Form Sglv 8285a - Request For Family Coverage
Download a blank fillable Form Sglv 8285a - Request For Family Coverage in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Sglv 8285a - Request For Family Coverage with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Request for Family Coverage
Part I - To Be Completed By Member
1.
First Name - Middle Name - Last Name - Suffix
2. Social Security Number
3. Branch of Service
4. Amount of SGLI Now In Force
5. Amount of Coverage Desired for Spouse
I understand that if I fail to furnish satisfactory evidence of my spouse’s insurability, the fact that withholdings have been made from my
pay for the insurance being requested will not create any liability for insurance, and that I will be entitled to appropriate credit for such
withholdings.
6. Signature of Servicemember
7. Date
(dd-mmm-yyyy e.g. 12-NOV-2001)
Part II – To Be Completed By Spouse
8. First Name - Middle Name - Last Name - Suffix
9. Social Security Number
10. Date of Birth
(dd-mmm-yyyy
e.g. 12-NOV-2001)
11. Weight (lbs)
12. Height (ft & ins)
13. Gender
Male
Female
Yes
No
Yes
No
14. Have you ever been diagnosed as having a
C. Nervous disorder?
disease or disorder of the immune system?
15. Have you had or been treated for known
D. Diabetes?
indications of :
A.
A heart condition?
E. Cancer or tumors?
B. High blood pressure?
14. Do you have any known physical or mental
impairments, deformities, or ill health not
covered above?
17. If your answer to any part of items 12 through 14 is yes, please refer to item number and give dates, duration and other details.
(If more space is needed, attach a separate sheet)
The answers I have given are for securing approval of this request for insurance and I certify that they are true and correct to the best of
my knowledge and belief. I understand that the insurance being requested requires approval of insurability by the Office of
Servicemembers’ Group Life Insurance. Any deception or knowingly false statement either by inference or omission may result in
cancellation of the insurance or in the refusal to pay a claim.
18. Signature of Spouse
19. Mailing Address
20. Date
(dd-mmm-yyyy
e.g. 12-NOV-2001)
To be retained in member’s
SGLV 8285A,
September 2007
official personnel file
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form De 1378j - Application For Elective Coverage Of Disability Insurance (excluded Family Employment) - California Edd
Legal
Form Hr/cs #13 - Request For Family And Medical Leave (family And Medical Leave Act) - Dallas, Texas
Business
Form Dss-5278 - Request For Placement Evaluation For Infant Born To An Incarcerated Mother (formerly Prison Baby Program) - Family Support And Child Welfare Services
Legal
Related Categories
Parent category: Legal