RI 76-10 Revised

RI76-10_Revised.pdf

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

RI 76-10 Revised

OMB: 3206-0270

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OMB Approval 3206-0270

Assignment
Federal Employees' Group Life Insurance (FEGLI) Program
Federal Employees
Group Life Insurance

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

*This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries.

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 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 must continue to pay life insurance premiums,
even after the assignment.
I understand that I can never cancel this assignment.

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)
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

Updated edition date
RI 76-10
Revised February 2020
Previous editions are not usable.

Examples of Assignments
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)

Relationship Percent or fraction
assigned
Niece

214 Central Avenue
Muncie, IN 47303

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
Nephew

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

Relationship Percent or fraction
assigned
Corporation

100%

OMB Approval 3206-0270

Assignment
Federal Employees' Group Life Insurance (FEGLI) Program
Federal Employees
Group Life Insurance

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

*This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries.

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.

I understand that the Insured must continue to pay life insurance premiums,
even after the assignment.
I understand that I can never cancel this assignment.



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

Updated edition date.
RI 76-10
Revised February 2020
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.
exclude FEGLI benefits from your estate. It is also possible that you could inherit
General
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? 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 use this form
(RI 76-10) to make an assignment and SF 2823 to make a designation.
How Does This Assignment Affect My Rights? By assigning the insurance, you
give up:

the FEGLI coverage through designation or death of your assignee(s).

Is There Anything I Cannot Assign? Yes. You cannot assign: (1) Family optional
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

1.
2.

The right to cancel the insurance coverage;

The right to port (continue) Option B, if eligible, after the Insured resigns or
ends 12 months nonpay status;

The right to convert to a private insurance policy when the FEGLI coverage
terminates for any reason other than cancellation;

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
compensation. 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.

What If 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, respectively.

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 compensation, 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.

Can I Assign Dollar Amounts? No.

The right to designate and change beneficiaries;

What Reduction Elections Can The Insured Make At Retirement? The Insured
has the right to make the original election on 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).

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.

Can I Assign Basic To Someone And Optional To Someone Else? No. You
cannot assign types of coverage.
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

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.

send it to the Insured's employing agency.

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 I Cancel This Assignment? No. This is an irrevocable assignment of life
insurance coverage. For example, you should not make an assignment as collateral
for a bank loan which you intend to repay in full. Even though you repay 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

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 Services and Management Group
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 Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to collect the information
requested on RI 76-10 pursuant to Title 5 U.S. CFR, Chapter 87, which discuss the authorization of OPM to administer the Federal Employees’ Group Life Insurance Program, and to issue
regulations to carry out the provisions of the FEGLI law. OPM is authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order
13478 (November 18, 2008). Purpose: This form is used to allow an insured individual to transfer ownership, or “assign” the FEGLI coverage, to a third party. Routine Uses: The information
requested on this form may be shared as a "routine use" to other Federal agencies and third-parties when it is necessary to process your application. For example, OPM may share your information
with other Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary for a determination of your disability retirement
benefits, or to report income for tax purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation or potential violation of civil or criminal law.
A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance Records system of records notice, available at www.opm.gov/privacy.
Consequences of Failure to Provide Information: This information collection is voluntary. Respondents aren’t required to report information, it is their choice to do so if they choose to assign
the life insurance to someone else. However, in declining to provide information, the FEGLI cannot be assigned to a new owner. (Updated Privacy Act Statement)
Public Burden Statement
We estimate this form takes an average of 15 minutes per response 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 United States Office of Personnel Management (OPM), Retirement
Services Publications Team (3206-0270), Washington, D.C. 20415-0001. Completed application forms should not be sent to this address. The OMB Number 3206-0270, is currently valid. OPM
may not collect this information, and you are not required to respond, unless this number is displayed. (Updated Public Burden Statement)

Assignment
Federal Employees' Group Life Insurance (FEGLI) Program
Federal Employees
Group Life Insurance

OMB Approval 3206-0270

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

*This is NOT a Designation of Beneficiary. Use SF 2823 to designate beneficiaries.

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.

I understand that the Insured must continue to pay life insurance premiums,
even after the assignment.
I understand that I can never cancel this assignment.



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 February 2020
Previous editions are not usable.
Updated edition date.

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, 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 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.

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 or by porting
Option B.
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.

Port (continue) the Insured's Option B coverage after he/she
separates from service or ends 12 months in nonpay status, if
applicable.

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).

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.

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

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 Booklet (or RI 76-20 for Postal employees) and the RI 76-26, FEGLI Handbook at
www.opm.gov/healthcare-insurance/life-insurance/.

File Type	application/pdf
File Title	Printing E:\RI_76-10.FRP
Author	PRPINKNE
File Modified	2019-11-13
File Created	2014-08-26