SF 2817 Life Insurance Election

Life Insurance Election

SF2817_2018_06_MarkUp

Life Insurance Election

OMB: 3206-0230

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Life Insurance Election

Federal Employees' Group Life Insurance Program

Federal Employees'
Group Life Insurance

1
2

See Privacy Act Statement on back of Part 3

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) 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.

*This election supersedes all previous elections.*

Name (last, first, middle)

Date of birth (mm/dd/yyyy)
OWCP claim number,
if applicable

Social Security Number

Location of department or agency where you Daytime telephone number
work (city, state, ZIP code)
(including area code)

To elect or retain Basic, sign and date below. If you do not sign for Basic, you (or your assignee) may not elect or retain any form of optional
insurance. If you do not want any insurance at all, skip to Section 5.
I want Basic. I authorize deductions to pay my share of the cost. (Basic may be provided without cost to U.S. Postal Service employees.)

Basic

Read the back of Part 3 - Employee Copy carefully.
Assignees completing this form should read Items 5 and 6 on the
back of Part 3.
Give all parts of your completed form to your employing office.
Your employing office will complete Section 6 of this form (or its
electronic equivalent) and return your copy to you.

Fill in identifying information concerning the employee.

Employing department or agency

Form Approved:
OMB No. 3206-0230

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

Date (mm/dd/yyyy)


Optional

If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS you have previously waived any or all
of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI Program Booklet). Sign the
box(es) below for any option(s) you are eligible for and wish to elect or retain. If you do not sign for an option, you have waived it and your future
opportunities to enroll in it are strictly limited.
You will not be covered for any option(s) for which you do not sign below, regardless of whether you previously elected the option(s).

Option A - Standard
I want Option A.
I authorize deductions to pay the full cost.

Option B - Additional

Option C - Family

I want Option B in the multiple of my annual basic pay I I want Option C in the multiple I indicate below.
indicate below. I authorize deductions to pay the full cost. I understand that each multiple is worth $5,000 upon
the death of my spouse, and $2,500 upon the death of an
eligible child. I authorize deductions to pay the full cost.
3 times my pay

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

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

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



Date (mm/dd/yyyy)

1 times my pay



3 multiples

Date (mm/dd/yyyy)

If you want NO life insurance coverage, sign and date below.
I want NO life insurance coverage. I understand that any life insurance I have will stop at the end of the last day of the pay period in which my
employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form and submit

Waiver of satisfactory medical information, or (2) I experience a life event, or (3) I have a break in Federal service of at least 180 days, or (4) I participate in an
all life open season, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand that my decision to
waive life insurance coverage now may affect my eligibility for coverage as a retiree.
insurance SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through Date (mm/dd/yyyy)
coverage a power of attorney are not valid.)



Agency
Use

Remarks:

Name and address of employing office

If new/newly eligible employee,
enter "0" for event.

Date received in employing office Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)

Number of event permitting
change
(See back of Part 2)

I followed the instructions on the back of Part 1.
Signature of authorized agency official

The employee's copy of this form, when completed by the employing office, together with the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service
employees) constitute the employee's Certificate (proof) of Insurance.
PART 1 - File in Official Personnel Folder
U.S. Office of Personnel Management
www.opm.gov/healthcare-insurance/life-insurance

Previous editions are not usable.

Standard Form 2817
Revised June 2018

Instructions for Agencies
1.

Who Should File This Form?

New employees eligible for life insurance who want
optional insurance or no insurance. Note: New employees
who want only Basic do not have to file.


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



Employees who want to change their life insurance.



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






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.

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.

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.

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

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.

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

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.

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.

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.

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).

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."

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.

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/healthcare-insurance/life-insurance.

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

Experience A Qualifying Life Event. An employee may
elect Basic, Option A, Option B and/or Option C within
60 days following a FEGLI qualifying life event. These
events are: marriage, divorce, spouse's death, or the
acquisition of an eligible child.
For Option B and Option C, an employee may elect from
1 to 5 multiples (up to 5 total) based on the life event.

Back of Part 1

Standard Form 2817
Revised June 2018

Life Insurance Election

Federal Employees' Group Life Insurance Program

Federal Employees'
Group Life Insurance

1
2

INSURANCE
INELIGIBLE
0000
1000
1100
1001
1002
1003
1004

Form Approved:
OMB No. 3206-0230

SF 50
A0
B0
C0
D0
E1
E2
E3
E4

SF 50 Equivalents of Insurance Codes
1005
1101
1102
1103
1104
1105
1010
1110

E5
F1
F2
F3
F4
F5
G0
H0

1011
1012
1013
1014
1015
1111
1112
1113

I1
I2
I3
I4
I5
J1
J2
J3

1114
1115
1020
1120
1021
1022
1023
1024

1025
1121
1122
1123
1124
1125
1030
1130

J4
J5
K0
L0
M1
M2
M3
M4

M5
N1
N2
N3
N4
N5
90
P0

1031
1032
1033
1034
1035
1131
1132
1133

1134
1135
1040
1140
1041
1042
1043
1044

Q1
Q2
Q3
Q4
Q5
R1
R2
R3

1045 U5
1141 V1
1142 V2
1143 V3
1144 V4
1145 V5
1050 W0
1150 X0

R4
R5
S0
T0
U1
U2
U3
U4

1051
1052
1053
1054
1055
1151
1152
1153

Name (last, first, middle)

3
Basic

Date of birth (mm/dd/yyyy)
OWCP claim number,
if applicable

Social Security Number

Location of department or agency where you Daytime telephone number
work (city, state, ZIP code)
(including area code)

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

Date (mm/dd/yyyy)



Option A - Standard
In item 7, box 2:
If this block is not signed, enter 0
If this block is signed, enter 1.

Option B - Additional

Option C - Family
In item 7, box 4:
If this block is not signed, enter 0
If this block is signed, enter the number marked "X"
below.

In item 7, box 3:
If this block is not signed, enter 0
If this block is signed, enter the number marked "X"
below.
3 times my pay

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



3 multiples

1 times my pay

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

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



Date (mm/dd/yyyy)

If you want NO life insurance coverage, sign and date below.
In item 7: If this block is signed, enter 0 in ALL FOUR boxes.

Waiver of
all life
insurance SIGNATURE (Do not print. Only you or your assignee may sign. Signatures by guardians, conservators or through a
coverage power of attorney are not valid.)

Z4
Z5

Fill in identifying information concerning the employee.

Employing department or agency

1154
1155

Y1
Y2
Y3
Y4
Y5
Z1
Z2
Z3

Date (mm/dd/yyyy)



Agency
Use

Remarks:

Name and address of employing office

If new/newly eligible employee,
enter "0" for event.
Number of event permitting
change

Date received in employing office Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)

(See back of Part 2)

I followed the instructions on the back of Part 1.
Signature of authorized agency official

INSTRUCTIONS: Enter codes in the boxes on the right as directed in items 3, 4 and 5 above. (If the
employee is in non-pay status more than 12 months and the FEGLI [SF 50] code is "A1", DO NOT USE
THIS FORM.)

U.S. Office of Personnel Management
www.opm.gov/healthcare-insurance/life-insurance

Insurance Code
1

SF 50
Equivalent

PART 2 - For Agency Use
Previous editions are not usable.

Standard Form 2817
Revised June 2018

Table of Effective Dates: Changes in Life Insurance Coverage
Deductions: Begin, increase, stop or decrease in the same pay period in which coverage begins, increases, stops, or decreases.
Event Allowing Change

Change Permitted? (To elect any option, employee must elect or retain Basic)
Option A - Standard
Option B - Additional

Basic

Option C - Family

0. New/Newly Eligible
Employee:

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

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).

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.

Yes. Coverage is effective the first day the employee is in
a pay and duty status on or after the date of OFEGLI's
approval and the agency receives the SF 2817.

Yes. Same as Option A.

No. An employee may NOT elect Option C by
providing medical information.

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.

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.

Coverage - Same as Basic.

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

Time Limit - Same as Basic.

Coverage - Same as Basic.

Yes. Employee may elect or increase multiples (up to 5
total). If the employee has Basic, Coverage is effective
the day the employing office receives the election, or
the date of the event, if the election is received before
the event. If Basic and Option C are elected at the same
time, Option C is effective when Basic becomes
effective.

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

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

Time Limit - Same as Basic.

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.

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

Same as Option A.
Yes. Employee may elect Option A within 60 days after
reinstatement. However, if employee does not submit

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.

No. However, if employee is later converted to a
non-excluded position, coverage is automatically
effective on the first day the employee is in a pay and
duty 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 in a pay and duty status in the
converted position on or after the date the agency receives
the SF 2817 electing such coverage.

5A. CANCELING/
WAIVING
COVERAGE:
employee/assignee

(Note: If the employee already has Basic, there is no
pay and duty status requirement for Option C.)
Same as Option A.

SF 2817 electing coverage within 60 days after
reinstatement, s/he has the same Optional
insurance carried before the break in service
effective to the beginning of the reinstatement.

Same as Option A.

A. Same as Basic.

Time Limit - Employee must submit the SF 2817 within
60 days after conversion to an eligible position.
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.

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.

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

or
5B. REDUCING
OPTION B and/or
OPTION C
MULTIPLES:
employee/assignee

Not applicable.

6. Open Season.

If permitted under conditions specified by OPM.

7. CERTAIN DEPT. OF
DEFENSE AND
CIVILIAN
EMPLOYEES
AFFECTED
BY PUBLIC LAWS
106-398 AND 110-417:

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.

B. Not applicable.

B. Yes. Employee may at any time reduce the number
of multiples. This new coverage is effective at
the beginning of the pay period following the
one in which the employing office receives the
SF 2817. Assignee(s) cannot reduce Option C.

Same as Basic.

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. This new coverage is
effective at the beginning of the pay period following
the one in which the employing office receives the
SF 2817.
Same as Basic.

Same as Basic.

No. An employee may NOT elect Option C via these
provisions of law.

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

Same as Basic.

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.

Back of Part 2

Standard Form 2817, Revised June 2018

Life Insurance Election

Federal Employees' Group Life Insurance Program

Federal Employees'
Group Life Insurance

1
2

See Privacy Act Statement on back of Part 3

*This election supersedes all previous elections. *

Name (last, first, middle)

Date of birth (mm/dd/yyyy)
OWCP claim number,
if applicable

Social Security Number

Location of department or agency where you Daytime telephone number
work (city, state, ZIP code)
(including area code)

Basic

Fill in identifying information concerning the employee.

Employing department or agency

Form Approved:
OMB No. 3206-0230

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

Date (mm/dd/yyyy)


Optional

Option A - Standard
I want Option A.
I authorize deductions to pay the full cost.

Option B - Additional

Option C - Family

3 multiples

1 times my pay

4 times my pay

1 multiple

4 multiples

2 times my pay

5 times my pay

2 multiples

5 multiples

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



Date (mm/dd/yyyy)

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


Date (mm/dd/yyyy)



Agency
Use

Remarks:

Name and address of employing office

If new/newly eligible employee,
enter "0" for event.

Date received in employing office Effective date of coverage
(mm/dd/yyyy)
(mm/dd/yyyy)

Number of event permitting
change
(See back of Part 2)

I followed the instructions on the back of Part 1.
Signature of authorized agency official

The employee's copy of this form, when completed by the employing office, together with the FEGLI Program Booklet (FE 76-21 or FE 76-20 for U.S. Postal Service
employees)
constitute the employee's Certificate (proof) of
Insurance.
PART 3 - Employee Copy
U.S. Office of Personnel Management
www.opm.gov/healthcare-insurance/life-insurance

Previous editions are not usable.

Standard Form 2817
Revised June 2018

Instructions for Employees
1.

General Information
The major provisions of this program are described in the Federal
Employees' Group Life Insurance (FEGLI) Program Booklet (FE 76-21
or FE 76-20 for U.S. Postal Service employees). Please read the entire booklet
carefully. Your completed copy of this election form (SF 2817) and the FEGLI
Program Booklet constitute your certificate (proof) of insurance. These
publications, as well as comprehensive FEGLI information, are available at
www.opm.gov/healthcare-insurance/life-insurance.

to the employee's employing office. If the insured is an annuitant, you should not
use this form. Instead, send a letter (email and/or FAX is not acceptable) to OPM
Retirement Operations Center, P.O. Box 45, Boyers, PA 16017-0045. See #11
for where to send the completed form or letter if the insured is a compensationer.
7.

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.

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.

To elect Basic: You do not have to submit this form unless you also wish to elect
Optional insurance. However, we recommend you do so to help document your
FEGLI coverage history.

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.

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.

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).

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.

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.

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.

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.

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

10.

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.

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/healthcare-insurance/life-insurance.

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).
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

Privacy Act Statement
Pursuant to 5 U.S.C.§ 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to collect the information
requested on this form by 5 U.S.C. Chapter 87. OPM is authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November
18, 2008). Purpose: The information collected on this form is used by eligible individuals to enroll or change enrollment status under the FEGLI Program. Routine Uses: The information requested on this
form may be shared externally as a "routine use" to other Federal agencies and third-parties when it is necessary to process your application. For example, OPM may share your information with other
Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary for determining your eligibility for refund, or to report income for tax
purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine uses can be
found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing
this information to OPM is voluntary. However, if you fail to provide this information, OPM may be unable to process and administer your life insurance benefit request.

Public Burden Statement
We estimate this form takes an average of 15 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our
estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0230),
Washington, DC 20415-0001. The OMB Number, 3206-0230 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Back of Part 3

Standard Form 2817, Revised June 2018

File Type	application/pdf
File Title	SF2817_2018_06
Author	CSBENSON
File Modified	2020-12-01
File Created	2018-02-28