Fillable Designation Of Beneficiary 2001 (Page 4 of 4) in pdf

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

certified court orders involving FEGLI on or after July 22, 1998, and 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

Can I use a common disaster clause? Yes. A common disaster clause is a

Employees' Group Life Insurance (OFEGLI) pays benefits in this order:

statement that says that a designated beneficiary is entitled to the benefits only if

If the Insured assigned ownership of his/her insurance (usually by filing an

he/she survives the Insured by a specified minimum number of days. The number

RI 76-10, Assignment of Life Insurance), OFEGLI will pay:

of days cannot exceed 30. You can name a contingent beneficiary. If you don't

First, to the beneficiary(ies) the assignee(s) validly designated;

name a contingent and your beneficiary does not live long enough to qualify,

Second, if none, to the assignee(s).

OFEGLI will pay according to the order listed in the first column.

If the Insured did not assign ownership and there is a valid court order (see 5

Can I designate a trust? Yes. See examples 5 and 6 on the Back of Part 1. Those

Code of Federal Regulations Part 870) on file with the agency or OPM, as

examples name a contingent beneficiary in case the trust is not valid. You don't

appropriate, OFEGLI will pay benefits according to the court order.

have to name a contingent beneficiary unless you want to. If the trust is not valid,

If the Insured did not assign ownership and there is no valid court order on

and you do not name a contingent, OFEGLI will pay according to the order listed

file with the agency or OPM, as appropriate, then OFEGLI will pay:

in the first column.

First, to the beneficiary(ies) the Insured validly designated;

When is a designation canceled? A designation of beneficiary is automatically

Second, if none, to the Insured's widow or widower;

canceled 31 days after the Insured stops being insured. It is also canceled if either

Third, if none of the above, to the Insured's child or children and the

the Insured or assignee assigns the insurance or if the Insured or assignee submits

descendants of any deceased children (a court will usually have to

another valid designation.

appoint a guardian to receive payment for a minor child);

Fourth, if none of the above, to the Insured's parents in equal shares, or

What if the Insured elected a full living benefit? Then there is no Basic left.

the entire amount to the surviving parent;

So if you want to designate different types of insurance to different beneficiaries

Fifth, if none of the above, to the court-appointed executor or

(see example 4 on the Back of Part 1), you should only list Option A and Option

administrator of the Insured's estate;

Who can sign this form? The Insured or Assignee (if applicable) must sign this

Sixth, if none of the above, to the Insured's other next of kin entitled

form. The signature of a guardian, conservator or other fiduciary (including, but

under the laws of the State where the Insured lived.

not limited to, those acting according to a Power of Attorney or a Durable Power

Do I have to designate a beneficiary? No. But if you want OFEGLI to pay

of Attorney) is not acceptable.

differently than listed above and you have not assigned the life insurance and

What if I erase or cross out something on this form? You should complete

there is no valid court order on file with the agency or OPM, as appropriate, you

another form. Erasures, cross-outs and alterations cause a delay in the payment of

need to designate a beneficiary.

benefits and may make the entire designation invalid.

What if one of the beneficiaries dies or is disqualified for any reason? Unless

What if I need more room? Write "See Attached" in Part B of the form. Use a

you indicate otherwise on your designation of beneficiary, OFEGLI will distribute

blank sheet. Print your name, date of birth and social security number at the top of

that beneficiary's share equally among the surviving beneficiaries, or entirely to

the attachment. List the information required in Part B for each beneficiary. Sign

the sole survivor.

the form and attachment. Have the same two people witness both of your

What if none of the beneficiaries is living when the Insured dies? OFEGLI

signatures and sign the form and attachment.

will pay the benefits according to the order of precedence listed above.

Where can I get more information? The FEGLI Handbook (RI 76-26) and

Can I cancel or change this designation at any time? Yes, you may cancel or

FEGLI Booklet (RI 76-21 or RI 76-20 for Postal employees) contain more

change your designation at any time, without the knowledge of or consent of the

information. You can read them at .

beneficiary(ies), unless you assigned the insurance or there is a valid court order

Where should I send this form? Send it to the Insured's employing agency if the

on file with the agency or OPM, as appropriate.

Insured:

Is a change or cancellation of beneficiary in my last will or testament valid?

is an employee; or

It is valid only if you sign your will, two people who witnessed your signature

has been receiving compensation payments from the Office of Workers'

sign your will, and your agency (or OPM, for retirees or insured compensationers)

Compensation Programs for less than 12 months and is still on the agency's

receives your will before the Insured's death.

rolls as an employee.

What if I don't know a beneficiary's social security number? If you don't

Send it to the Office of Personnel Management, Retirement Operations Center,

know the number, leave it blank. But having the number helps speed up the

P.O. Box 45, Boyers, PA 16017-0045 if the Insured:

payment of benefits.

is a retiree; or

is receiving compensation payments from the Office of Workers'

Can a witness receive benefits as a designated beneficiary? No.

Compensation Programs and is not still employed or has been receiving

Who can I name as a beneficiary? You may name any person, firm, corporation

compensation payments for at least 12 months.

or legal entity (except an agency of the Federal or District of Columbia

The agency or OPM will note receipt in section E of the form and return a copy to

government).

you as evidence that it received and filed the original.

Properly completed designations are not valid unless the appropriate office listed

above receives them before the Insured's death.

Privacy

Privacy Act

Privacy

Act

Act and

and

and Public

and

Public

Public Burden

Public

Burden

Burden Statements

Burden

Statements

Title 5, U.S. Code, chapter 87, Life Insurance, authorizes solicitation of this information. The

requires that any person doing business with the Federal government furnish a social security

Office of Federal Employees' Group Life Insurance (OFEGLI) will use the information you

number or tax identification number. This is an amendment to title 31, Section 7701.

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

While the law does not require you to supply all the information requested on this form, doing

contracted life insurance carrier. It may share this information with the Office of Personnel

so will help in the prompt processing of your designation.

Management (OPM). Agencies and/or OPM will place this information in the Insured's Official

Agencies other than the Office of Personnel Management may have further routine uses for

Personnel Folder or retirement file. OPM or OFEGLI may disclose this information to other

disclosure of information from the records systems in which they file copies of this form. If this

Federal agencies or Congressional offices which may have a need to know it in connection with

is the case, they should provide you with any such uses which are applicable at the time you

your application for a job, license, grant or other benefit. It may also be shared and is subject to

complete this form.

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

We think this form takes an average of 15 minutes to complete, including the time for reviewing

indicates possible violation of civil or criminal law, it may be shared and verified, as noted

instructions, getting the needed data, and reviewing the completed form. Send comments

above, with an appropriate Federal, state, or local law enforcement agency.

regarding our estimate or any other aspect of this form, including suggestions for reducing

completion time, to the Office of Personnel Management, Reports and Forms Coordinator,

(3206-0136), Washington, D.C. 20415-7900. The OMB number, 3206-0136, is currently valid.

OPM may not collect this information, and you are not required to respond, unless this number

We also ask for the Insured's Social Security Number to use it as an individual identifier in the

is displayed.

Federal Employees' Group Life Insurance Program. Public Law 104-134 (April 26, 1996)

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.)

SF 2823

Back of Part 2

Revised April 2001

Designation Of Beneficiary 2001 Page 4

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