Standard Form 2821 PDF Details

The seamless operation of federal benefits, particularly life insurance within the context of public sector employment, is underpinned by meticulous documentation and procedural adherence, exemplified by the Standard Form 2821. This form serves as a critical instrument in the administration of the Federal Employees' Group Life Insurance (FEGLI) Program, enabling agencies to certify an employee's insurance status in various circumstances such as separation, retirement, or death. It requires detailed information regarding an employee's identity, employment, and insurance selections, including any assignments of insurance or elections of living benefits. Furthermore, it mandates certifications from both personnel and payroll records to verify the accuracy of the employment and insurance information provided. The form also contemplates different insurance options available to the employee, asking for specific details about standard, family, and additional insurance coverages at the time of the event requiring certification. The comprehensive nature of the Standard Form 2821 underscores its importance not just as a bureaucratic necessity but as a facilitator of continuity and assurance for federal employees and their beneficiaries navigating through significant life events.

QuestionAnswer
Form NameStandard Form 2821
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namessf2821 fegli form 2823 march 2011

Form Preview Example

No
Yes

Agency Certification of Insurance Status

Federal Employees Group Life Insurance

Federal Employees' Group Life Insurance Program

To Agency: See reverse for information and instructions

1.Name of employee (Last, first, middle)

2.Date of birth (Month, day, year)

3. Social Security number

4a. Event requiring certification

Separation (includes resignation)

Retirement

Death as an employee

Had employee filed Application for Retirement (SF 2801 or SF 3107) with OPM?

No

 

Yes

Death as a reemployed annuitant

End of 12 months non-pay status

Other (Specify)

4b. Employee's retirement system

 

 

 

 

 

 

 

 

 

 

 

5. Disposition of Designations of Beneficiary

 

 

CSRS/FERS

 

CIA

 

 

 

Other (Specify)

(SF 54, SF 2823)

 

 

 

 

 

 

 

 

 

 

 

 

TVA

 

FICA

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

DCRS*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None on file with this agency

 

 

FSRS *D.C. Police & Fire/Public School Teachers

 

 

 

 

On file in employee's Official Personnel

 

4c. OWCP number (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

Folder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Did the employee assign his/her

7. Did the employee elect living benefits?

 

insurance?

 

 

 

 

 

 

 

 

 

 

Amount elected (check one and attach EOB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

No

 

 

 

 

 

 

Partial (post-election BIA $

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes (attach RI 76-10)

 

 

 

Yes

 

 

 

 

 

 

 

Full

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Date of event checked in item 4a

9.Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose coverage as an employee terminates, including all retiring employees)

10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert

11. Effective date of continuous coverage under the FEGLI Program (If any

hourly, daily, piecework, etc., rate to annual rate)

break in service, list dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

12a. Did employee have Option A - Standard Insurance on date in item 8?

13a. Did employee have Option C - Family Insurance on date in item 8?

 

 

 

 

 

 

12b. Amount of Option A

 

 

 

 

 

 

No

 

 

 

 

No

 

 

Yes

 

 

 

 

12c. Effective date of election

 

Yes

 

 

13b. Effective date of election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14a. Did employee have Option B - Additional Insurance on date in item 8?

14b. Effective date of election 14c. Number of multiples on date in item 8 14d. Lowest number of multiples during last 5 years

15.Personnel records certification (This form will not be accepted without both personnel and payroll certification.)

I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal Employee's Group Life Insurance on the date in item 8.

15a. Signature of certifying official (Facsimile not acceptable)

15b. Typed name of certifying official

15c. Title

15d. Date

15e. Name and address of agency (Including ZIP Code)

15f. Telephone number (Including area code)

16. Payroll records certification (This form will not be accepted without dual certification.)

Alpha code

I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree.

 

 

Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code

 

 

 

 

 

(Insurance code and SF 50 equivalent) on the date in the item 8.

 

 

 

 

 

 

 

 

 

 

16a. Signature of certifying official (Facsimile not acceptable)

16f. Name and address of payroll office (If different from that given in item 15e)

 

 

 

 

 

 

16b. Typed name of certifying official

 

 

 

 

 

 

 

 

 

 

16c. Title

 

 

 

 

 

 

 

 

 

16d. Date

16e. Telephone number (Including area code)

16g. Payroll office number

 

 

 

 

 

 

 

Remarks (For agency use only)

OPM use only

U.S. Office of Personnel Management

 

PART 1 - Original

Standard Form 2821

 

 

The FEGLI Handbook for Personnel and Payroll Offices

NSN 7540-01-231-5587

Previous editions are not usable

Revised May 1995
No
Yes

Agency Certification of Insurance Status

Federal Employees Group Life Insurance

Federal Employees' Group Life Insurance Program

To Agency: See reverse for information and instructions

1.Name of employee (Last, first, middle)

2.Date of birth (Month, day, year)

3. Social Security number

4a. Event requiring certification

Separation (includes resignation)

Retirement

Death as an employee

Had employee filed Application for Retirement (SF 2801 or SF 3107) with OPM?

No

 

Yes

Death as a reemployed annuitant

End of 12 months non-pay status

Other (Specify)

4b. Employee's retirement system

 

 

 

 

 

 

 

 

 

 

 

5. Disposition of Designations of Beneficiary

 

 

CSRS/FERS

 

CIA

 

 

 

Other (Specify)

(SF 54, SF 2823)

 

 

 

 

 

 

 

 

 

 

 

 

TVA

 

FICA

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

DCRS*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None on file with this agency

 

 

FSRS *D.C. Police & Fire/Public School Teachers

 

 

 

 

On file in employee's Official Personnel

 

4c. OWCP number (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

Folder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Did the employee assign his/her

7. Did the employee elect living benefits?

 

insurance?

 

 

 

 

 

 

 

 

 

 

Amount elected (check one and attach EOB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

No

 

 

 

 

 

 

Partial (post-election BIA $

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes (attach RI 76-10)

 

 

 

Yes

 

 

 

 

 

 

 

Full

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Date of event checked in item 4a

9.Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose coverage as an employee terminates, including all retiring employees)

10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert

11. Effective date of continuous coverage under the FEGLI Program (If any

hourly, daily, piecework, etc., rate to annual rate)

break in service, list dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

12a. Did employee have Option A - Standard Insurance on date in item 8?

13a. Did employee have Option C - Family Insurance on date in item 8?

 

 

 

 

 

 

12b. Amount of Option A

 

 

 

 

 

 

No

 

 

 

 

No

 

 

Yes

 

 

 

 

12c. Effective date of election

 

Yes

 

 

13b. Effective date of election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14a. Did employee have Option B - Additional Insurance on date in item 8?

14b. Effective date of election 14c. Number of multiples on date in item 8 14d. Lowest number of multiples during last 5 years

15.Personnel records certification (This form will not be accepted without both personnel and payroll certification.)

I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal Employee's Group Life Insurance on the date in item 8.

15a. Signature of certifying official (Facsimile not acceptable)

15b. Typed name of certifying official

15c. Title

15d. Date

15e. Name and address of agency (Including ZIP Code)

15f. Telephone number (Including area code)

16. Payroll records certification (This form will not be accepted without dual certification.)

Alpha code

I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree.

 

 

Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code

 

 

 

 

 

(Insurance code and SF 50 equivalent) on the date in the item 8.

 

 

 

 

 

 

 

 

 

 

16a. Signature of certifying official (Facsimile not acceptable)

16f. Name and address of payroll office (If different from that given in item 15e)

 

 

 

 

 

 

16b. Typed name of certifying official

 

 

 

 

 

 

 

 

 

 

16c. Title

 

 

 

 

 

 

 

 

 

16d. Date

16e. Telephone number (Including area code)

16g. Payroll office number

 

 

 

 

 

 

 

Remarks (For agency use only)

OPM use only

U.S. Office of Personnel Management

PART 2 - Enrollee/Assignee

 

Standard Form 2821

 

 

The FEGLI Handbook for Personnel and Payroll Offices

NSN 7540-01-231-5587

Previous editions are not usable

Revised May 1995
No
Yes

Agency Certification of Insurance Status

Federal Employees Group Life Insurance

Federal Employees' Group Life Insurance Program

To Agency: See reverse for information and instructions

1.Name of employee (Last, first, middle)

2.Date of birth (Month, day, year)

3. Social Security number

4a. Event requiring certification

Separation (includes resignation)

Retirement

Death as an employee

Had employee filed Application for Retirement (SF 2801 or SF 3107) with OPM?

No

 

Yes

Death as a reemployed annuitant

End of 12 months non-pay status

Other (Specify)

4b. Employee's retirement system

 

 

 

 

 

 

 

 

 

 

 

5. Disposition of Designations of Beneficiary

 

 

CSRS/FERS

 

CIA

 

 

 

Other (Specify)

(SF 54, SF 2823)

 

 

 

 

 

 

 

 

 

 

 

 

TVA

 

FICA

 

 

 

 

 

 

 

 

 

 

 

 

Attached

 

 

DCRS*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None on file with this agency

 

 

FSRS *D.C. Police & Fire/Public School Teachers

 

 

 

 

On file in employee's Official Personnel

 

4c. OWCP number (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

Folder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Did the employee assign his/her

7. Did the employee elect living benefits?

 

insurance?

 

 

 

 

 

 

 

 

 

 

Amount elected (check one and attach EOB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

No

 

 

 

 

 

 

Partial (post-election BIA $

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes (attach RI 76-10)

 

 

 

Yes

 

 

 

 

 

 

 

Full

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Date of event checked in item 4a

9.Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose coverage as an employee terminates, including all retiring employees)

10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert

11. Effective date of continuous coverage under the FEGLI Program (If any

hourly, daily, piecework, etc., rate to annual rate)

break in service, list dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

12a. Did employee have Option A - Standard Insurance on date in item 8?

13a. Did employee have Option C - Family Insurance on date in item 8?

 

 

 

 

 

 

12b. Amount of Option A

 

 

 

 

 

 

No

 

 

 

 

No

 

 

Yes

 

 

 

 

12c. Effective date of election

 

Yes

 

 

13b. Effective date of election

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14a. Did employee have Option B - Additional Insurance on date in item 8?

14b. Effective date of election 14c. Number of multiples on date in item 8 14d. Lowest number of multiples during last 5 years

15.Personnel records certification (This form will not be accepted without both personnel and payroll certification.)

I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal Employee's Group Life Insurance on the date in item 8.

15a. Signature of certifying official (Facsimile not acceptable)

15b. Typed name of certifying official

15c. Title

15d. Date

15e. Name and address of agency (Including ZIP Code)

15f. Telephone number (Including area code)

16. Payroll records certification (This form will not be accepted without dual certification.)

Alpha code

I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree.

 

 

Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code

 

 

 

 

 

(Insurance code and SF 50 equivalent) on the date in the item 8.

 

 

 

 

 

 

 

 

 

 

16a. Signature of certifying official (Facsimile not acceptable)

16f. Name and address of payroll office (If different from that given in item 15e)

 

 

 

 

 

 

16b. Typed name of certifying official

 

 

 

 

 

 

 

 

 

 

16c. Title

 

 

 

 

 

 

 

 

 

16d. Date

16e. Telephone number (Including area code)

16g. Payroll office number

 

 

 

 

 

 

 

Remarks (For agency use only)

OPM use only

U.S. Office of Personnel Management

 

PART 3 - File Copy

Standard Form 2821

 

 

The FEGLI Handbook for Personnel and Payroll Offices

NSN 7540-01-231-5587

Previous editions are not usable

Revised May 1995

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This document requires some specific information; to ensure consistency, you need to consider the next guidelines:

1. When filling out the Standard Form 2821, make certain to incorporate all of the necessary fields in the relevant area. It will help to speed up the work, allowing for your details to be handled swiftly and appropriately.

Step # 1 of filling out Standard Form 2821

2. Just after performing the previous part, go to the next step and fill out the essential particulars in all these blanks - a Signature of certifying official, e Name and address of agency, b Typed name of certifying official, c Title, d Date, f Telephone number Including area, Payroll records certification, I certify that I have compared the, Alpha code, a Signature of certifying official, f Name and address of payroll, b Typed name of certifying official, c Title, d Date, and e Telephone number Including area.

The best ways to complete Standard Form 2821 portion 2

3. This subsequent step is usually quite uncomplicated, Remarks For agency use only, OPM use only, US Office of Personnel Management, NSN, PART Original, Previous editions are not usable, and Standard Form Revised May - all these fields is required to be completed here.

Filling out part 3 in Standard Form 2821

4. The fourth subsection arrives with these fields to fill out: To Agency See reverse for, Name of employee Last first middle, Date of birth Month day year, Social Security number, a Event requiring certification, Separation includes resignation, b Employees retirement system CIA, CSRSFERS TVA DCRS FSRS, DC Police FirePublic School, c OWCP number if applicable, Disposition of Designations of, Other Specify, SF SF, Attached None on file with this, and Yes.

Stage # 4 in completing Standard Form 2821

5. The very last section to complete this form is integral. Make sure you fill in the required blanks, like a Did employee have Option B, No Yes, b Effective date of election, c Number of multiples on date in, d Lowest number of multiples during, last years, Personnel records certification, I certify that the above, a Signature of certifying official, e Name and address of agency, b Typed name of certifying official, c Title, d Date, f Telephone number Including area, and Payroll records certification, before finalizing. Otherwise, it might produce an unfinished and potentially nonvalid form!

c Number of multiples on date in, last years, and a Did employee have Option B of Standard Form 2821

Always be very careful while filling in c Number of multiples on date in and last years, as this is where a lot of people make some mistakes.

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