Servicemembers’ Group Life Insurance
Election and Certificate
1. About You
Print Name (First, Middle, Last)
Rank, title or grade
Social Security Number
Duty Location
Branch of Service
Current Amount of SGLI
2. About Your Coverage
This form replaces all prior designations.
I am completing this form to: (Check all that apply)
SGLI coverage is
Name or update my SGLI beneficiary. You must complete sections 3 & 5.
available in increments
of $50,000 up to a
Increase or restore my SGLI coverage to $ ______________ . You must complete sections 3, 4, & 5.
maximum of $400,000.
(Increasing SGLI does not automatically increase FSGLI, if FSGLI was < $100,000.)
Traumatic Injury
Reduce my SGLI coverage to $ _______________. You must complete sections 3 & 5.
Protection (TSGLI)
coverage is automatic
Decline or cancel SGLI coverage. Write below “I do not want insurance at this time.” You must complete section 5 only.
with SGLI coverage.
“
”
___________________________________________________________________________.
3. About Your Beneficiaries
Please always complete this section unless you are declining coverage. If you do not specifically
name beneficiaries, your insurance will be paid by law. Please read the information on page 3 before selecting your beneficiaries.
Payment Option
Share to each (%) – The
sum of shares must equal
(Lump sum* or
Primary
100%. Each share must
36 equal monthly
Social Security Number
Relationship
Name and Address
(If available)
to you
be greater than 0%.
payments)
1.
2.
3.
4.
Secondary
1.
2.
3.
4.
Have more beneficiaries? Check this box if 1.) You have additional beneficiaries and are completing the Supplemental SGLI Beneficiary Form,
SGLV 8286S or, 2.) You are attaching additional documentation to complete your beneficiary designation noted above.
* If the insured member elects a lump sum payment, the beneficiary(ies) will be given the option of receiving the lump sum payment through the
Prudential Alliance Account
, by check, or Electronic Funds Transfer (EFT). Alliance Account is not available for payments less than $5,000,
®
payments to individuals residing outside the United States and its territories, and certain other payments. These will be paid by check.
The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential
Insurance Company of America, located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The
Bank of New York Mellon. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). The Bank of New
York Mellon is not a Prudential Financial company.
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GL.2010.094 Ed. 02/2017
SGLV 8286
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