the
Back of Part 2 before completing this form.

A. Information About the Insured (not the Assignee, if there is one) (type or print)
Date of birth of Insured (mm/dd/yyyy)

Name of Insured (Last, first, middle)

The Insured is:
Place an "X" in the
appropriate box.

Social Security Number of Insured

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

an employee
a retiree
a compensationer

Department or agency where the Insured works (If retired, last department or agency where the Insured worked):
Bureau or division

Department or agency

Location (City, state, and ZIP code)

B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print)
First name, middle initial, and last name of
each beneficiary

Social Security Number

Address (Including ZIP code)

Relationship

Percent or fraction
designated

Total (Must equal 100% or 1.0) (Do not use dollar amounts)
(Do not put a Total if you designated types of insurance. See example 4 on Back of Part 1.)

C. Statement of Insured or Assignee (type or print)
Your name and address (Including ZIP code)

Please check one:
I am:

Please check all three:

I have not assigned the insurance.

the Insured
an Assignee
See Back of Part 2 for definitions
I understand that if there is a valid assignment on file, only the assignee has the
right to designate a beneficiary. If a valid assignment is not on file, but there is a
valid court order on file with the agency or the U.S. Office of Personnel
Management, as appropriate, any designation I complete for the same benefits is
not valid.
I understand that if this Designation is valid, it will stay in effect unless it is
canceled. (See "When Is A Designation Canceled?" on the Back of Part 2).

Two people who witnessed my
signature signed below.
I did not name either witness as a
beneficiary.

I understand that if this Designation is invalid for any reason, the Office of
Federal Employees' Group Life Insurance will pay benefits according to the
next most recent valid designation. If there isn't one, it will pay according to the
order listed on the Back of Part 2.
I am canceling any and all previous Designations of Beneficiary under the
Federal Employees' Group Life Insurance Program and am now designating the
beneficiary(ies) named above.

Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power
of attorney are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box.

Date (mm/dd/yyyy)

Â
D. Witnesses To Signature (A witness is not eligible to receive a payment as a beneficiary.)
Signature of witness

Address (Including ZIP code)

Â
Signature of witness

Address (Including ZIP code)

Â
E. For Agency Use Only (or OPM, as appropriate)
Receiving agency

U.S. Office of Personnel Management
FEGLI Handbook (RI 76-26)

Date of receipt (mm/dd/yyyy)

Signature of authorized official

Title

Part 2 - Duplicate
Previous editions are not usable.

SF 2823
Revised January 2014

INSTRUCTIONS: The Insured or assignee must sign this form. Two people must witness the signature and sign as witnesses. The Insured's agency (or U.S. Office of
Personnel Management [OPM], if the Insured is an annuitant or insured as a compensationer) must receive the designation before the Insured's death. A person with a power
of attorney or other similar legal authority may not sign for the Insured or assignee. A witness cannot be a beneficiary. The agency or OPM, as appropriate, must receive valid
court orders involving FEGLI before the Insured's death.

Please read the additional instructions below before completing this form.

"You" and "your" refer to the person completing this form (the Insured or an assignee). The "Insured" is the insured employee, annuitant or
compensationer. The "Assignee" is a 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.
Who receives benefits when the Insured dies? By law, the Office of Federal
contingent and your beneficiary does not live long enough to qualify, OFEGLI will
Employees' Group Life Insurance (OFEGLI) pays benefits in this order:
pay according to the order listed in the first column.
™ If the Insured assigned ownership of his/her insurance (usually by filing an
Can I designate a trust? Yes. See examples 5 and 6 on the Back of Part 1. Those
RI 76-10, Assignment of Life Insurance), OFEGLI will pay:
examples name a contingent beneficiary in case the trust is not valid. You don't
First, to the beneficiary(ies) the assignee(s) validly designated;
have to name a contingent beneficiary unless you want to. If the trust is not valid,
Second, if none, to the assignee(s).
and you do not name a contingent, OFEGLI will pay according to the order listed in
If
the
Insured
did
not
assign
ownership
and
there
is
a
valid
court
order
(see
™
the first column. The trust designation should include the name of the grantor, the
5 Code of Federal Regulations Part 870) on file with the agency or OPM, as
trust name (if different), the name(s) of the trustees, and the date the trust was
appropriate, OFEGLI will pay benefits according to the court order.
signed.
™ If the Insured did not assign ownership and there is no valid court order on file
When is a designation canceled? A designation of beneficiary is automatically
with the agency or OPM, as appropriate, then OFEGLI will pay:
canceled 31 days after the Insured stops being insured. It is also canceled if either
First, to the beneficiary(ies) the Insured validly designated;
the Insured or assignee assigns the insurance or if the Insured or assignee submits
Second, if none, to the Insured's widow or widower;
another valid designation.
Third, if none of the above, to the Insured's child or children in equal
What if the Insured elected a full living benefit? Then there is no Basic left. So
shares, and the descendants of any deceased children (a court will usually
if you want to designate different types of insurance to different beneficiaries (see
have to appoint a guardian to receive payment for a minor child);
example 4 on the Back of Part 1), you should only list Option A and Option B.
Fourth, if none of the above, to the Insured's parents in equal shares, or
the entire amount to the surviving parent;
Who can sign this form? The Insured or Assignee (if applicable) must sign this
Fifth, if none of the above, to the court-appointed executor or
form. The signature of a guardian, conservator or other fiduciary (including, but not
administrator of the Insured's estate;
limited to, those acting according to a Power of Attorney or a Durable Power of
Sixth, if none of the above, to the Insured's other next of kin entitled
Attorney) is not acceptable.
under the laws of the State where the Insured lived.
What if I erase or cross out something on this form? You should complete
Do I have to designate a beneficiary? No. But if you want OFEGLI to pay
another form. Erasures, cross-outs and alterations cause a delay in the payment of
differently than listed above and you have not assigned the life insurance and there
benefits and may make the entire designation invalid.
is no valid court order on file with the agency or OPM, as appropriate, you need to
designate a beneficiary.
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
What if one of the beneficiaries dies or is disqualified for any reason? Unless
the attachment. List the information required in Part B for each beneficiary. Sign the
you indicate otherwise on your designation of beneficiary, OFEGLI will distribute
form and attachment. Have the same two people witness both of your signatures and
that beneficiary's share equally among the surviving beneficiaries, or entirely to the
sign the form and attachment.
sole survivor.
Where can I get more information? The FEGLI Handbook (RI 76-26) and FEGLI
What if none of the beneficiaries is living when the Insured dies? OFEGLI will
Booklet (FE 76-21 or FE 76-20 for Postal employees) contain more information.
pay the benefits according to the order of precedence listed above.
You can read them at www.opm.gov/healthcare-insurance/life-insurance.
Can I cancel or change this designation at any time? Yes, you may cancel or
Where should I send this form? Send it to the Insured's employing agency if the
change your designation at any time, without the knowledge of or consent of the
Insured:
beneficiary(ies), unless you assigned the insurance or there is a valid court order
on file with the agency or OPM, as appropriate.
™ is an employee; or
™ has been receiving compensation payments from the Office of Workers'
Is a change or cancellation of beneficiary in my last will or testament valid?
Compensation Programs for less than 12 months and is still on the agency's
It is valid only if you sign your will, two people who witnessed your signature sign
rolls as an employee.
your will, and your agency (or OPM, for retirees or insured compensationers)
Send it to the Office of Personnel Management, Retirement Operations Center, P.O.
receives your will before the Insured's death.
Box 45, Boyers, PA 16017-0045 if the Insured:
What if I don't know a beneficiary's social security number? If you don't know
the number, leave it blank. But having the number helps speed up the payment of
™ is a retiree; or
benefits.
™ is receiving compensation payments from the Office of Workers'
Compensation Programs and is not still employed or has been receiving
Can a witness receive benefits as a designated beneficiary? No.
compensation payments for at least 12 months.
Who can I name as a beneficiary? You may name any person, firm, corporation or
The agency or OPM will note receipt in section E of the form and return a copy to
legal entity (except an agency of the Federal or District of Columbia government).
you as evidence that it received and filed the original.
Can I use a common disaster clause? Yes. A common disaster clause is a
PROPERLY COMPLETED DESIGNATIONS ARE NOT VALID UNLESS
statement that says that a designated beneficiary is entitled to the benefits only if
THE APPROPRIATE OFFICE LISTED ABOVE RECEIVES THEM
he/she survives the Insured by a specified minimum number of days. The number of
BEFORE THE INSURED'S DEATH.
days cannot exceed 30. You can name a contingent beneficiary. If you don't name a
Privacy Act and Public Burden Statements
Title 5, U.S. Code, chapter 87, Life Insurance, authorizes solicitation of this information. The
Office of Federal Employees' Group Life Insurance (OFEGLI) will use the information you
furnish to determine your beneficiary(ies) for benefits under the Federal Employees' Group
Life Insurance Program. OFEGLI is not a Federal agency. It is staffed by employees of the
contracted life insurance carrier. It may share this information with the Office of Personnel
Management (OPM). Agencies and/or OPM will place this information in the Insured's Official
Personnel Folder or retirement file. OPM or OFEGLI may disclose this information 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 ask for the Insured's Social Security Number to use it as an individual identifier in the
Federal Employees' Group Life Insurance Program.

Executive Order 9397, dated November 22, 1943, allows Federal agencies to use the Social
Security Number as an individual identifier to distinguish between people with the same or
similar names.
While the law does not require you to supply all the information requested on this form, doing
so will help in the prompt processing of your designation.
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 15 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 Office of Personnel Management, Retirement Services
Publications Team (3206-0136), Washington, D.C. 20415-3430. The OMB number,
3206-0136, is currently valid. OPM may not collect this information, and you are not required
to respond, unless this number is displayed.

KEEP YOUR DESIGNATION CURRENT. SUBMIT A NEW ONE IF THE ADDRESS OF ONE OF YOUR BENEFICIARIES CHANGES OR IF YOUR
INTENTIONS CHANGE (FOR EXAMPLE, DUE TO A CHANGE IN FAMILY STATUS, SUCH AS MARRIAGE, DIVORCE, DEATH, BIRTH, ETC.).
Back of Part 2

SF 2823
Revised January 2014