Form Sf 2817 PDF Details

Embarking on a new job or making changes to existing benefits can often involve navigating through a multitude of forms and administrative procedures, particularly for federal employees facing decisions about their life insurance coverage. At the heart of these decisions is the SF 2817 form, a crucial document that governs the election of life insurance under the Federal Employees' Group Life Insurance (FEGLI) Program. This form serves as a vehicle for employees to clearly articulate their choices regarding their life insurance coverage, ensuring that their preferences are officially recorded and executed. It outlines options not only for basic life insurance, which is automatically enacted unless explicitly waived, but also for additional layers of coverage that employees might elect based on their individual needs and circumstances. With provisions for designating the extent of coverage through Optional insurance - including Standard, Additional, and Family options - the form encapsulates a range of decisions from maintaining the default basic insurance to tailoring a more comprehensive plan. What makes SF 2817 particularly significant is its finality; elections made on this form supersede previous ones, marking a critical juncture in an employee's benefit selection process. Furthermore, the form provides guidelines on how life-changing events or transitions, such as a break in service or reappointment, might affect an employee's eligibility and choices moving forward. Additionally, for those electing to part ways with all coverage, it underlines the implications such decisions may have, especially regarding future eligibility and the potential impact on retirement benefits. Notably, the form also serves an educational purpose, directing employees to substantial resources like the FEGLI Program Booklet for a deeper understanding of the choices available to them, thereby emphasizing the importance of informed decision-making regarding one’s life insurance coverage.

QuestionAnswer
Form NameForm Sf 2817
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other names2817 life, sf 2817 pdf, form sf 2817, sf 2818

Form Preview Example

*This election supersedes all previous elections.*

 

Life Insurance Election

Form Approved:

 

OMB No. 3206-0230

 

Federal Employees' Group Life Insurance Program

Federal Employees'

 

See Privacy Act Statement on back of Part 3

 

Group Life Insurance

 

 

 

1General Instructions

By law, unless you waive all coverage or are ineligible, you are automatically covered for Basic life insurance as an employee. When you first become eligible for FEGLI, you may (1) do nothing and have Basic automatically,

(2)elect Basic and any or all of the options, or (3) waive all life insurance coverage. If you are changing a previous election, see the back of Part 3 - Employee Copy.

.Read the back of Part 3 - Employee Copy carefully.

.Assignees completing this form should read Items 5 and 6 on the

back of Part 3.

.Give all parts of your completed form to your employing office. Your employing office will complete Section 6 of this form (or its electronic equivalent) and return your copy to you.

Fill in identifying information concerning the employee.

 

 

 

2

 

 

 

 

 

Name (last, first, middle)

 

Date of birth (mm/dd/yyyy)

Social Security Number

 

 

 

 

 

 

 

Employing department or agency

OWCP claim number,

Location of department or agency where you

Daytime telephone number

 

 

if applicable

work (city, state, ZIP code)

 

(including area code)

 

 

 

 

 

 

3To elect or retain Basic, sign and date below. If you do not sign for Basic, you (or your assignee) may not elect or retain any form of optional insurance. If you do not want any insurance at all, skip to Section 5.

I want Basic. I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)

 

 

Basic

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of

Date (mm/dd/yyyy)

 

 

attorney are not valid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS you have previously waived any or all

 

of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI Program Booklet). Sign the

Optional

box(es) below for any option(s) you are eligible for and wish to elect or retain. If you do not sign for an option, you have waived it and your future

 

 

 

opportunities to enroll in it are strictly limited.

 

 

 

 

 

 

 

 

 

 

 

You will not be covered for any option(s) for which you do not sign below, regardless of whether you previously elected the option(s).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Option A - Standard

 

 

Option B - Additional

 

 

Option C - Family

I want Option A.

 

 

I want Option B in the multiple of my annual basic pay I

I want Option C in the multiple I indicate below.

I authorize deductions to pay the full cost.

indicate below. I authorize deductions to pay the full cost.

I understand that each multiple is worth $5,000 upon

 

 

 

 

 

 

 

 

 

 

the death of my spouse, and $2,500 upon the death of an

 

 

 

 

 

 

 

 

 

 

eligible child. I authorize deductions to pay the full cost.

 

 

 

 

 

 

 

 

 

3 times my pay

 

 

 

 

3 multiples

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 times my pay

 

4 times my pay

 

 

1 multiple

 

4 multiples

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 times my pay

 

5 times my pay

 

 

2 multiples

 

5 multiples

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE (Do not print. Only you or your assignee

SIGNATURE (Do not print. Only you or your assignee

SIGNATURE (Do not print. Only you or your assignee

may sign. Signatures by guardians, conservators or

may sign. Signatures by guardians, conservators or

may sign. Signatures by guardians, conservators or

through a power of attorney are not valid.)

through a power of attorney are not valid.)

through a power of attorney are not valid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

5If you want NO life insurance coverage, sign and date below.

I want NO life insurance coverage. I understand that any life insurance I have will stop at the end of the last day of the pay period in which my

employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form and submit Waiver of satisfactory medical information, or (2) I experience a life event, or (3) I have a break in Federal service of at least 180 days, or (4) I participate in an

 

 

all life

open season, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand that my decision to

 

 

insurance

waive life insurance coverage now may affect my eligibility for coverage as a retiree.

 

 

 

 

 

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through

Date (mm/dd/yyyy)

 

 

coverage a power of attorney are not valid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Remarks:

 

 

If new/newly eligible employee,

6Use

 

 

 

 

enter "0" for event.

 

 

 

 

Number of event permitting

 

Name and address of employing office

Date received in employing office

Effective date of coverage

change

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

(See back of Part 2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I followed the instructions on the back of Part 1.

Signature of authorized agency official

The employee's copy of this form, when completed by the employing office, together with the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees)

constitute the employee's Certificate (proof) of Insurance.

U.S. Office of Personnel Management

 

 

Standard Form 2817

 

 

www.opm.gov/insure/life

Previous edition is not usable.

Revised November 2011

Instructions for Agencies

1.Who Should File This Form?

New employees eligible for life insurance who want optional insurance or no insurance. Note: New employees who want only Basic do not have to file.

Employees appointed to positions that allow life insurance coverage following service in positions that did not allow life insurance coverage.

Employees who want to change their life insurance.

Reinstated employees who filed a previous waiver of any type of life insurance, were separated from service for at least 180 days, and wish to elect coverage.

An employee who is already enrolled in Option B and/or Option C may elect from 1 to 5 multiples (up to 5 total) within 60 days based on the life event.

3.What Should You Review After The Employee Submits This Form?

Review all three parts of the SF 2817 to see that they are legible and complete. If an employee signs the box for Option A, Option B, or Option C, he or she must also sign Section 3, Basic. If the employee uses a downloaded copy, be sure all parts are completed. Contact the employee if any part is unclear.

Assignees who want to decrease or cancel coverage.

Department of Defense employees designated "emergency essential" and civilian employees deployed in support of a contingency operation per Public Law 110-417.

Give a new employee a copy of the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) when he or she reports for duty and ask the employee to return the completed SF 2817 as soon as possible (preferably before the end of the first pay period), but no later than 60 days after his or her appointment.

Employees with prior government service in non-excluded positions who were separated after March 31, 1981, should have an SF 2817 on file in their personnel folders, and that election or waiver of coverage may still be in effect. Do not accept a new SF 2817 unless the employee has a break in Federal service of at least 180 days or is eligible to cancel a previous waiver that has been in effect for at least one year, or wishes to reduce coverage.

Until you verify an employee's SF 2817 on file, make deductions based on his or her statement about earlier insurance coverage. Once coverage is confirmed, make any necessary adjustments to correct the withholdings.

An employee may at any time file an SF 2817 to waive or reduce coverage, unless the employee has assigned his/her insurance coverage. If the employee has assigned the insurance, only the assignee(s) may waive or reduce the coverage (except for Option C which cannot be assigned).

2.How Else Can An Employee Elect More Coverage?

Provide Medical Information. An employee may elect or increase Basic, Option A, or Option B insurance (but not Option C), if a previously completed SF 2817 waiving coverage has been in effect for more than one year, by submitting satisfactory evidence of insurability via a Request for Insurance, SF 2822. If approved, the employee should make the election on the SF 2817 and submit to the employing agency. More details are contained on the SF 2822.

Experience A Qualifying Life Event. An employee may elect Basic, Option A, Option B and/or Option C within 60 days following a FEGLI qualifying life event. These events are: marriage, divorce, spouse's death, or the acquisition of an eligible child.

For Option B and Option C, an employee may elect from 1 to 5 multiples (up to 5 total) based on the life event.

Only the employee may sign this form in Sections 3, 4, or 5, with one exception (noted below). Signatures by guardians, conservators, or through a power of attorney are NOT valid.

Exception: If the employee assigned the insurance, only the assignee(s) may waive or reduce some or all of the employee's coverage. In that case, the assignee(s) must sign the form (although the information in Section 2 must refer to the employee). Please note that assignees cannot increase the employee's coverage. Only the employee can do that.

The employee is solely responsible for ensuring that the SF 2817 accurately reflects his or her intentions.

If the employee is electing new coverage, always make sure that the authorized agency official confirms that the employee is eligible for the coverage, and that the official signs the form in Section 6.

4.When Did You Receive This?

Enter the date the employing office received this form.

5.What Is The Event Permitting The Change?

Enter the number of the event permitting a change, if applicable. See the Table of Effective Dates on the back of Part 2 for event numbers.

6.What Is The Effective Date Of The Coverage?

Enter the effective date of coverage. For new and newly eligible employees: Basic is effective on the first day the employee is in a pay and duty status; Optional coverage is effective on the first day the employee is in a pay and duty status on or after the day the employing office receives the SF 2817. For changes in elections, see the Table of Effective Dates on the back of Part 2. If there is more than one effective date for this election, the 2nd effective date should be notated in Part 6 under "Remarks."

7.What Do You Do With Parts 1, 2, and 3?

After completion, give Part 3 to the employee. File Part 1 in the employee's personnel folder. Destroy Part 2 after payroll office use. Part 3, and the FEGLI Program Booklet (FE 76-21, or FE 76-20 for U.S. Postal Service employees), serve as the employee's certificate of insurance.

8.Where Can You Find More Information?

Consult the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) or the FEGLI Handbook, which are available on the FEGLI web site at www.opm.gov/insure/life.

Back of Part 1

Standard Form 2817

 

Revised November 2011

Life Insurance Election

Federal Employees' Group Life Insurance Program

Form Approved: OMB No. 3206-0230

Federal Employees' Group Life Insurance

1

INSURANCE

SF 50

INELIGIBLE

A0

0000

B0

 

1000

C0

 

1100

D0

 

1001

E1

 

1002

E2

 

1003

E3

 

1004

E4

1005 E5

1101 F1

1102 F2

1103 F3

1104 F4

1105 F5

1010 G0

1110 H0

1011 I1

1012 I2

1013 I3

1014 I4

1015 I5

1111 J1

1112 J2

1113 J3

SF 50 Equivalents of Insurance Codes

1114

J4

1025

M5

1031

Q1

1115

J5

1121

N1

1032

Q2

1020

K0

1122

N2

1033

Q3

1120

L0

1123

N3

1034

Q4

1021

M1

1124

N4

1035

Q5

1022

M2

1125

N5

1131

R1

1023

M3

1030

90

1132

R2

1024

M4

1130

P0

1133

R3

 

 

 

 

 

 

1134 R4

1135 R5

1040 S0

1140 T0

1041 U1

1042 U2

1043 U3

1044 U4

1045 U5

1141 V1

1142 V2

1143 V3

1144 V4

1145 V5

1050 W0

1150 X0

1051 Y1

1052 Y2

1053 Y3

1054 Y4

1055 Y5

1151 Z1

1152 Z2

1153 Z3

1154 Z4

1155 Z5

Fill in identifying information concerning the employee.

 

 

 

2

 

 

 

 

 

Name (last, first, middle)

 

Date of birth (mm/dd/yyyy)

Social Security Number

 

 

 

 

 

 

 

Employing department or agency

OWCP claim number,

Location of department or agency where you

Daytime telephone number

 

 

if applicable

work (City, state, ZIP Code)

 

(including area code)

 

 

 

 

 

 

3In item 7: If this block is not signed, enter 0 in ALL FOUR boxes. If this block is signed, enter 1 in box 1.

Basic

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a power of

Date (mm/dd/yyyy)

attorney are not valid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

Option A - Standard

 

 

Option B - Additional

 

 

Option C - Family

In item 7, box 2:

In item 7, box 3:

 

 

In item 7, box 4:

 

 

If this block is not signed, enter 0

If this block is not signed, enter 0

If this block is not signed, enter 0

If this block is signed, enter 1.

If this block is signed, enter the number marked "X"

If this block is signed, enter the number marked "X"

 

 

below.

 

 

below.

 

 

 

 

 

 

 

 

3 times my pay

 

 

 

 

3 multiples

 

 

 

 

1 times my pay

 

4 times my pay

 

 

1 multiple

 

4 multiples

 

 

 

 

 

 

 

 

 

 

 

 

2 times my pay

 

5 times my pay

 

 

2 multiples

 

5 multiples

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE (Do not print. Only you or your assignee

SIGNATURE (Do not print. Only you or your assignee

SIGNATURE (Do not print. Only you or your assignee

may sign. Signatures by guardians, conservators or

may sign. Signatures by guardians, conservators or

may sign. Signatures by guardians, conservators or

through a power of attorney are not valid.)

through a power of attorney are not valid.)

through a power of attorney are not valid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

5

 

If you want NO life insurance coverage, sign and date below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In item 7: If this block is signed, enter 0 in ALL FOUR boxes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Waiver of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

all life

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a

Date (mm/dd/yyyy)

 

 

 

coverage

power of attorney are not valid.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency

Remarks:

 

 

 

 

 

 

 

 

 

 

 

If new/newly eligible employee,

6Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enter "0" for event.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of event permitting

 

 

Name and address of employing office

 

Date received in employing office

Effective date of coverage

 

change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

(mm/dd/yyyy)

 

 

 

(See back of Part 2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I followed the instructions on the back of Part 1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of authorized agency official

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

INSTRUCTIONS: Enter codes in the boxes on the right as directed in items 3, 4 and 5 above.

 

 

 

Insurance Code

 

 

SF 50

 

 

 

 

 

 

 

 

1

2

 

3

 

4

 

Equivalent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Office of Personnel Management

PART 2 - For Agency Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Standard Form 2817

www.opm.gov/insure/life

 

 

Previous edition is not usable.

 

Revised November 2011

Table of Effective Dates: Changes in Life Insurance Coverage

Deductions: Begin, increase, stop or decrease in the same pay period in which coverage begins, increases, stops, or decreases.

Event Allowing Change

Change Permitted? (To elect any option, employee must elect or retain Basic)

Basic

Option A - Standard

Option B - Additional

Option C - Family

 

 

 

 

0.New/Newly Eligible Employee:

Yes. See "Instructions to Agencies", #5, back of Part 1.

Yes. Same as Basic.

Yes. Same as Basic.

Yes. Same as Basic.

1.PROVIDING MEDICAL

INFORMATION: Approval of Request for Insurance (SF 2822) by the Office of Federal Employees' Group

Life Insurance (OFEGLI).

2.LIFE EVENT: Marriage, divorce, death of spouse, or acquisition of an eligible child.

3.REINSTATEMENT: Employee is reinstated after a break in service of at least 180 days in a position that is not excluded from life insurance by law or regulation.

4.REINSTATEMENT: Employee is reinstated after a break in service of at least 180 days in a position that is excluded from life insurance by law or regulation.

5A. CANCELING/

WAIVING

COVERAGE:

employee/assignee

or

5B. REDUCING

OPTION B and/or

OPTION C

MULTIPLES:

employee/assignee

6.Open Season.

7.CERTAIN DEPT. OF DEFENSE AND CIVILIAN EMPLOYEES AFFECTED

BY PUBLIC LAWS

106-398 AND 110-417:

Yes. Coverage is automatically effective the first day the employee is in a pay and duty status on or after date of OFEGLI's approval.

Time Limit - on or after OFEGLI's date of approval. If employee is not in a pay and duty status within 60 days, Basic does NOT become effective, and the employee must start over.

Yes. Coverage is effective the day of the event if the SF 2817 is received before the event and the employee is in pay and duty status on the day of the event. Otherwise, Coverage is effective the first day in pay and duty status after the event and after receipt of the SF 2817.

Time Limit - Agency must receive the SF 2817 and proof of the event within 60 days after the day of the event.

Yes. Coverage is effective on the first day the employee is in a pay and duty status, unless waived by employee.

No. However, if employee is later converted to a non-excluded position, the coverage is effective on the first day the employee is in a pay and duty status on or after being converted to such a position.

A.Yes. If the coverage is canceled in the first pay period, no premiums are due. Otherwise, coverage stops at the end of the last day of the pay period in which the agency receives the SF 2817, with no 31-day extension of coverage.

Time Limit - None. Employee may cancel coverage at any time. However, if the insurance is assigned, only the assignee(s) may cancel

B.Not applicable.

If permitted under conditions specified by OPM.

Yes, if employing agency determines employee meets criteria to elect coverage. Coverage is effective the first day the employee is in a pay and duty status on or after the date the agency receives the SF 2817.

Time Limit - Agency must receive the SF 2817 within 60 days of the date the employee receives official notice of deployment in support of a contingency operation or designation as an emergency essential employee.

Yes. Coverage is effective the first day the employee is in

Yes. Same as Option A.

No. An employee may NOT elect Option C by

a pay and duty status on or after the date of OFEGLI's

 

providing medical information.

approval and the agency receives the SF 2817.

 

 

Time Limit - Employee must submit the SF 2817 and be

 

 

in a pay and duty status within 60 days after date of

 

 

OFEGLI's approval. If employee is not in a pay and duty

 

 

status or doesn't submit the SF 2817 within those 60 days,

 

 

Option A does not become effective, and the employee

 

 

must start over.

 

 

Yes. Same as Basic.

Yes. Same as Basic.

Yes. Employee may elect or increase multiples (up to 5

 

 

total). If the employee has Basic, Coverage is effective

Coverage - Same as Basic.

Employee may elect or increase multiples (up to 5 total).

the day the employing office receives the election, or the

 

 

date of the event, whichever is later. If Basic and Option

Time Limit - Same as Basic.

Coverage - Same as Basic.

C are elected at the same time, Option C is effective

 

 

when Basic becomes effective.

 

Time Limit - Same as Basic.

 

 

 

Time Limit - Same as Basic.

 

 

(Note: If the employee already has Basic, there is no pay

 

 

and duty status requirement for Option C.)

 

 

 

Yes. Employee may elect Option A within 60 days after

Same as Option A.

Same as Option A.

reinstatement. However, if employee does not submit

 

 

SF 2817 electing coverage within 60 days after

 

 

reinstatement, s/he has the same Optional

 

 

insurance carried before the break in service

 

 

effective the beginning of the reinstatement.

 

 

 

 

 

No. However, if employee is later converted to a

Same as Option A.

Same as Option A.

non-excluded position, the coverage is effective on the first

 

 

day the employee is in a pay and duty status in the

 

 

converted position on or after the date the agency receives

 

 

the SF 2817 electing such coverage.

 

 

Time Limit - Employee must submit the SF 2817 within 60

 

 

days after conversion to an eligible position.

 

 

 

 

 

A.Same as Basic.

A. Same as Basic.

A. Same as Basic.

 

 

Option C cannot be assigned.

 

 

If Option C is canceled because there no longer are

 

 

eligible family members, the effective date is

 

 

retroactive to the end of the pay period in which

 

 

there no longer are any eligible family members.

 

 

The employing agency must refund Option C

 

 

premiums retroactive to that effective date.

B. Not applicable.

B.Yes. Employee may at any time reduce the number

B.Yes. Employee may at any time reduce the number

 

of multiples, unless the insurance has been assigned.

of multiples. This new coverage is effective at

 

In that case, only the assignee(s) may reduce coverage

the beginning of the pay period following the

 

– the employee may not. This new coverage is

one in which the employing office receives the

 

effective at the beginning of the pay period following

SF 2817. Assignee(s) cannot reduce Option C.

 

the one in which the employing office receives the

 

 

SF 2817.

 

Same as Basic.

Same as Basic.

Same as Basic.

 

 

 

Same as Basic.

Same as Basic.

No. An employee may NOT elect Option C via these

 

Employee may elect or increase multiples (up to 5

provisions of law.

 

 

 

total).

 

 

 

 

Back of Part 2

STANDARD FORM 2817, REVISED NOVEMBER 2011

Instructions for Employees

1.General Information

The major provisions of this program are described in the Federal Employees' Group Life Insurance (FEGLI) Program Booklet (FE 76-21

or FE 76-20 for U.S. Postal Service employees). Please read the entire booklet carefully. Your completed copy of this election form (SF 2817) and the FEGLI Program Booklet constitute your certificate (proof) of insurance. These publications, as well as comprehensive FEGLI information, are available at www.opm.gov/insure/life.

2.I Am A New Employee or Newly Eligible for Life Insurance. What Do I Need To Know?

You are automatically enrolled in Basic (even if you don't complete this form) unless you waive it. If you waive Basic, you automatically waive all forms of Optional insurance. You will not have any Optional insurance unless you elect it.

To elect Basic: You do not have to submit this form unless you also wish to elect Optional insurance.

To waive Basic: Sign Section 5 of the form and give it to your employing office. Your agency will withhold Basic premiums from your salary from your first day at work in a pay status UNLESS you submit your waiver before the end of your first pay period.

To elect Optional: Sign Section 3 and one or more of the blocks in Section 4 of the form and give it to your employing office within 60 days after the date you are appointed or first become eligible for life insurance.

To waive Optional: If you do not sign for a particular type of Optional coverage in Section 4, you automatically waive that coverage.

3.I Am An Employee With Prior Government Service. What Do I Need To Know?

When you return to work after a break in service of less than 180 days, your human resources office will automatically enroll you in the same coverage that you had before you left your prior position, if any. This coverage will be effective on your first day in a pay and duty status in a FEGLI eligible position. You will have to qualify to elect other coverage (open season, providing medical information, or a life event). If you waived some coverage, then the waiver of that coverage is still in effect.

When you return to work after a break in service of 180 days or more, your human resources office will automatically enroll you in Basic and the same Optional insurance that you had in your prior position. This coverage will be effective on your first day in a pay and duty status in a FEGLI eligible position. You may elect more insurance (if you don't already have the maximum) within 60 days of your appointment to an eligible position. If you previously waived coverage then that waiver is no longer in effect. You will automatically be enrolled in Basic, unless you file a new waiver.

See the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service Employees) for more details.

4.I Am A Reemployed Annuitant. What Do I Need To Know? If you waive your insurance when you return to Federal Service as a reemployed annuitant, you also waive your insurance with your retirement annuity. You will have no FEGLI life insurance. It is important that you contact your human resources office and inform them that you are a reemployed annuitant. More details can be found in OPM Form 1482, Agency Certification of Status of Reemployed Annuitants.

5.What If I Assigned My Coverage?

If you have assigned your insurance by filing an RI 76-10, Assignment of Federal Employees' Group Life Insurance, you may not cancel any of your insurance coverage (except Option C). Only the assignee(s) may cancel your coverage. However, you may elect new coverage if you otherwise meet the requirements for electing such coverage. Any new coverage you elect will automatically be subject to your existing assignment, except for Option C, which you cannot assign. All assignments are automatically canceled after a break in service of at least 31 days, or upon cancellation of all life insurance coverage by the assignee(s).

6.I Am An Assignee. What Can I Do?

If you are completing this form in order to cancel some or all of the employee's life insurance coverage, you must sign the form. The information in Section 2 of the form refers to the employee, but you must sign in Section 3, 4 or 5, as applicable. Indicate "assignee" after your

signature. Return the completed form to the employee's employing office. If the insured is an annuitant, return the completed form to OPM, Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045. See #11 for where to return the completed form if the insured is a compensationer.

7.How Do I Complete The Form?

Follow the instructions for each item carefully. After you fill out the form, review it to be sure it is complete and correct. The following checklist should help.

If you sign Section 3, you elect (or retain) Basic.

If you sign any block in Section 4, you elect (or retain) Optional Insurance. You must also elect (or retain) Basic by signing Section 3.

If you sign Section 4 for Option B and/or Option C, you must also mark one of the five boxes to show how many multiples you wish to elect (or retain). Do not mark more than one box.

Be Sure You Sign For All Options You Want. This election supersedes all previous ones. If you have optional coverage and wish to keep it, you must sign the appropriate box(es). If you do not sign for it, you have waived it.

If you sign Section 5, you waive all FEGLI coverage.

Only you, the employee, may sign this form. Signatures by guardians, conservators, or through a power of attorney are not acceptable. Exception: If you have assigned your insurance, only the assignee(s) may cancel some or all of your coverage. In that case, the assignee(s) must sign the form (although the information in Section 2 must refer to you).

REMEMBER THAT YOU, NOT YOUR AGENCY, ARE RESPONSIBLE FOR ENSURING THAT YOUR SF 2817 (OR ITS ELECTRONIC EQUIVALENT) IS CORRECT AND ACCURATELY REFLECTS YOUR INTENTIONS. IF YOU DO NOT SIGN FOR IT, YOU HAVE CANCELED/WAIVED IT.

8.Open Seasons

If you elected coverage during an Open Season, and that coverage has not yet become effective, and you want to make a further change to your FEGLI coverage on this SF 2817, you should check with your employing office. That office can tell you about any special election procedures that may apply.

9.What If I Waive or Reduce My Coverage?

If you do not sign for a particular type of coverage, you have waived that coverage. If you waive Basic or one or more of the options, your opportunities to enroll in the coverage you waived are strictly limited. A waiver may

also affect your eligibility to continue coverage into retirement. See the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) for more details.

10.Where Do I Send The Completed Form?

After you have completed this form and verified that it accurately reflects your intentions, send the entire form (without separating the parts) to your human resources office. Do not send the form to OPM or OFEGLI.

11.What If I Receive Workers' Compensation?

If you are receiving compensation payments from the Office of Workers' Compensation Programs (OWCP), provide your OWCP number in Section 2 of the form. If you are still employed, return the completed form to your employing office. If you are not still employed or if you have been receiving compensation payments for at least 12 months, see your human resources office about your continued eligibility under the FEGLI Program.

12.How Do I Verify That My Agency Processed My Election?

After your employing office processes your election form, you will receive an SF 50, Notification of Personnel Action. A two digit code appearing on the SF 50 will explain your insurance coverage. These codes are explained in Part 2 of the SF 2817. Also check your pay statement for the correct withholdings. If you are insured as a compensationer, you will receive a notice from OPM which will explain your insurance coverage.

13.Where Do I Get More Information About The FEGLI Program? Consult the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service employees) or the FEGLI Handbook (RI 76-26), which are available on the FEGLI web site at www.opm.gov/insure/life.

Privacy Act and Public Burden Statements

Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance, authorizes solicitation of this information. The data you furnish will be used to determine your life insurance coverage. This information may be shared and is subject to verification, via paper, electronic media, or through the use of the computer matching programs, 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 civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number to distinguish between the applicant and people with similar names. Failure to furnish the requested information may result in your agency's inability to determine your life insurance coverage.

We estimate this form takes an average of 15 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0230), Washington, DC 20415-3430. The OMB Number, 3206-0230 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Back of Part 3

STANDARD FORM 2817

REVISED NOVEMBER 2011

 

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1. Whenever filling in the 2817, ensure to complete all of the necessary fields in its corresponding section. This will help to speed up the work, allowing for your details to be processed quickly and accurately.

Filling out section 1 in insurance election

2. Once your current task is complete, take the next step – fill out all of these fields - I want Option C in the multiple I, times my pay, times my pay, times my pay, multiple, times my pay, times my pay, multiples, multiples, multiples, multiples, SIGNATURE Do not print Only you or, SIGNATURE Do not print Only you or, SIGNATURE Do not print Only you or, and Date mmddyyyy with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

insurance election writing process clarified (part 2)

Concerning times my pay and Date mmddyyyy, be certain you get them right in this section. These are definitely the most significant ones in this PDF.

3. This 3rd segment is typically quite easy, Signature of authorized agency, The employees copy of this form, constitute the employees, US Office of Personnel Management, Previous edition is not usable, and Standard Form Revised November - all these fields is required to be completed here.

Previous edition is not usable, constitute the employees, and Standard Form  Revised November inside insurance election

4. The subsequent part comes next with the following blanks to consider: elect Basic Option A Option B, For Option B and Option C an, Consult the FEGLI Program Booklet, Back of Part, and Standard Form Revised November.

How one can fill out insurance election step 4

5. To finish your form, this particular part includes several extra blanks. Filling out Fill in identifying information, Name last first middle, Date of birth mmddyyyy, Social Security Number, Employing department or agency, OWCP claim number if applicable, Location of department or agency, Daytime telephone number including, In item If this block is not, Basic, Date mmddyyyy, Option A Standard, Option B Additional, Option C Family, and In item box should wrap up the process and you can be done in a blink!

Part no. 5 for submitting insurance election

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