Form Sf 2817 – Fill Out and Use This PDF

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.

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

1.Who Should File This Form?

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

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

ｙEmployees who want to change their life insurance.

ｙReinstated 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.

ｙAn 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.

ｙAssignees who want to decrease or cancel coverage.

ｙDepartment 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?

ｙProvide 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.

ｙExperience 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.

Life Insurance Election

Federal Employees' Group Life Insurance Program

Form Approved: OMB No. 3206-0230

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

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

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).

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.