Standard Form 2819 - Notice Of Conversion Privilege Page 2

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Part C - Eligibility Statement

1. Please check the correct box(es).

Basic

Option A-Standard

Option B-Additional

I have read Part B on page 1 and am interested in converting my

insurance to an individual policy. Please send additional information.

I have read Part B on page 1. The family members listed in item 7 below

are eligible for conversion of Option C-Family insurance to a direct-pay policy.

Please send me additional information.

4. Full name and address of person completing this

2. Signature of person completing this statement

3. Date (mo., day, yr.)

statement (including ZIP code)

5. Was the FEGLI coverage assigned?

Yes

If Yes, are you the assignee of the insured's FEGLI coverage?

Yes

6. Check one:

I have attached an SF 2821.

I am a family member and do

I will obtain and submit an

not need an SF 2821.

SF 2821 later.

7. Eligible family members

Birth date

Relationship

Eligible family members

Part D - Information About Individual Policies

the cash if he/she stops paying premiums, and (4) may borrow against the cash

Types of Policies

There are two basic types of life insurance available.

value.

An Ordinary Life policy, also known as a Whole Life policy or a Straight

Cost of Individual Policy

Life policy, provides lifetime protection in return for premium payments

Life insurance policies (whether Ordinary Life or a variation) are issued on a

throughout the insured's entire life (or to age 100). The policy builds a

participating or non-participating basis.

CASH VALUE after one, two, or three years. The cash may be withdrawn

if premium payments are stopped. You may borrow against the cash value

Premiums for participating policies are higher than those charged for

of the policy at any time for any purpose.

non-participating policies. Part of the premium is refunded in the form of an annual

dividend to the policyholder - the part found not needed to furnish protection. The

A variation of Ordinary Life provides for a shorter premium payment

first dividend is usually available after premiums have been paid for one, two, or

period, usually to age 95, at which time the policy becomes paid-up for the

three years. To obtain the net cost of a participating policy, deduct these yearly

remainder of the insured's life. This variation provides the same lifetime

dividends from the premiums.

protection and benefits as an Ordinary Life policy, provided that premiums

are paid for the prescribed premium payment period. However, since

For non-participating policies, premiums are set as close as possible to the actual

premiums are payable for a shorter period of time, they normally would be

cost of insurance protection. The premium is the guaranteed cost to the

higher. And, because the premiums are normally higher, the policy's CASH

policyholder. No dividends are paid under these policies.

VALUE usually increases more quickly.

The following are approximate premium rates on a participating basis for Ordinary

Assignment

Life policies with premiums payable for life (or to age 100) and for Ordinary Life

If you have assigned (given up ownership of) your insurance, only the

policies with premiums payable to age 95. Premium rates for non-participating

assignee(s) has (have) the right to convert your non-option C coverage. If an

policies are somewhat lower and no dividends will be paid under these policies. The

assignee converts his/her share of your insurance, he/she (1) is responsible for

rates shown below are examples only and are not rates for any one company.

paying the premiums, (2) will receive the dividends, if any, (3) may withdraw

Sample Annual Premium Rates per $1,000 of Insurance

Participating Insurance (any dividends paid will reduce these costs)

Age of insured

Life

Age of insured

Life

Ordinary

at issuance

Paid-Up

at issuance

Paid-Up

Life

of policy

at Age 95

of policy

at Age 95

$ 9.00

$10.50

$24.50

$28.00

$10.50

$12.50

$31.50

$36.50

$12.50

$14.50

$40.50

$48.00

$15.50

$17.50

$53.00

$64.00

$19.50

$21.50

$66.50

$77.50

Privacy Act Statement - Title 5, United States Code, Chapter 87, Life Insurance, authorizes solicitation of this information. The data you furnish will be used by the Office of

Federal Employees' Group Life Insurance to determine eligibility for conversion of life insurance coverage. This information may be shared with national, state, local, or other

charitable or social security administrative agencies to determine and issue benefits under their programs, or law enforcement agencies, when they are investigating a violation or

potential violation of the civil or criminal law.