Form Cg 4113 PDF Details

In the intricate and sometimes unforeseen circumstances of service in the U.S. Coast Guard, preparing for every eventuality is paramount, and the CG-4113 form plays a crucial role in this preparation. As a comprehensive record of emergency data, it serves multiple purposes, ensuring that service members' personal information, prior military service, and family details are meticulously documented. It's designed to facilitate prompt and accurate notifications in case of emergencies or death, specify beneficiaries for gratuity payments, unpaid pay, and allowances, and detail insurance policies and survivor benefits plans. The form also enlists the names and relationships of those eligible to receive benefits, thereby streamlining the process of benefits distribution at critical times. The CG-4113, revised as of June 2004 and issued by the U.S. Department of Homeland Security, underscores the importance of readiness and thoroughness, reflecting the broader commitment of the Coast Guard to safeguard the welfare of its personnel and their families. This form not only serves as a testament to the meticulousness required in military documentation but also provides a safety net, ensuring that service members' last wishes and the well-being of their loved ones are honored and protected.

QuestionAnswer
Form NameForm Cg 4113
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names10a, 11a, SGLV, USC

Form Preview Example

U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-4113 (Rev. 6-04)

R E C O R D O F E M E R G E N C Y D A T A

SHIP OR STATION

1.SELECTIVE SERVICE BOARD(Enter number, location and date of first entry into Armed Services)

2.PRIOR MILITARY SERVICE (Check)

3. FORMER SERVICE NUMBERS AND BRANCH OF SERVICE

YES

NO

4. DATE OF BIRTH

5. RELIGION

Indicate by "X" in block opposite name, person(s) listed below who are NOT to be notified due to ill health. Include Zip Code in address.

6.

WIFE OR HUSBAND (If none, or deceased, so state)

6a. ADDRESS AND TELEPHONE NUMBER

7.

NAMES OF CHILDREN (Will be notified if no spouse survives or if children of other than present spouse)

7a. ADDRESS AND TELEPHONE NUMBER

MAR- SIN-

RIED GLE

SEX

BIRTHDATE

8.

FATHER

8a. ADDRESS AND TELEPHONE NUMBER

9.

MOTHER

9a. ADDRESS AND TELEPHONE NUMBER

10.

ADULT NEXT OF KIN NOT NAMED IN ANY OTHER ITEM

10a. ADDRESS AND TELEPHONE NUMBER

RELATIONSHIP

11.ALL PERSONS RECEIVING MORE THAN 50%

OF THEIR SUPPORT FROM ME (Other than wife or

children under 21)

11a. ADDRESS AND TELEPHONE NUMBER

BIRTHDATE

RELATIONSHIP

DESIGNATIONS (Include zip code in all addresses)

NAME (Principal Beneficiary)

ADDRESS

12. BENEFICIARY FOR GRATUITY

 

PAY IN EVENT THERE IS NO

 

SURVIVING SPOUSE OR

 

ELIGIBLE CHILDREN

 

NAME (Contingent Beneficiary)

ADDRESS

(Name parents or brother or sisters

 

only and indicate principal and

 

 

 

contingent beneficiary) (10 USC,

 

Section 1475-1480)

 

 

 

13. BENEFICIARY OR

 

 

NAME

ADDRESS

 

 

 

 

 

 

BENEFICIARIES

 

 

 

 

FOR UNPAID PAY

 

 

 

 

AND ALLOWANCE

 

 

%

 

(10 USC Section 2771)

 

 

 

 

 

 

 

(Percent of shares must

 

 

NAME

ADDRESS

total 100%)

 

 

 

 

 

 

14. PERSON TO

 

 

%

 

RECEIVE ALLOT-

 

% OF PAY NAME

ADDRESS

MENT OF PAY IF

 

MISSING OR

 

EACH MO.

 

 

 

 

 

UNABLE TO

 

 

 

 

TRANSMIT

 

 

 

 

FUNDS

 

 

 

 

 

 

 

 

 

RELATIONSHIP

RELATIONSHIP

RELATIONSHIP

RELATIONSHIP

RELATIONSHIP

15. INSURANCE POLICIES IN FORCE INCLUDING USGLI AND NSLI (Agencies to be notified in case of death in Active Service) (SEE PAGE 2)

PREVIOUS EDITIONS ARE OBSOLETE

PAGE 2 OF CG-4113 (Rev. 6-04)

BENEFICIARY DESIGNATION

The Record of Emergency Data (CG Form 4113) does not designate SGLI beneficiaries. Such designations are made by executing SGLV-8286. Members who do not have a completed SGLV-8286 in their record or who have completed it as indicated "By Law" thereon will, upon their death, have their SGLI proceeds paid under the provision of law in the following order: Widow(er), child(ren), parent(s), appointed executor or other next of kin. Beneficiary designations, including "By Law" designations, on SGLV- 8286 remain in effect until cancelled or changed by completion of a new SGLV-8286.

15.INSURANCE POLICIES IN FORCE INCLUDING USGLI AND NSLI (Agencies to be notified in case of death in Active Service)

(Check appropriate box)

SGLI $5,000

SGLI $30,000

SGLI $10,000

SGLI $35,000

SGLI $15,000

SGLI $50,000

SGLI $20,000

SGLI $100,000

SGLI $25,000

SGLI $200,000

NOT PARTICIPATING

FULL NAME AND ADDRESS OF COMPANY

ADDRESS OF OFFICE RECEIVING PAYMENT OR HOME OFFICE

POLICY NUMBER

16.SURVIVOR BENEFIT PLAN (Check one)

YES

NO

ELECTED CHANGED

REVOKED

DATE WITNESSED AND FORWARDED TO PERSONNEL AND MILITARY PAY CENTER

OPTION

ANNUITY

 

 

 

ANNUAL

CERTIFICATION

Item 6 through 16 Certified Correct.

19

 

APR 01

Member's Signature

 

 

Item 6 through 16 Certified Correct.

19

 

APR 01

Member's Signature

 

 

Item 6 through 16 Certified Correct.

19

 

APR 01

Member's Signature

 

 

Item 6 through 16 Certified Correct.

19

 

APR 01

Member's Signature

 

 

Item 6 through 16 Certified Correct.

19

 

APR 01

Member's Signature

 

 

Item 6 through 16 Certified Correct.

19

 

APR 01

Member's Signature

 

 

SIGNATURE OF DESIGNATOR

SIGNATURE AND TITLE OF WITNESS

DATE SIGNED

NAME OF DESIGNATOR

(Last, first, middle)

PRESENT SERVICE NO.

GRADE/RATE

SOCIAL SECURITY NUMBER

PRIVACY ACT STATEMENT

In accordance with 5 USC 552a(e)(3), the following information is provided to you when supplying personal information to the U.S. Coast Guard.

1.AUTHORITY which authorizes the solicitation of the information: 10 USC 1475-1480. 10 USC 2771.

2.PRINCIPAL PURPOSE(S) for which information is intended to be used: (1) Person(s) to be notified in case of emergency or death. (2) Person(s) to receive death gratuity, (3) Person(s) to receive unpaid pay and allowances (arrears in pay).

(4) Person(s) to receive allotment of pay if missing or enable to transmit funds. (5) Commercial insurance companies to be notified in case of death. (6) U.S. Government and National Service Life Insurance in force. (7) Servicemen's Group Life Insurance participation.

3.ROUTINE USES which may be made of the information: (1) To provide various agencies with information as to the person or persons eligible to receive benefits as the result of a member's death. (2) To provide immediate current information for casualty in a timely manner or delay or failure to pay certain death benefits.

4.DISCLOSURE of the information is voluntary, but failure to provide this information may result in the inability to notify the next of kin of a casualty in a timely manner or delay or failure to pay certain death benefits.

How to Edit Form Cg 4113 Online for Free

You'll be able to fill out USGLI instantly with the help of our online editor for PDFs. Our development team is relentlessly working to enhance the tool and make it even better for people with its multiple functions. Enjoy an ever-evolving experience now! For anyone who is seeking to get started, this is what it requires:

Step 1: First, open the pdf tool by clicking the "Get Form Button" above on this page.

Step 2: When you open the online editor, you will find the document prepared to be filled out. Besides filling in various blanks, you can also do various other things with the form, namely putting on custom textual content, editing the initial text, adding images, signing the document, and much more.

This form needs specific details; in order to ensure consistency, be sure to adhere to the next steps:

1. Start filling out the USGLI with a group of major fields. Collect all the required information and be sure absolutely nothing is forgotten!

The right way to fill in SGLV part 1

2. Once the previous segment is finished, you have to put in the essential details in MOTHER, a ADDRESS AND TELEPHONE NUMBER, ADULT NEXT OF KIN NOT NAMED IN, a ADDRESS AND TELEPHONE NUMBER, RELATIONSHIP, ALL PERSONS RECEIVING MORE THAN, OF THEIR SUPPORT FROM ME children, Other than wife or, a ADDRESS AND TELEPHONE NUMBER, BIRTHDATE, RELATIONSHIP, DESIGNATIONS Include zip code in, ADDRESS, NAME, and RELATIONSHIP so you're able to proceed to the third part.

Learn how to prepare SGLV stage 2

3. Your next stage is going to be straightforward - fill out all the empty fields in BENEFICIARY OR BENEFICIARIES FOR, PERSON TO, RECEIVE ALLOT MENT OF PAY IF, NAME, OF PAY EACH MO, NAME, ADDRESS, ADDRESS, RELATIONSHIP, RELATIONSHIP, and INSURANCE POLICIES IN FORCE to conclude the current step.

SGLV writing process detailed (part 3)

4. It's time to fill out this fourth part! In this case you'll have these INSURANCE POLICIES IN FORCE, SGLI, SGLI, SGLI, SGLI, SGLI, SGLI, SGLI, SGLI, SGLI, SGLI, NOT PARTICIPATING, FULL NAME AND ADDRESS OF COMPANY, ADDRESS OF OFFICE RECEIVING, and POLICY NUMBER empty form fields to fill out.

INSURANCE POLICIES IN FORCE, SGLI, and SGLI of SGLV

5. This document must be finished by going through this area. Further you will see a detailed listing of fields that need correct information for your form usage to be accomplished: NAME OF DESIGNATOR, Last first middle, PRESENT SERVICE NO, GRADERATE, SOCIAL SECURITY NUMBER, PRIVACY ACT STATEMENT, In accordance with USC ae the, AUTHORITY which authorizes the, PRINCIPAL PURPOSES for which, Persons to receive death gratuity, or death Persons to receive, ROUTINE USES which may be made of, eligible to receive benefits as, DISCLOSURE of the information is, and the next of kin of a casualty in a.

Filling in segment 5 of SGLV

Be extremely careful when filling out AUTHORITY which authorizes the and PRINCIPAL PURPOSES for which, since this is the part where a lot of people make errors.

Step 3: Revise all the information you've typed into the form fields and click on the "Done" button. Get your USGLI after you sign up for a 7-day free trial. Immediately gain access to the form inside your FormsPal account page, along with any modifications and changes automatically saved! Here at FormsPal, we endeavor to be sure that all your information is kept private.

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