Deceaseds Details

Form Fe 6 is an annual form that must be completed by all Massachusetts tax filers. The form is used to report your wages, salaries, and other compensation. Your employer will provide you with a copy of Form Fe 6, which you will need to complete and return to the IRS. Make sure to include all of your income on the form, including commissions and bonuses. If you have any questions about completing the form, consult your tax preparer.

Before you fill out form fe 6, you will need to learn more in regards to the type of form you will work with.

QuestionAnswer
Form NameForm Fe 6
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other names

Form Preview Example

Statement of Claim — Option C

Family Life Insurance

Federal Employees’ Group Life Insurance Program

Instructions

General

The Metropolitan Life Insurance Company (MetLife) pays claims for the Federal Employees’ Group Life Insurance (FEGLI) Program through its administrative office, the Office of Federal Employees’ Group Life Insurance (OFEGLI). “I” and “you” refer to the individual completing this form.

How do I complete this form?

Read the instructions carefully.

Please type or print legibly in ink.

Complete parts A, B, C, and page 3.

What else do I have to submit?

In addition to this claim form, you must send a certified copy of the deceased’s death certificate that contains the cause and manner of death. You can get the certificate from your city or state’s Bureau of Vital Statistics or equivalent agency. MetLife cannot process your claim until it receives the certified death certificate. MetLife will let you know if it needs anything else.

What should I do if I need help completing this form?

If you need help in completing this form, you may contact MetLife/OFEGLI’s customer service representatives, toll-free, at 1-800-OFE-GLIA (1-800-633-4542).

Where do I send this form and other documents?

Please do not send your claim form and other documents directly to MetLife/OFEGLI.

If you are an active employee, send everything to your employing office.

If you are retired or receiving Federal Workers’ Compensation benefits, send everything to:

Office of Personnel Management (OPM) Retirement Operations Center Attention: FE6-DEP

Boyers, PA 16017

How will I receive benefits?

If your claim is for less than $5,000, MetLife will mail you a check.

If your claim is for $5,000 or more, you must choose one of two payment options: (1) a check, or (2) a MetLife Total Control Account (TCA), an interest bearing account set up in your name and administered by MetLife. This account is not insured by the Federal Deposit Insurance Company (FDIC). The choice is yours. See Page 2 for details. See Page 3 to make your selection.

What should I do if I no longer want Option C-Family Life Insurance?

If you are an active employee, contact your employing office’s servicing human resources office.

If you are retired or receiving Federal Workers’ Compensation benefits, write to:

Office of Personnel Management (OPM)

Retirement Operations Center

Attention: Annuity Adjustment Section

Boyers, PA 16017

Please include your retirement or compensation claim number and be sure to sign your letter.

Instructions to the employing agency/retirement system

Complete Part D of this claim form.

If the claim requires that you determine eligibility for foster children or disabled children older than age 22, first review

the definitions on page 5 and then complete Part D of this claim form. Please note that MetLife does not need the background documentation.

Send the completed claim form and certified death certificate to: MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080

Do NOT use previous editions

Page 1

Form FE-6 DEP

Revised 'HFHPEH 2013

OFEGLI Form in Adobe Acrobat PDF (12/13)

Claim for Death Benefits

Federal Employees’ Group Life Insurance Program

Understanding Your Life Insurance Payment Options

If your claim is for less than $5,000, Metropolitan Life Insurance Company (MetLife) will mail you a check.

If your claim is for $5,000 or more, you have an important choice to make regarding how you wish to receive the payment. On Page 3, you must select one of two ways to receive your payment:

Check (mailed to you through the U.S. Postal Service)

MetLife Total Control Account (TCA) - an interest bearing account set up in your name and administered by MetLife.

The MetLife TCA is a settlement option offered by MetLife for the payment of claims. A MetLife TCA is not a checking, savings, or money market bank account. Since your MetLife TCA is not a bank account, it is not insured by the FDIC or any government agency. Instead, MetLife guarantees the full amount in your MetLife TCA, including all interest earned. MetLife’s guarantee is further backed by your respective state insurance guaranty association. Maximum guarantee limits vary from state to state and may change over time. If you choose a MetLife TCA, the relationship is between you and MetLife, not with the federal government or any of its agencies.

The MetLife TCA offers you a minimum guaranteed annual effective interest rate, meaning that MetLife commits to pay you at least that specified rate of interest on the money in the account. You begin earning interest the day the MetLife TCA is created. Interest is earned daily, but is not credited until the last day of the month. The interest rate offered on the MetLife TCA may be better or worse than the prevailing market rates. The MetLife TCA is a product offered by MetLife on which the company may make a profit. You pay no monthly maintenance fees on a MetLife TCA.

You have complete control of, and access to, the entire amount of your insurance proceeds. You can withdraw the full amount from the MetLife TCA at any time. The information packet you receive will include a draft book (similar to a checkbook). At any time and at no cost, you can write drafts (similar

to checks) from a minimum of $250 up to the full balance of your account. In addition, you will receive periodic activity statements, and you can designate a beneficiary for your account. If you choose the MetLife TCA settlement option, you will receive more detailed information when the account is opened.

Please keep pages 1 and 2 for your records

Do NOT use previous editions

Page 2

Form FE-6 DEP

Revised December 2013

MetLife OFEGLI Form in Adobe Acrobat PDF (12/13)

Claim for Death Benefits

Federal Employees’ Group Life Insurance (FEGLI) Program

Part 1: Select Method to Receive Your Payment

Please SELECT ONE method of settlement in order to receive your payment. By selecting below, you confirm that you have read the enclosed materials on both FEGLI payment options (Check and MetLife Total Control Account).

Check

Your payment will be sent via the U.S. Postal Service to the address you enter below.

MetLife Total Control Account (TCA)

You are eligible for a MetLife TCA if your payment is for $5,000 or more. MetLife TCA is not a bank account and is not FDIC-insured. See Page 2 for more details.

lf no box is checked above (and your payment is $5,000 or more), a MetLife Total Control Account will be established in your name and your payment will be deposited on your behalf.

Part 2: Enter the Following Information to Receive Payment

Please complete, in ink, the information below. This information is needed to send you a check or to open your MetLife Total Control Account. Even if this information is provided elsewhere on this form, you must also provide it here.

Your signature

Your name (please print)

Address (number, street, apartment number)

City, State, ZIP Code

Your Social Security Number

 

 

 

 

 

 

 

 

 

 

or

 

 

 

 

 

 

 

 

 

 

Estate/Trust/Tax ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date (mm/dd/yyyy)

Daytime telephone number

 

 

Evening telephone number

 

(

)

 

 

(

)

 

 

 

 

Area Code

 

 

Area Code

Please return pages 3 through 5 to OFEGLI

Do NOT use previous editions

Page 3

Form FE-6 DEP

Revised December 2013

MetLife OFEGLI Form in Adobe Acrobat PDF (12/13)

Statement of Claim — Option C

Family Life Insurance

Federal Employees’ Group Life Insurance (FEGLI)

Part A. Information about You

 

1.

Your name

 

 

(Last)

 

 

 

 

(First)

 

(Middle)

 

 

 

2. Date of birth (mm/dd/yyyy)

3. Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Department or agency in which last employed, including bureau or division

 

 

 

5. Location of last employment

(City, state, ZIP code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Are you retired and receiving a monthly annuity under any Federal civilian retirement system?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If “Yes”, provide the Claim number (CSA, CSF, CSI)____________________________________

 

 

 

Yes

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Special Note: Social Security monthly payments are not Federal civilian retirement annuities.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If “Yes”, provide the effective date of Retirement ______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part B. Information about the Deceased Family Member

 

1.

 

Deceased’s full name

(Last)

 

 

 

(First)

 

(Middle)

 

 

 

2. Date of birth (mm/dd/yyyy)

 

 

 

 

3. Date of death (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Items 4 through 9 if this claim is for your spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

Date of marriage (mm/dd/yyyy)

5.

Place of marriage (City and state)

 

 

 

 

 

 

 

 

 

 

 

6. Marriage was performed by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clergy or Justice of the Peace

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify)________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Were you living with the

 

 

8.

Were you divorced from the deceased

 

9. If you were divorced

from the deceased, give the date (mm/dd/yyyy)

 

 

 

deceased at the time of death?

 

 

at the time of death?

 

 

 

 

 

and place of the divorce. (City and state)

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete Items 10 through 13 if this claim is for your child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Child’s marital status

 

11. Child’s relationship to you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foster child

 

 

 

 

 

 

Single

 

 

 

 

 

 

 

 

Legitimate child

 

 

 

 

 

 

Stepchild

 

 

 

 

 

 

 

Disabled dependent child 22 yrs. or over

 

 

 

 

 

 

Married

 

 

 

 

 

 

 

 

Adopted child

 

 

 

 

 

 

Recognized natural child

 

 

 

Other (Specify) ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. If the deceased was a stepchild,

recognized natural child, or foster child

 

 

 

 

13. If the deceased was a recognized natural child and was not living with

 

 

 

was the child living with you at the time of death?

 

 

 

 

 

 

 

 

you at the time of death, did you provide financial support for the child?

 

 

 

 

 

 

 

Yes

 

 

No (Explain on separate sheet)

 

 

 

 

 

 

 

 

 

 

Yes

 

No (Explain on separate sheet)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part C. Your Certification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If your claim is for less than $5,000, MetLife will mail you a check.

 

Your name (Please print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If your claim is for $5,000 or more, you must choose one of two

 

________________________________________________________________

 

 

payment options. See Page 2 for details. See Page 3 to make your

 

Address (Number, street, apt. no.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

selection.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEGLI death benefits are not subject to Federal income tax, but the

 

________________________________________________________________

 

 

 

City, State, ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

interest that MetLife pays on those benefits is subject to such tax.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MetLife will report all interest payments to the Internal Revenue

 

________________________________________________________________

 

 

Service.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Social Security Number

 

 

or

 

Estate / Trust / Tax ID Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Under penalty of perjury, I certify:

1. That the number shown on this form is my correct taxpayer identification number; and

2. That I am NOT subject to backup withholding because: (a) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (b) the IRS has notified me that I am no longer subject to backup withholding.

If you are currently subject to backup withholding, check this box:

 

 

3. I am a U.S. citizen or a U.S. resident for tax purposes.

Check one:

Yes

No

If you are not a U.S. citizen or resident for tax purposes, we will send you a W-8BEN that you are required to complete to certify your foreign status.

The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

_____________________________________________________

( ______ ) ___________________ ( ______ ) ___________________

My signature (Do not print)

Area Code Daytime telephone no.

Area Code Evening telephone no.

Warning – If you knowingly and willfully make any materially false, fictitious or fraudulent statement or representation on this form, or conceal a material fact related to the requests for information on this form, you may be subject to a monetary fine or imprisonment for not more than five years, or both, under 18 U.S.C. 1001.

Do NOT use previous editions

Page 4

Form FE-6 DEP

Revised December 2013

OFEGLI Form in Adobe Acrobat PDF (12/13)

Part D. Employing Agency/OPM Certification of Insurance Status

Employing agency completes items 1, 2 and 4 through 8 for Active Employees

OPM completes all items 1 through 8 for Retirees and Compensationers

1. Did the insured have Option C on the date of death of the family member?

No

 

Yes

 

If “Yes” provide effective date of election _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

If “Yes” mark the box to show the number of multiples

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

 

3

 

4

 

5

 

2.Did the insured indicate in Part B - Item 11 that the deceased was a foster child or disabled dependent child?

No

Yes

If “Yes” do you certify that the child qualifies for Option C coverage?

No

Yes

If the insured is retired or receiving compensation, complete items 3a. through 3c.

3a. What is the effective date of the insured’s retirement or receipt of compensation? ____________________

(mm/dd/yyyy)

3b. What is the insured’s date of birth? _____________________

(mm/dd/yyyy)

3c. What was the insured’s Option C election?

Number of multiples for full reduction

1

 

 

Number of multiples for no reduction

1

2

2

3

3

4

4

5

5

4.Agency Name

_______________________________________________

_______________________________________________

Agency Telephone Number

( ________ ) ____________________

Area Code

5.Agency Mailing Address

_______________________________________________

_______________________________________________

Number, Street

_______________________________________________

City, State, ZIP code

I certify that the information I gave in Part D of this form is correct and that I obtained it from the employee’s/retiree’s/compensationer’s official records.

6.Name of authorized agency official (Please print)

__________________________________________

7.Signature of authorized agency official (Do not print)

__________________________________________

8. Date signed

___________________________________________

(mm/dd/yyyy)

Send this completed claim form and certified death certificate to: MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080

Definition of Terms

Disabled dependent child age 22 years or over means a child who was incapable of self-support because of a mental or physical disability that existed before the child became 22 years of age.

Foster child means a child living with you in a regular parent-child relationship where you are the primary source of financial support for the child and expect to raise the child to adulthood. A child placed in your home by a welfare or social service agency under an agreement where the agency retains control of the child or pays for maintenance does not qualify as a foster child. Grandchildren, as such, are not eligible family members. However, grandchildren can qualify as foster children if they meet all of the requirements.

Recognized natural child means a child born out of wedlock whom you recognized as your child during the child’s lifetime. In addition, at the time of the child’s death, he/she must have either lived with you in a regular parent-child relationship or been dependent on you financially.

Regular parent-child relationship means that you exercise parental authority, responsibility, and control over the child by caring for, supporting, disciplining, and guiding the child, including making decisions about the child’s education and health care.

If you have any questions concerning your child’s eligibility for coverage, you must contact your employing agency or retirement system, and not MetLife/OFEGLI.

Do NOT use previous editions

Page 5

Form FE-6 DEP

Revised December 2013

OFEGLI Form in Adobe Acrobat PDF (12/13)

MetLife’s TCA (“Total Control Account”) is a settlement option for the payment of claims. The TCA is not a checking, savings or money market account from a bank. If you receive your life insurance proceeds by TCA, your customer relationship is with MetLife, not the Federal government or any of its agencies.

The Total Control Account® Settlement Option Features

INTEREST

TCA eams interest from the date it is established. The rate credited to your TCA will never fall below the annual effective interest rate guaranteed in your Customer Agreement issued to you when proceeds are paid through a TCA, and will equal or exceed the rate established by one of the following indices: the prior week’s Money Fund Report AveragesTM/Government 7-Day Simple Yield or the Bank Rate MonitorTM National Money Market Rate Index.

Interest is compounded daily and credited monthly to your TCA. (Generally, the interest you are paid will be subject to income tax. You should consult your own tax advisor about your particular circumstances.)

METLIFE TCA FINANCIAL SECURlTY

The assets backing the TCA are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCA, and expects to receive a profit. Regardless of the investment experience of such assets, the interest credited to your TCA will never fall below the rate guaranteed in your Customer Agreement. Call 1-800-METSAVE (1-800-638-7283) for your guaranteed annual effective interest rate.

The TCA is not insured by the FDIC (“Federal Deposit Insurance Corporation”) or any government agency. However, the entire amount of your TCA, including all interest paid to you, is fully guaranteed by the financial strength and claims paying ability of MetLife. MetLife’s guarantee is further backed by your respective state insurance guaranty association. Maximum limits vary from state to state and may change over time. MetLife’s obligation to pay the total policy proceeds is satisfied by depositing such proceeds in your TCA.

IMMEDIATE ACCESS TO FUNDS AND FLEXIBILITY

You can withdraw all or part of your TCA balance immediately or at any time thereafter, without penalty or loss of interest.

There are no limits on the number of drafts you can write each month.

You can name a beneficiary to receive your TCA balance, in case something happens to you.

NO MONTHLY MAINTENANCE FEES

There are no monthly maintenance fees for the TCA, and no charges for withdrawals, drafts or reordering drafts.

You can write drafts from a minimum amount of $250 up to the full amount in your TCA at any time.

Please note: automatic electronic fund transfers, electronic bill payments, and phone payments are not available from the TCA.

You may be charged a fee for special services. The current special servicing fees are:

Draft Copy: $2.00

Stop Payment: $10.00

Wire Transfer: $10.00

Overdrawn TCA: $15.00

These fees may be subject to change in accordance with the terms of the TCA Customer Agreement.

METLIFE TCA FEATURES AND RELATED SERVICES

When a claim is paid through a TCA, you’ll receive a TCA Starter Kit with information about TCA, a draftbook, and a Customer Agreement specifying your guaranteed annual effective interest rate.

MetLife sends each account holder a quarterly statement regarding account balances and activity. Statements are also sent monthly if there has been withdrawal activity in the account.

Dedicated customer service representatives are within easy reach to answer any questions you may have about your TCA. You will be provided with a toll-free customer service number with your starter kit materials.

TIME TO DECIDE

TCA provides you with interest on your funds while you take the time to decide how to best use your proceeds.

Your rights to elect other MetLife settlement options are preserved. You may, at any time, place some or all of your TCA balance in any other available option.

You will receive information on settlement options which are available to you along with your TCA Starter Kit.

If the proceeds payable to you are less than $5,000, or you reside in a foreign country, or the claimant is a corporation or similar entity, payment is usually made by a single, lump-sum check. Proceeds payable to minors will either be paid to the appropriate guardian or held by MetLife until age of majority.

Total Control Account® is a registered service mark of Metropolitan Life Insurance Company

 

Form TCA-FEATURES

 

Revised February 2011

Do NOT use previous editions

MetLife OFEGLI Form in Adobe Acrobat PDF (02/11)

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