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Designation of Beneficiary

Form Approved

OMB No. 3206-0136

Federal Employees' Group Life Insurance (FEGLI) Program

Important:

Federal Employees

Read instructions on the

Group Life Insurance

(DO NOT erase or cross-out. Use a new form.)

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)

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

Social Security Number of Insured

an employee

The Insured is:

If the Insured is retired or receiving Federal Employees' Compensation, give CSA,

CSI, or OWCP claim number:

a retiree

Place an "X" in the

appropriate box.

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

Social Security Number

Address (Including ZIP code)

Relationship

Percent or fraction

each beneficiary

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:

Please check all three:

I am:

the Insured

I have not assigned the insurance.

Two people who witnessed my

an Assignee

signature signed below.

I did not name either witness as a

See Back of Part 2 for definitions

beneficiary.

I understand that if there is a valid assignment on file, only the assignee has the right to

I understand that if this Designation is invalid for any reason, the Office of Federal

designate a beneficiary. If a valid assignment is not on file, but there is a valid court order on

Employees' Group Life Insurance will pay benefits according to the next most recent valid

file with the agency or the U.S. Office of Personnel Management, as appropriate, any

designation. If there isn't one, it will pay according to the order listed on the Back of Part 2.

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.

I am canceling any and all previous Designations of Beneficiary under the Federal

(See "When Is A Designation Canceled?" on the Back of Part 2).

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

Date (mm/dd/yyyy)

of attorney are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box.

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

Signature of witness

Address (Including ZIP code)

Signature of witness

Address (Including ZIP code)

E. For Agency Use Only

Receiving agency

Date of receipt (mm/dd/yyyy)

Signature of authorized agency official

Title

Part 1 - Original

U.S. Office of Personnel Management

SF 2823

FEGLI Handbook (RI 76-26)

NSN 7540-01-231-6228

2823-103

Previous editions are not usable.

Revised April 2001

Designation Of Beneficiary 2001

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