Standard Form 2819 - Notice Of Conversion Privilege Page 3
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3Notice of Conversion Privilege
Federal Employees' Group Life Insurance Program
Federal Employees
Group Life Insurance
Part A - Instructions to Employing Agency
C-Family coverage. Also, upon request, give this notice to the family of an eligible
Complete Part A of this form whenever an employee’s life insurance coverage
terminates due to separation, resignation, retirement, death or end of 12
employee who does not convert his or her Option C-Family insurance.
months in non-pay status. On the date insurance terminates (except by
If this notice is prepared for a retiring employee, forward Part 2 (duplicate) to OPM
with the employee's retirement papers. Otherwise, place Part 2
waiver), give this notice to every employee and/or the assignee(s), if
applicable, and to the family of each deceased employee who had the Option
(duplicate) in the employee’s Official Personnel Folder.
1. Name of employee
2. Date of birth (mo., day, yr.)
3. Date insurance terminated
Yes
No
4. Was employee insured for Option C-Family insurance on date in item 3?
Agency Certification
I certify that the above information has been obtained from, and correctly reflects, official personnel records.
6. Name and mailing address of agency
5. Signature of authorized agency official
7. Typed name of authorized agency official
8. Title
9. Telephone number
10. Date of this notice (mo., day, yr.)
Part B - Conversion Information for Employees, Assignees, and Family Members Who are Losing FEGLI Coverage
If you are eligible and you will be carrying all of your Federal Employees’ Group Life
General information about conversion
If you have assigned your FEGLI coverage, you can only convert your Option
Insurance (FEGLI) coverage into retirement, do not apply for conversion. Employees (and
C coverage (if any). Your assignee(s) retain(s) the right to convert your other
assignees, if applicable) and their family members who are losing FEGLI coverage,
however, may be eligible and wish to convert some or all of their coverage to an individual
coverage(s).
direct-pay policy.
No medical examination is required.
You or the assignee(s), if applicable, must pay the premium applicable to
Employees - If you have not assigned your FEGLI coverage, you are entitled to convert to
the individual policy.
an individual direct-pay policy unless, within 3 calendar days after the date your insurance
The government will not pay any part of the individual policy premium.
terminates, you return to a Government position that qualifies you to reacquire FEGLI
The individual policy will be issued by an insurance company you select from
coverage. You may purchase an individual policy in an amount equal to or less than your
the list of eligible companies you will receive if you apply for conversion.
Basic life insurance plus any optional coverage you may have.
The individual policy may be an ordinary life policy or a variation of ordinary
life (see Part D). It must be a type of insurance customarily issued by the
Assignees - You are entitled to convert your share of the insured’s FEGLI
insurance company you select. However, it cannot be term insurance or
universal life insurance or any other form of life insurance that has an
coverage to an individual direct-pay policy unless, within 3 calendar days after the date the
indeterminate premium. It cannot have disability or accidental death and
insured’s insurance terminated, he/she returns to a Government position that qualifies
disemberment benefits.
him/her to reacquire FEGLI coverage. If that is the case, his/her previous assignment is still
valid. You may purchase an individual policy in an amount equal to or less than the amount
How to convert
of insurance which the insured assigned to you.
1. Complete the appropriate eligibility statement on the reverse side of this
Family members - If, upon termination of the employee’s FEGLI coverage,
form and mail it to the Office of Federal Employees' Group Life Insurance
he/she does not convert Option C-Family coverage (if any), you, as an eligible family
(OFEGLI), 200 Park Avenue, New York, NY 10166-0188.
member, may do so. Spouses may convert up to $5,000, and eligible children up to $2,500
2. If you have an SF 2821, Agency Certification of Insurance Status, attach
each. Eligible family members are the employee’s spouse and unmarried dependent
the original (Part 1) to this form when you mail it to OFEGLI. Note: Retiring
children under age 22 (including adopted children, stepchildren who lived with the
employees (and assignees of those employees) who are continuing Basic
employee in a regular parent-child relationship, and recognized natural children) and
Life insurance but converting one or more of the options should submit their
unmarried dependent children over age 22 who are incapable of self-support because of a
duplicate (Part 2) of the SF 2821 with this form to OFEGLI. The original
mental or physical disability that existed before they reached age 22.
(Part 1) of the SF 2821 should be submitted with the retirement application.
OFEGLI will mail you detailed information on how to apply for conversion,
Your time to convert is limited - You must mail your request for information
together with a list of eligible insurance companies. You have 31 days (from
the date in item 3 of Part A above, or the date you receive this notice,
regarding conversion within 31 days of the date in item 3 of Part A above,
whichever gives you more time) to request conversion information from
or within 31 days of the date you receive this notice, whichever gives you more time. If you
OFEGLI.
fail to request conversion information within the 31-day time limit due to a cause beyond
3. In the event you do not have an SF 2821, you should request a completed
your control, you may be allowed to convert your life insurance within six months after the
form from the employing agency before the expiration of your 31 day time
date in item 3, provided you attach a full explanation of what prevented you from making a
limit and forward it to OFEGLI at the address given in item 1 above.
timely request. If approved, the effective date of the conversion policy will be retroactive to
However, don't delay sending the SF 2819 requesting conversion
the day following the day group coverage ended.
information to OFEGLI -- send it anyway while you await the SF 2821.
Note: Under certain circumstances, life insurance is payable if death occurs within 31 days
4. If you are using this form to convert some of your life insurance coverage,
after the group life insurance terminates, regardless of whether conversion has been
but not Option C, have your employing office prepare another SF 2819 for
requested. However, extension of the conversion privilege beyond 31 days does not extend
your family members.
coverage under any circumstances. If death occurs within the 31-day period, further
5. Family members may apply for conversion by sending a completed SF 2819
information concerning possible benefits may be obtained from the agency named in item 6
(this form) to OFEGLI, 200 Park Avenue, New York, NY 10166-0188.
above.
(Note: Family members do not need an SF 2821.)
Part 2 - Forward with Retirement Papers/File in OPF
Office of Personnel Management
Standard Form 2819
FEGLI Handbook for Personnel and Payroll Offices
NSN 7540-01-231-5586
2819-102
Previous editions are not usable
Rev. May 1995
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