Standard Form 2819 PDF Details

Navigating changes in employment status can be challenging, especially when it comes to ensuring the continued protection of life insurance coverage. The Standard Form 2819, a critical document within the Federal Employees' Group Life Insurance (FEGLI) Program, serves as a lifeline for those facing loss of coverage due to several reasons including separation, resignation, retirement, or death. This form offers eligible individuals the opportunity to convert their group life insurance to an individual direct-pay policy without the need for a medical examination. Specifically designed to guide not only employees but also their assignees and family members through the conversion process, the form details how to maintain life insurance protection seamlessly. It encapsulates directions for employing agencies on how to fill out the form, explains the conversion rights available to employees, assignees, and family members, and outlines the types of individual policies available. Furthermore, it discusses the eligibility for conversion, the requisite steps to initiate conversion, and the deadlines for application, aiming to ensure that individuals do not find themselves without life insurance coverage during transitions in their employment status.

QuestionAnswer
Form NameStandard Form 2819
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesichever, assignee, standard form 2819, sf2819 form

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Notice of Conversion Privilege

Federal Employees' Group Life Insurance Program

Federal Employees

Group Life Insurance

Part A - Instructions to Employing Agency

Complete Part A of this form whenever an employee’s life insurance coverage

C-Family coverage. Also, upon request, give this notice to the family of an eligible

terminates due to separation, resignation, retirement, death or end of 12

employee who does not convert his or her Option C-Family insurance.

months in non-pay status. On the date insurance terminates (except by

If this notice is prepared for a retiring employee, forward Part 2 (duplicate) to OPM

waiver), give this notice to every employee and/or the assignee(s), if

with the employee's retirement papers. Otherwise, place Part 2

applicable, and to the family of each deceased employee who had the Option

(duplicate) in the employee’s Official Personnel Folder.

1. Name of employee

2. Date of birth (mo., day, yr.)

3. Date insurance terminated

4. Was employee insured for Option C-Family insurance on date in item 3?

Yes

No

Agency Certification I certify that the above information has been obtained from, and correctly reflects, official personnel records.

5. Signature of authorized agency official

6. Name and mailing address of agency

7.Typed name of authorized agency official

8.Title

9. Telephone number

10. Date of this notice (mo., day, yr.)

Part B - Conversion Information for Employees, Assignees, and Family Members Who are Losing FEGLI Coverage

If you are eligible and you will be carrying all of your Federal Employees’ Group Life Insurance (FEGLI) coverage into retirement, do not apply for conversion. Employees (and assignees, if applicable) and their family members who are losing FEGLI coverage, however, may be eligible and wish to convert some or all of their coverage to an individual direct-pay policy.

Employees - If you have not assigned your FEGLI coverage, you are entitled to convert to an individual direct-pay policy unless, within 3 calendar days after the date your insurance terminates, you return to a Government position that qualifies you to reacquire FEGLI coverage. You may purchase an individual policy in an amount equal to or less than your Basic life insurance plus any optional coverage you may have.

Assignees - You are entitled to convert your share of the insured’s FEGLI

coverage to an individual direct-pay policy unless, within 3 calendar days after the date the insured’s insurance terminated, he/she returns to a Government position that qualifies him/her to reacquire FEGLI coverage. If that is the case, his/her previous assignment is still valid. You may purchase an individual policy in an amount equal to or less than the amount of insurance which the insured assigned to you.

Family members - If, upon termination of the employee’s FEGLI coverage,

he/she does not convert Option C-Family coverage (if any), you, as an eligible family member, may do so. Spouses may convert up to $5,000, and eligible children up to $2,500 each. Eligible family members are the employee’s spouse and unmarried dependent children under age 22 (including adopted children, stepchildren who lived with the employee in a regular parent-child relationship, and recognized natural children) and unmarried dependent children over age 22 who are incapable of self-support because of a mental or physical disability that existed before they reached age 22.

Your time to convert is limited - You must mail your request for information regarding conversion within 31 days of the date in item 3 of Part A above,

or within 31 days of the date you receive this notice, whichever gives you more time. If you fail to request conversion information within the 31-day time limit due to a cause beyond your control, you may be allowed to convert your life insurance within six months after the date in item 3, provided you attach a full explanation of what prevented you from making a timely request. If approved, the effective date of the conversion policy will be retroactive to the day following the day group coverage ended.

Note: Under certain circumstances, life insurance is payable if death occurs within 31 days after the group life insurance terminates, regardless of whether conversion has been requested. However, extension of the conversion privilege beyond 31 days does not extend coverage under any circumstances. If death occurs within the 31-day period, further information concerning possible benefits may be obtained from the agency named in item 6 above.

General information about conversion

If you have assigned your FEGLI coverage, you can only convert your Option coverage (if any). Your assignee(s) retain(s) the right to convert your other coverage(s).

No medical examination is required.

You or the assignee(s), if applicable, must pay the premium applicable to the individual policy.

The government will not pay any part of the individual policy premium. The individual policy will be issued by an insurance company you select from the list of eligible companies you will receive if you apply for conversion.

The individual policy may be an ordinary life policy or a variation of ordinary life (see Part D). It must be a type of insurance customarily issued by the insurance company you select. However, it cannot be term insurance or universal life insurance or any other form of life insurance that has an indeterminate premium. It cannot have disability or accidental death and dismemberment benefits.

How to convert

1.Complete the appropriate eligibility statement on the reverse side of this form and mail it to the Office of Federal Employees' Group Life Insurance (OFEGLI), 200 Park Avenue, New York, NY 10166-0188.

2.If you have an SF 2821, Agency Certification of Insurance Status, attach

the original (Part 1) to this form when you mail it to OFEGLI. Note: Retiring employees (and assignees of those employees) who are continuing Basic Life insurance but converting one or more of the options should submit their duplicate (Part 2) of the SF 2821with this form to OFEGLI. The original (Part 1) of the SF 2821 should be submitted with the retirement application. OFEGLI will mail you detailed information on how to apply for conversion, together with a list of eligible insurance companies. You have 31 days (from the date in item 3 of Part A above, or the date you receive this notice,

wh ichever gives you more time) to request conversion information from

OFEGLI.

3.In the event you do not have an SF 2821, you should request a completed form from the employing agency before the expiration of your 31 day time limit and forward it to OFEGLI at the address given in item 1 above.

However, don't delay sending the SF 2819 requesting conversion information to OFEGLI -- send it anyway while you await the SF 2821.

4.If you are using this form to convert some of your life insurance coverage, but not Option C, have your employing office prepare another SF 2819 for your family members.

Office of Personnel Management

Part 1 - Employee/Assignee/Family Member

Standard Form 2819

 

 

 

Rev. May 1995

FEGLI Handbook for Personnel and Payroll Offices

NSN 7540-01-231-5586

2819-102

Previous editions are not usable

 

Part C - Eligibility Statement

1. Please check the correct box(es).

I have read Part B on page 1 and am interested in converting my insurance to an individual policy. Please send additional information.

I have read Part B on page 1. The family members listed in item 7 below

are eligible for conversion of Option C-Family insurance to a direct-pay policy. Please send me additional information.

Basic

Option A-Standard

Option B-Additional

2.

Signature of person completing this statement

3. Date (mo., day, yr.)

4. Full name and address of person completing this

 

 

 

 

 

 

statement (including ZIP code)

 

 

 

 

 

 

 

5.

Was the FEGLI coverage assigned?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, are you the assignee of the insured's FEGLI coverage?

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Check one:

 

I have attached an SF 2821.

 

 

I am a family member and do

 

 

I will obtain and submit an

 

 

 

 

 

 

 

 

not need an SF 2821.

 

 

SF 2821 later.

 

 

 

 

 

 

 

 

 

 

7.

Eligible family members

Birth date

Relationship

Eligible family members

Birth date

Relationship

a.

d.

b.

e.

c.

f.

Part D - Information About Individual Policies

Types of Policies

There are two basic types of life insurance available.

An Ordinary Life policy, also known as a Whole Life policy or a Straight Life policy, provides lifetime protection in return for premium payments throughout the insured's entire life (or to age 100). The policy builds a CASH VALUE after one, two, or three years. The cash may be withdrawn if premium payments are stopped. You may borrow against the cash value of the policy at any time for any purpose.

A variation of Ordinary Life provides for a shorter premium payment period, usually to age 95, at which time the policy becomes paid-up for the remainder of the insured's life. This variation provides the same lifetime protection and benefits as an Ordinary Life policy, provided that premiums are paid for the prescribed premium payment period. However, since premiums are payable for a shorter period of time, they normally would be higher. And, because the premiums are normally higher, the policy's CASH VALUE usually increases more quickly.

Assignment

If you have assigned (given up ownership of) your insurance, only the assignee(s) has (have) the right to convert your non-option C coverage. If an assignee converts his/her share of your insurance, he/she (1) is responsible for paying the premiums, (2) will receive the dividends, if any, (3) may withdraw

the cash if he/she stops paying premiums, and (4) may borrow against the cash value.

Cost of Individual Policy

Life insurance policies (whether Ordinary Life or a variation) are issued on a participating or non-participating basis.

Premiums for participating policies are higher than those charged for non-participating policies. Part of the premium is refunded in the form of an annual dividend to the policyholder - the part found not needed to furnish protection. The first dividend is usually available after premiums have been paid for one, two, or three years. To obtain the net cost of a participating policy, deduct these yearly dividends from the premiums.

For non-participating policies, premiums are set as close as possible to the actual cost of insurance protection. The premium is the guaranteed cost to the policyholder. No dividends are paid under these policies.

The following are approximate premium rates on a participating basis for Ordinary Life policies with premiums payable for life (or to age 100) and for Ordinary Life policies with premiums payable to age 95. Premium rates for non-participating policies are somewhat lower and no dividends will be paid under these policies. The rates shown below are examples only and are not rates for any one company.

Sample Annual Premium Rates per $1,000 of Insurance

Participating Insurance (any dividends paid will reduce these costs)

Age of insured

Ordinary

Life

Age of insured

Ordinary

Life

at issuance

Paid-Up

at issuance

Paid-Up

Life

Life

of policy

at Age 95

of policy

at Age 95

 

 

 

 

 

 

 

 

20

$ 9.00

$10.50

45

$24.50

$28.00

25

$10.50

$12.50

50

$31.50

$36.50

30

$12.50

$14.50

55

$40.50

$48.00

35

$15.50

$17.50

60

$53.00

$64.00

40

$19.50

$21.50

65

$66.50

$77.50

 

 

 

 

 

 

Privacy Act Statement - Title 5, United States Code, Chapter 87, Life Insurance, authorizes solicitation of this information. The data you furnish will be used by the Office of Federal Employees' Group Life Insurance to determine eligibility for conversion of life insurance coverage. This information may be shared 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 the civil or criminal law.

Notice of Conversion Privilege

Federal Employees' Group Life Insurance Program

Federal Employees

Group Life Insurance

Part A - Instructions to Employing Agency

Complete Part A of this form whenever an employee’s life insurance coverage

C-Family coverage. Also, upon request, give this notice to the family of an eligible

terminates due to separation, resignation, retirement, death or end of 12

employee who does not convert his or her Option C-Family insurance.

months in non-pay status. On the date insurance terminates (except by

If this notice is prepared for a retiring employee, forward Part 2 (duplicate) to OPM

waiver), give this notice to every employee and/or the assignee(s), if

with the employee's retirement papers. Otherwise, place Part 2

applicable, and to the family of each deceased employee who had the Option

(duplicate) in the employee’s Official Personnel Folder.

1. Name of employee

2.Date of birth (mo., day, yr.)

3. Date insurance terminated

4. Was employee insured for Option C-Family insurance on date in item 3?

Yes

No

Agency Certification

I certify that the above information has been obtained from, and correctly reflects, official personnel records.

 

 

5. Signature of authorized agency official

6. Name and mailing address of agency

7.Typed name of authorized agency official

8.Title

9. Telephone number

10. Date of this notice (mo., day, yr.)

Part B - Conversion Information for Employees, Assignees, and Family Members Who are Losing FEGLI Coverage

If you are eligible and you will be carrying all of your Federal Employees’ Group Life Insurance (FEGLI) coverage into retirement, do not apply for conversion. Employees (and assignees, if applicable) and their family members who are losing FEGLI coverage, however, may be eligible and wish to convert some or all of their coverage to an individual direct-pay policy.

Employees - If you have not assigned your FEGLI coverage, you are entitled to convert to an individual direct-pay policy unless, within 3 calendar days after the date your insurance terminates, you return to a Government position that qualifies you to reacquire FEGLI coverage. You may purchase an individual policy in an amount equal to or less than your Basic life insurance plus any optional coverage you may have.

Assignees - You are entitled to convert your share of the insured’s FEGLI

coverage to an individual direct-pay policy unless, within 3 calendar days after the date the insured’s insurance terminated, he/she returns to a Government position that qualifies him/her to reacquire FEGLI coverage. If that is the case, his/her previous assignment is still valid. You may purchase an individual policy in an amount equal to or less than the amount of insurance which the insured assigned to you.

Family members - If, upon termination of the employee’s FEGLI coverage,

he/she does not convert Option C-Family coverage (if any), you, as an eligible family member, may do so. Spouses may convert up to $5,000, and eligible children up to $2,500 each. Eligible family members are the employee’s spouse and unmarried dependent children under age 22 (including adopted children, stepchildren who lived with the employee in a regular parent-child relationship, and recognized natural children) and unmarried dependent children over age 22 who are incapable of self-support because of a mental or physical disability that existed before they reached age 22.

Your time to convert is limited - You must mail your request for information regarding conversion within 31 days of the date in item 3 of Part A above,

or within 31 days of the date you receive this notice, whichever gives you more time. If you fail to request conversion information within the 31-day time limit due to a cause beyond your control, you may be allowed to convert your life insurance within six months after the date in item 3, provided you attach a full explanation of what prevented you from making a timely request. If approved, the effective date of the conversion policy will be retroactive to the day following the day group coverage ended.

Note: Under certain circumstances, life insurance is payable if death occurs within 31 days after the group life insurance terminates, regardless of whether conversion has been requested. However, extension of the conversion privilege beyond 31 days does not extend coverage under any circumstances. If death occurs within the 31-day period, further information concerning possible benefits may be obtained from the agency named in item 6 above.

General information about conversion

If you have assigned your FEGLI coverage, you can only convert your Option C coverage (if any). Your assignee(s) retain(s) the right to convert your other coverage(s).

No medical examination is required.

You or the assignee(s), if applicable, must pay the premium applicable to the individual policy.

The government will not pay any part of the individual policy premium.

The individual policy will be issued by an insurance company you select from the list of eligible companies you will receive if you apply for conversion. The individual policy may be an ordinary life policy or a variation of ordinary life (see Part D). It must be a type of insurance customarily issued by the insurance company you select. However, it cannot be term insurance or universal life insurance or any other form of life insurance that has an indeterminate premium. It cannot have disability or accidental death and disemberment benefits.

How to convert

1.Complete the appropriate eligibility statement on the reverse side of this form and mail it to the Office of Federal Employees' Group Life Insurance (OFEGLI), 200 Park Avenue, New York, NY 10166-0188.

2.If you have an SF 2821, Agency Certification of Insurance Status, attach

the original (Part 1) to this form when you mail it to OFEGLI. Note: Retiring employees (and assignees of those employees) who are continuing Basic Life insurance but converting one or more of the options should submit their duplicate (Part 2) of the SF 2821 with this form to OFEGLI. The original (Part 1) of the SF 2821 should be submitted with the retirement application. OFEGLI will mail you detailed information on how to apply for conversion, together with a list of eligible insurance companies. You have 31 days (from the date in item 3 of Part A above, or the date you receive this notice, whichever gives you more time) to request conversion information from

OFEGLI.

3.In the event you do not have an SF 2821, you should request a completed form from the employing agency before the expiration of your 31 day time limit and forward it to OFEGLI at the address given in item 1 above.

However, don't delay sending the SF 2819 requesting conversion information to OFEGLI -- send it anyway while you await the SF 2821.

4.If you are using this form to convert some of your life insurance coverage, but not Option C, have your employing office prepare another SF 2819 for your family members.

5.Family members may apply for conversion by sending a completed SF 2819 (this form) to OFEGLI, 200 Park Avenue, New York, NY 10166-0188. (Note: Family members do not need an SF 2821.)

Office of Personnel Management

Part 2 - Forward with Retirement Papers/File in OPF

Standard Form 2819

 

 

 

FEGLI Handbook for Personnel and Payroll Offices

NSN 7540-01-231-5586

2819-102

Previous editions are not usable

Rev. May 1995

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This document requires specific details to be typed in, hence be sure to take some time to enter what is requested:

1. It is crucial to complete the sf 2819 correctly, thus be attentive while working with the segments containing these particular blank fields:

Part number 1 of filling out assignee

2. Immediately after the last section is done, proceed to enter the applicable details in these: Part C Eligibility Statement, I have read Part B on page and am, I have read Part B on page The, Basic, Option AStandard, Option BAdditional, Signature of person completing, Date mo day yr, Full name and address of person, statement including ZIP code, Was the FEGLI coverage assigned, Yes, If Yes are you the assignee of the, Yes, and Check one.

Part C  Eligibility Statement, Signature of person completing, and Date mo day yr in assignee

3. The following section will be about Part D Information About, An Ordinary Life policy also known, Life policy provides lifetime, A variation of Ordinary Life, Assignment If you have assigned, the cash if heshe stops paying, Cost of Individual Policy Life, Premiums for participating, For nonparticipating policies, The following are approximate, Sample Annual Premium Rates per, Participating Insurance any, Age of insured, Ordinary, and Life - type in all these blank fields.

How to fill out assignee portion 3

4. This next section requires some additional information. Ensure you complete all the necessary fields - Name of employee, Date of birth mo day yr, Date insurance terminated, Was employee insured for Option, Yes, Agency Certification, I certify that the above, Signature of authorized agency, Name and mailing address of agency, Typed name of authorized agency, Title, Telephone number, Date of this notice mo day yr, Part B Conversion Information for, and If you have assigned your FEGLI - to proceed further in your process!

How you can fill in assignee stage 4

Be very careful while filling out Name of employee and Date insurance terminated, as this is where many people make some mistakes.

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