Form Sglv 8286 - Directions To Personnel Clerks Of The Uniformed Services Page 2
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Please read the instructions before completing this form.
Servicemembers’ Group Life Insurance Election and Certificate
Use this form to: (check all that apply)
Important: This form is for use by Active Duty and Reserve members. This
Name or update your beneficiary
form does not apply to and cannot be used for any other Government Life
Reduce the amount of your insurance coverage
Insurance.
Decline insurance coverage
Last name
First name
Middle name
Rank, title or grade
Social Security Number
Branch of Service (Do not abbreviate)
Current Duty Location
US Army
New Mexico Military Institute, Roswell, New Mexico
Amount of Insurance
By law, you are automatically insured for $400,000. If you want $400,000 of insurance, skip to Beneficiary(ies) and Payment Options. If
you want less than $400,000 of insurance, please check the appropriate block below and write the amount desired and your initials.
Coverage is available in increments of $50,000. If you do not want any insurance*, check the appropriate block below and write (in your
own handwriting), “I do not want insurance at this time.”
Declining SGLI coverage also cancels all family coverage and traumatic injury protection under the SGLI program.
I want coverage in the amount of $_______________________
Your initials________________
_______________________________________________________________________________
(Write “I do not want Insurance at this time.”)
*Note: Reduced or refused insurance can only be restored by completing form SGLV 8285 with proof of good health and compliance with other requirements. Reduced or refused
insurance will also affect the amount of Veterans’ Group Life Insurance you can convert to upon separation from service.
Beneficiary(ies) and Payment Options
I designate the following beneficiary(ies) to receive payment of my insurance proceeds. I understand that the principal beneficiary(ies) will receive payment
upon my death. If all principal beneficiaries predecease me, the insurance will be paid to the contingent beneficiary(ies).
Complete Name (first, middle, last) and Address
Social Security
Relationship
Share to each
Payment Option
(Lump sum or 36 equal monthly
of each beneficiary
Number
to you
beneficiary
payments)
(Use %, $ amounts or
(if known)
fractions)
Principal
1.
Lump sum
2.
3.
4.
Additional Principals on page 4 (check if applicable)
Contingent
1.
2.
3.
4.
Additional Contingents on page 4 (check if applicable)
I HAVE READ AND UNDERSTAND the instructions on pages 2 and 3 of this form. I ALSO UNDERSTAND that:
•
This form cancels any prior beneficiary or payment instructions.
•
The proceeds will be paid to beneficiaries as stated in #6 on page 3 of this form, unless otherwise stated above.
•
If I have legal questions about this form, I may consult with a military attorney at no expense to me.
•
I cannot have combined SGLI and VGLI coverages at the same time for more than $400,000.
•
If I am married or If I get married after completing this form, my spouse is automatically covered under Family SGLI for which premiums will be
deducted from my pay, unless I decline Family SGLI coverage by completing SGLV 8286A. For Family SGLI premium deductions, my spouse MUST
be registered in DEERS. Failure to do so will result in debts owed for unpaid premiums.
SIGN HERE IN INK
_______________________________________________
Date: ______________
(Your signature. Do not print.)
Do not write in space below. For official use only.
RECEIVED BY:
RANK, TITLE OR GRADE
ORGANIZATION
DATE RECEIVED
SGLV 8286, December 2007
p. 2
Copy 1 = Member’s Official Personnel File
Copy 2 - To Member
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Copy 3 - To Active or Reserve Component of Uniformed Service
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