Life Insurance Election

Option C - FamilyOption B - AdditionalOption A - Standard

I followed the instructions on the back of Part 1.

See Privacy Act Statement on back of Part 3

Federal Employees' Group Life Insurance Program

I want Basic.

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

Effective date of coverage

(mm/dd/yyyy)

Number of event

permitting change

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 satisfactory results of a physical, or (2) I have a break in Federal service of at least 180 days, or (3) I participate in an open

enrollment period, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand

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

This election supersedes all previous elections.

Fill in identifying information concerning the employee.

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

booklet). Sign the 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).

Form Approved:

OMB No. 3206-0230

Name (Last) (First) (Middle)

Social Security Number

Date of birth (mm/dd/yyyy)

To elect or retain Basic, sign and date below. If you do not sign for Basic, you may not elect or retain any form of optional insurance. If

you do not want any insurance at all, skip to Section 5.

Employing department or agency

I want Option A.

I authorize deductions to pay the full cost.

I want Option B in the multiple of my annual basic

pay I indicate below. I authorize deductions to pay

the full cost.

I want Option C in the multiple I indicate below. 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.

If you want NO life insurance coverage,

sign and date below.

PART 1 - File in Official Personnel Folder

NSN 7540-01-231-4280

2817-105

Standard Form 2817

Rev. June 2000

The employee's copy of this form, when completed by the employing office, together with the FEGLI booklet (RI 76-21 or RI 76-20 for Postal Service employees)

constitute the employee's Certificate of Insurance.

Signature of authorized agency official

Agency

Use

(See back of Part 2)

Name and address of employing office Date received in employing office

(mm/dd/yyyy)

Do not separate the parts. Give this form to your employing

office which will complete the form and return your copy to

you.

General 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) elect Basic and any

or all of the options, (2) elect Basic but waive 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.

Signature (Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature

(Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature

(Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or

through a power of attorney are not acceptable.)

Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or

through a power of attorney are not acceptable.)

Date (mm/dd/yyyy)

1 multiple

3 multiples

2 multiples

4 multiples

5 multiples

1 times my pay

3 times my pay

2 times my pay

4 times my pay

5 times my pay

Assignees completing this form should read Items 5 and 6 on

the back of Part 3.

OWCP claim number,

if applicable

Date (mm/dd/yyyy)

Remarks:

Location of department or agency where

employee works (City, state, ZIP Code)

Read the back of Part 3 - Employee Copy carefully.

U.S. Office of Personnel Management

Federal Employees' Group Life Insurance Handbook (RI 76-26)

Daytime telephone number

(including area code)

April 1999 edition is usable.

All other editions are obsolete and unusable.

Optional

Basic

Waiver of

all life

insurance

coverage

2. Review of Completed Form

Review the original and both copies 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 item 3,

Basic.

Only the employee may sign this form in items 3, 4, or 5, with one

exception (noted below). Signatures by guardians, conservators, or

through a power of attorney are not acceptable.

Exception: If the employee assigned his or her insurance, only the

assignee(s) may waive 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.

Instruct the employee that, while the agency will make sure that

the SF 2817 is complete, he or she is solely responsible for

ensuring that the SF 2817 accurately reflects his or her intentions.

3. Completion of Form

The Personnel Officer or his or her designated representative must

confirm that the employee is eligible for the coverage that he or

she has elected and sign the form in item 6.

4. Date Received

Enter the date the employing office received this form.

5. Number of Event Permitting 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. Effective Date of Coverage

Enter the effective date of coverage. For new and newly eligible

employees: Basic is effective on the first day the employee is at

work in a pay status; Optional coverage is effective on the first

day the employee is at work in a pay 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 the

employee elected more than one type of coverage and there is

more than one effective date, write in both dates and provide

details in the Remarks section.

7. Disposition of SF 2817

After completion, remove Part 3 and return it to the employee.

File Part 1 in the employee's personnel folder. Destroy Part 2 after

payroll office use.

8. Further Information

For further information, consult the FEGLI Handbook (RI 76-26)

or the FEGLI Booklet (RI 76-21 or RI 76-20 for Postal Service

employees), which are available on the FEGLI web site at

www.opm.gov/insure/life.

Instructions for Agencies

1. Who Should File This Form

Give a new employee a copy of the FEGLI booklet (RI 76-21 or

RI 76-20 for 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 31 days after his or her appointment.

Employees with prior service in nonexcluded positions who were

separated after March 31, 1981, will 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 in

the employee's Declaration for Federal Employment, OF 306, if

completed.

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).

An employee may elect or increase Basic, Option A, or Option B

insurance (but not Option C), if a signed waiver has been in effect

for more than one year, by submitting a Request for Insurance, SF

2822. If approved, ask the employee to submit an SF 2817

showing his or her election. More details are contained on the SF

2822.

An employee who is already enrolled in Basic may elect Option B

and/or Option C within 60 days following marriage, divorce,

spouse's death, or the acquisition of an eligible child. Exception:

Acquiring a foster child does not count as a life event for Option

B purposes.

An employee who is already enrolled in Option B and/or Option C

for at least one multiple may change to a higher multiple within 60

days following marriage, divorce, spouse's death, or the

acquisition of an eligible child. The number of multiples is limited

as listed above.

• For Option B, the number of multiples he or she may elect

(up to 5 total) is limited to the following: (a) for marriage or

acquisition of a child, the number of additional family mem-

bers; (b) for divorce or death of spouse, the total number of

the employee's dependent children.

• For Option C, he or she may elect from 1 to 5 multiples (up

to 5 total) no matter how many family members he/she has

or acquires with the event.

• New employees eligible for life insurance.

• 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 insurance.

• Reinstated employees who filed a previous waiver of any

type of life insurance and who were separated from service

for at least 180 days.

Option C - FamilyOption A - Standard Option B - Additional

Fill in identifying information concerning the employee.

Life Insurance Election

Federal Employees' Group Life Insurance Program

Form Approved:

OMB No. 3206-0230

Name (Last) (First) (Middle) Social Security NumberDate of birth (mm/dd/yyyy)

Employing department or agency

In item 7, box 2:

If this block is not signed, enter 0

If this block is signed, enter 1

In item 7, box 3:

If this block is not signed, enter 0

If this block is signed, enter the number

marked "X" below

In item 7, box 4:

If this block is not signed, enter 0

If this block is signed, enter the number

marked "X" below

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

Effective date of coverage

(mm/dd/yyyy)

PART 2 - For Agency Use

NSN 7540-01-231-4280

2817-105

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

Signature of authorized agency official

Name and address of employing office Date received in employing office

(mm/dd/yyyy)

I followed the instructions on the back of Part 1.

SF 50

Equivalent

Signature (Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature

(Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature (Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or

through a power of attorney are not acceptable.)

Date (mm/dd/yyyy) Date (mm/dd/yyyy)Date (mm/dd/yyyy)

Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or

through a power of attorney are not acceptable.)

1 multiple

3 multiples

2 multiples

4 multiples

5 multiples

1 times my pay

3 times my pay

2 times my pay

4 times my pay

5 times my pay

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

OWCP claim number,

if applicable

Date (mm/dd/yyyy)

INSURANCE SF 50

INELIGIBLE A0

0000 B0

1000 C0

1100 D0

1001 E1

1002 E2

1003 E3

1004 E4

SF 50 Equivalents of Insurance Codes

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

1114 J4

1115 J5

1020 K0

1120 L0

1021 M1

1022 M2

1023 M3

1024 M4

1025 M5

1121 N1

1122 N2

1123 N3

1124 N4

1125 N5

1030 90

1130 P0

1031 Q1

1032 Q2

1033 Q3

1034 Q4

1035 Q5

1131 R1

1132 R2

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

134

Insurance Code

Number of event

permitting change

(See back of Part 2)

Agency

Use

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

If this block is signed, enter 1 in box 1.

Remarks:

Location of department or agency where

employee works (City, state, ZIP Code)

Daytime telephone number

(including area code)

( )

Standard Form 2817

Rev. June 2000

April 1999 edition is usable.

All other editions are obsolete and unusable.

U.S. Office of Personnel Management

Federal Employees' Group Life Insurance Handbook (RI 76-26)

Basic

Waiver of

all life

insurance

coverage

B.Not applicable.

Table of Effective Dates: Changes in Life Insurance Election

Deductions:

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

Event Allowing Change

Change Permitted?

(To enroll in any option, employee must enroll or be enrolled in Basic)

Basic Option A - Standard Option B - Additional Option C - Family

1. Physical: Approval of

Request for Insurance

(SF 2822) by the Office of

Federal Employees' Group

Life Insurance (OFEGLI).

Yes.

Coverage

is effective on the first day the employee

is at work in a pay status after date of OFEGLI's

approval.

Time Limit

- OFEGLI's approval expires after

31 days. If employee is not at work in a pay status within

those 31 days, Basic does

not

become effective.

Employee must obtain a new physical.

Yes. Coverage

is effective on the first day the employee

is at work in a pay status on or after date of OFEGLI's

approval

and

agency receives the SF 2817.

Time Limit

Employee must submit SF 2817 and be at work in a

pay status within 31 days after date of OFEGLI's

approval. If employee is not at work in a pay status or

doesn't submit the SF 2817 within those 31 days, Option

A does

not

become effective. Employee must obtain a

new physical.

Same as Option A. No change permitted for this event.

2. Life Event: Marriage,

divorce, death of spouse or

acquisition of an eligible

child.

No change permitted for this event. No change permitted for this event.

Yes

Employee may elect or increase multiples (limited

to 5 total) up to (a) for marriage or children, the number

of additional family members; (b) for divorce or death of

spouse, the total number of dependent children.

Exception:

Acquiring a foster child does not count as a

life event for Option B purposes.

Coverage

is effective

the day of the event (

employee is at work in a pay

status on that day), if employee submits the SF 2817

before

the event.

Coverage

is effective the first day the

employee is at work in a pay status on or after the date of

the event, if employee submits the SF 2817 within 60

days

after

the event (or is not at work in a pay status on

the day of the event).

Time Limit

- Agency must receive

SF 2817 and proof of the event within 60 days after date

of event. (Time limit may be extended if event occurs

when employee was separated from Federal service or if

it occurs 60 days or less before separation.

)

Yes. Employee may elect or increase multiples (limited

to 5 total) no matter how many family members he/she

has or acquires with the event.

Coverage

is effective the

day of the event, if employee submits the SF 2817

before

the event.

Coverage

is effective the day the

agency receives the SF 2817, if employee submits it

within 60 days

after

the event.

Time Limit

- Agency

must receive SF 2817 and proof of the event within 60

days after date of event. (Time limit may be extended if

event occurs when employee was separated from Federal

service, 60 days or less before separation, or during the

year following waiver of Basic.)

3. Employee is reinstated

after a break in service of

at least 180 days in a posi-

tion that is not excluded

from life insurance by law

or regulation.

Yes. Coverage

is effective on the first day the employee

is at work in a pay status, if no new waiver is filed.

Yes.

Employee may elect any or all optional insurance

within 31 days after reinstatement.

Coverage

is the same

as with new employees. However, if employee does not

submit SF 2817 electing such coverage to his/her agency

within 31 days after reinstatement, he/she has the same

Optional insurance carried immediately before his/her

break in service.

Same as Option A.

4. Employee returns to

Federal Service after a

break in service of at least

180 days in a position

that is excluded from life

insurance by law or

regulation.

No.

However, if employee is later converted to a

non-excluded position, the coverage is effective on the

first day the employee is at work in a pay status on or

after being converted to such a position.

No.

However, if employee is later converted to a

non-excluded position, the coverage is effective on the

first day the employee is converted to such a position

wherein he or she is at work in a pay status on or after

the date the agency receives the SF 2817 electing such

coverage.

Time Limit

Employee must submit SF 2817

electing such coverage to his or her agency within 31

days after conversion.

Same as Option A. Same as Option A.

5A. Employee initially

waives or subsequently

cancels life insurance

coverage.

Yes. Coverage

stops at the end of the last day of the

pay period in which the agency receives the SF 2817,

with

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 coverage – the employee

may not.

A.Same as Basic. A. Same as Basic. A. Same as Basic, except information on assignment is

not applicable.

5B. Employee (or if applica-

ble, assignee(s)) elects

to decrease optional

coverage.

B. Not applicable. B.

Yes

. Employee may at any time reduce the number of

multiples, unless the insurance has been assigned. In

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

the employee may not.

Coverage

reduces effective on

the last day of the pay period in which the agency

receives the SF 2817.

Yes

. Employee may at any time reduce the number of

multiples.

Coverage

reduces effective on the last day

of the pay period in which the agency receives the SF

2817.

6. Open Enrollment Period. If permitted under conditions specified by OPM. Same as Basic. Same as Basic. Same as Basic.

Name (Last) (First) (Middle)

Option C - FamilyOption B - AdditionalOption A - Standard

I followed the instructions on the back of Part 1.

Life Insurance Election

See Privacy Act Statement on back of Part 3

Federal Employees' Group Life Insurance Program

I want Basic.

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

Effective date of coverage

(mm/dd/yyyy)

Number of event

permitting change

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 satisfactory results of a physical, or (2) I have a break in Federal service of at least 180 days, or (3) I participate in an open

enrollment period, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand

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

This election supersedes all previous elections.

Fill in identifying information concerning the employee.

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

booklet). Sign the 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).

Form Approved:

OMB No. 3206-0230

Social Security Number

Date of birth (mm/dd/yyyy)

To elect or retain Basic, sign and date below. If you do not sign for Basic, you may not elect or retain any form of optional insurance. If

you do not want any insurance at all, skip to Section 5.

Employing department or agency

I want Option A.

I authorize deductions to pay the full cost.

I want Option B in the multiple of my annual basic

pay I indicate below. I authorize deductions to pay

the full cost.

I want Option C in the multiple I indicate below. 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.

If you want NO life insurance coverage,

sign and date below.

PART 3 - Employee Copy

NSN 7540-01-231-4280

2817-105

Standard Form 2817

Rev. June 2000

The employee's copy of this form, when completed by the employing office, together with the FEGLI booklet (RI 76-21 or RI 76-20 for Postal Service employees)

constitute the employee's Certificate of Insurance.

Signature of authorized agency official

Agency

Use

(See back of Part 2)

Name and address of employing office Date received in employing office

(mm/dd/yyyy)

Do not separate the parts. Give this form to your employing

office which will complete the form and return your copy to

you.

General 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) elect Basic and any

or all of the options, (2) elect Basic but waive 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.

Signature (Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature

(Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature

(Do not print. Only the Employee/Assignee may

sign. Signatures by guardians, conservators or through a

power of attorney are not acceptable.)

Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or

through a power of attorney are not acceptable.)

Signature (Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or

through a power of attorney are not acceptable.)

Date (mm/dd/yyyy)

1 multiple

3 multiples

2 multiples

4 multiples

5 multiples

1 times my pay

3 times my pay

2 times my pay

4 times my pay

5 times my pay

Assignees completing this form should read Items 5 and 6 on

the back of Part 3.

OWCP claim number,

if applicable

Date (mm/dd/yyyy)

Remarks:

Location of department or agency where

employee works (City, state, ZIP Code)

Read the back of Part 3 - Employee Copy carefully.

U.S. Office of Personnel Management

Federal Employees' Group Life Insurance Handbook (RI 76-26)

Daytime telephone number

(including area code)

( )

April 1999 edition is usable.

All other editions are obsolete and unusable.

Optional

Basic

Waiver of

all life

insurance

coverage

7. How to Complete and Review Your Election 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 item 3, you elect (or retain) Basic. Do not also sign item 5. (You cannot

elect (or retain) and waive coverage.)

If you sign any block in item 4, you must also sign item 3. (To elect (or retain) an

option, you must also elect (or retain) Basic.)

If you sign item 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.

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 item 5, you waive Basic. Do not sign item 3 or any block in item 4. (You

cannot waive and elect 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 IS CORRECT AND ACCURATELY

REFLECTS YOUR INTENTIONS.

8. 1999 Open Enrollment Period

If you elected coverage during the 1999 Open Enrollment Period, 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. Waiving or Changing Your Insurance 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 booklet.

10. Where to Send 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 employing

office.

11. Compensationers

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, return the completed form to OPM, Retirement Operations Center,

P.O. Box 45, Boyers, PA 16017-0045.

12. How to Verify that Your Agency Processed Your Election

After your employing office processes your election form, you will receive an SF 50,

Notice of Personnel Action. A two digit code appearing on the SF 50 will explain your

insurance coverage. These codes are explained on 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. Further Information

For further information, consult the FEGLI Handbook (RI 76-26) or the FEGLI

Booklet (RI 76-21 or RI 76-20 for Postal Service employees), which are available on

the FEGLI web site at www.opm.gov/insure/life.

1. General Information

The major provisions of this program are described in the Federal Employees' Group

Life Insurance (FEGLI) booklet (RI 76-21 or RI 76-20 for Postal Service employees,

available from your employing office). Please read the entire booklet carefully. Your

completed copy of this election form and the FEGLI booklet constitute your

certification of coverage.

2. New Employees and Employees Newly Eligible for Life Insurance

You are automatically enrolled in Basic 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 need to submit this form unless you also wish to elect

Optional insurance. If you do not submit this form, you will have Basic, but no

Optional coverage.

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 31 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. If you do not submit the form at all,

you will have Basic, but no Optional coverage.

3. Employees With Prior Government Service

A life insurance election or waiver on SF 2817 filed during a prior period of Federal

employment stays in effect unless you change coverage or have a break in service of at

least 180 days.

A break in service of at least 180 days cancels any previous waiver of insurance.

Unless you file a new waiver, Basic becomes effective on the first day you actually

enter on duty in a pay status in a position in which you are eligible for coverage. You

can elect any amount of Optional insurance within 31 days of returning to service,

regardless of the coverage you had during previous employment. If you fail to elect

any Optional insurance, you will automatically get the Optional insurance you carried

immediately before your break in service.

If you had a break in service of less than 180 days and were eligible in your last period

of Federal employment, your life insurance in your new employment will be the same

as you had then and if you waived coverage then, the waiver is still in effect. Your

opportunities to cancel your waiver are strictly limited. See the FEGLI booklet.

4. Reemployed Annuitants

If you waive your insurance as a reemployed annuitant, you also waive your insurance

as an annuitant, and you will have no Federal life insurance.

5. Assignment

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 current insurance

coverage. 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. Attention Assignees

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.

Instructions for Employees

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 the civil or criminal law. Public

Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section

7701. Failure to furnish the requested information may result in OPM's inability to determine your life insurance coverage.

We think 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), Reports and Forms Manager, Paperwork Reduction Project

(3206-0230), Washington, DC 20415-7900. 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.

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