SERVICEMEMBERS’ GROUP LIFE INSURANCE – SPOUSE COVERAGE (FSGLI) ELECTION AND CERTIFICATE FORM (SGLV 8286A)

Forms and Documents

Document Name	Status
Form SGLV 8286A SERVICEMEMBERS' GROUP LIFE INSURANCE – SPOUSE COVERAGE (FSGLI) ELECTION AND CERTIFICATE FORM (SGLV 8286A) Form	New
Supporting Statement(2900-NEW).docx Supporting Statement A	2023-12-07
2023-26872.pdf Supplementary Document	2023-12-07
2023-21800.pdf Supplementary Document	2023-10-03

IC Document Collections

IC ID	Document Title	Status
262351	SERVICEMEMBERS' GROUP LIFE INSURANCE – SPOUSE COVERAGE (FSGLI) ELECTION AND CERTIFICATE FORM (SGLV 8286A) Form	New

ICR Details

OMB Control No:	ICR Reference No: 202309-2900-004
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VBA-INS-NK
Title: SERVICEMEMBERS’ GROUP LIFE INSURANCE – SPOUSE COVERAGE (FSGLI) ELECTION AND CERTIFICATE FORM (SGLV 8286A)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/07/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,600	0
Time Burden (Hours)	267	0
Cost Burden (Dollars)	6,816	0

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Abstract: Family Servicemembers' Group Life Insurance (FSGLI) provides insurance coverage to spouses of Servicemember’s Group Life Insurance (SGLI) insured individuals. SGLI and all associated insurance programs are VA benefits. The SGLV 8286A form is used by Service Members and their spouses when the Service Member is unable to access their Servicemembers Group Life Insurance Online Enrollment System (SOES) account to electronically elect, increase, decrease or decline coverage. If the member is increasing or electing coverage on their spouse after prior declination or reduction and the spouse has health issues, the member’s uniformed service reviews the request and sends to the primary insurer for the SGLI program, The Prudential Insurance Company of America (Prudential), through its’ Office of Servicemembers’ Group Life Insurance (OSGLI), to underwrite and make a decision on coverage. This form ensures members, and their spouses can continue to use the form to manage their FSGLI spousal benefits.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 21800	10/03/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 26872	12/07/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
SERVICEMEMBERS' GROUP LIFE INSURANCE – SPOUSE COVERAGE (FSGLI) ELECTION AND CERTIFICATE FORM (SGLV 8286A)	SGLV 8286A	SERVICEMEMBERS’ GROUP LIFE INSURANCE – SPOUSE COVERAGE (FSGLI) ELECTION AND CERTIFICATE FORM

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,600	0	0	1,600	0	0
Annual Time Burden (Hours)	267	0	0	267	0	0
Annual Cost Burden (Dollars)	6,816	0	0	6,816	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $16,694

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/07/2023

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