Form SGLV 8286A SGLV 8286A SERVICEMEMBERS’ GROUP LIFE INSURANCE – SPOUSE COVERAGE (

OMB Control No. 2900-New
Respondent Burden: 10 minutes
Expiration Date: xx/xx/xxxx
Spouse Coverage Election and Certificate
The SGLI Online Enrollment System (SOES) is the official system of record for Servicemembers’ Group Life Insurance for the United States
Navy, the United States Army and the United States Air Force. All coverage and beneficiary elections for members of the Navy, the Army
and the Air Force should be made in SOES. This form should only be used in special circumstances as defined by the United States Navy,
the United States Army and the United States Air Force.
By law, if you are insured under SGLI and your spouse is not a member of the uniformed services, your spouse is automatically insured
for $100,000 or the amount of your SGLI coverage, whichever is less. If your spouse is also a member of the uniformed services and you
were married on or after January 2, 2013, spouse SGLI coverage is not automatic.
Please check the appropriate box below. I am completing this form to:
Increase, restore, or apply for spouse coverage (complete Parts I, II, III, and IV)
Reduce spouse coverage (complete Parts I, II, and IV)
Decline spouse coverage (complete Parts I, II, and IV and in the space below write “I do not want coverage for my spouse at this time.”)
“_____________________________________________________________________________________________”

Part I – Service Member Information
1. Print Name (First, Middle, Last)

3. Branch of Service

2. Social Security Number

4. Amount of SGLI now in force

5. Amount of coverage desired for spouse
(available in $10,000 increments)

Part II – Spouse Information
7. Social Security Number

6. Print Name (First, Middle, Last)

9. Mailing Address (street, city, state, ZIP)

8. Date of Birth

10. Telephone Number

Part III – Spouse’s Health Information (to increase, restore, or apply for spouse coverage)
11. Weight in pounds

12. Height in feet and inches

13. Gender
Female

14. Have you had or been treated for known indications of:
a. A heart condition
Yes
No
b. High blood pressure
Yes
No
c. A neurological disorder
Yes
No
d. Diabetes
Yes
No
e. Cancer or tumors
Yes
No

Male

17. Did you answer “YES” to any question? If so, reference the question
by letter and list date, duration and details below.

15. Do you have any known physical impairments, deformities,
or ill health not covered above?
Yes
No
16. Have you ever been diagnosed as having a disease
or disorder of the immune system? Yes
No
The answers I have given are for securing approval of this request for insurance and I certify that they are true and correct to the
best of my knowledge and belief. I understand that the insurance being requested requires approval of insurability by the Office of
Servicemembers’ Group Life Insurance. Any deception or knowingly false statement either by inference or omission may result in
cancellation of the insurance or in the refusal to pay a claim.
Signature of spouse ____________________________________________________ Date Signed __________________________
GL.2013.066 Ed. 11/2022

SGLV 8286A

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Part IV – Certification by Service Member
The answers provided in Part III are for securing approval of this request for insurance and I certify that they are true and correct to
the best of my knowledge and belief. I understand that the insurance being requested requires approval of insurability by the Office
of Servicemembers’ Group Life Insurance. Any deception or knowingly false statement either by inference or omission may result in
cancellation of the insurance or in the refusal to pay a claim.
If I chose to reduce or decline spouse coverage, I understand this coverage can only be restored by providing proof of good
health and compliance with other requirements. It will also affect the amount of insurance my spouse can convert when spouse
coverage expires.
Signature of Service Member ______________________________________________ Date Signed __________________________

For Branch of Service Use Only

For OSGLI Use Only

Name of Personnel Clerk (please print)

Representative

Rank, title, or grade

Approve

Contact telephone/e-mail

Disapprove

Date

Date

Address

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy
Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., use by VA employees and your authorized representatives in the
maintenance of Government Insurance programs) identified in the VA system of records, 36VA29, Veterans and Uniformed Services Personnel
Programs of U. S. Government Life Insurance - VA, published in the Federal Register. Your obligation to respond is voluntary, but your failure to
provide us the information could impede processing. No insurance may be granted unless a completed application form has been received (38 U.S.C.
2106 and 38 CFR 8a3(e)). Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of
benefits . VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of
law in effect prior to January 1, 1975, and still in effect. The responses you submit are considered confidential (38 U.S.C. 5701).
RESPONDENT BURDEN: We need this information to determine, establish or verify your eligibility for VA Insurance benefits. Title 38, United States
Code, allows us to ask for this information. We estimate that you will need an average of 10 minutes to review the instructions, find the information, and
complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to
respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at
www.reginfo.gov/public/do/PRAMain. If desired, you can call1-800-827-1000 to get information on where to send comments or suggestions about this
form.

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Directions To Personnel Clerks Of The Uniformed Services
For Spouse Coverage Election and Certificate
1. All appropriate items on this form must be completed.
2. The amount of the service member’s SGLI coverage should be verified to make sure the amount requested for the spouse
does not exceed that of the service member.
3. A representative of the uniformed services must complete the “For Branch of Service Official Use Only” section to indicate receipt of
the form from the member (whether in person, by mail, or electronically) and should include the date the form was received.
4. This form, properly completed, is authority to a payroll office to change or stop the deductions for spouse coverage premiums
if the amount of insurance is changed or canceled.
5. After the form is completed in its entirety, you should:
• Enter form data into the SGLI Web application
• Make one copy of the completed form (pages 1 and 2)
• File a copy in the member’s official personnel file
• Provide a copy to the service member
6. Additional copies may be required as directed by your service.

Responses to questions 14, 15, and 16
If the answers to all items in question 14 and questions 15 and 16 are “No,” then the completed form should be retained in the member’s
personnel file. Once this is done, action should be initiated to deduct premiums from the member’s pay. It is not necessary to send a
copy of this form to the Office of Servicemembers’ Group Life Insurance (OSGLI) for approval.
If the answers to any item in question 14 or questions 15 or 16 are “Yes,” then the spouse should also complete question 17.
A copy of the completed form should be sent to:
Office of Servicemembers’ Group Life Insurance
PO Box 41618
Philadelphia, PA 19176-1618
Upon receipt, OSGLI will review the application and return an annotated copy to the member’s organization showing whether the
request is approved or disapproved. The copy returned from OSGLI is to be filed in the member’s personnel file. No action should be
taken to deduct the premium from the member’s pay until the “APPROVED” form is received from OSGLI. At this time, the premium
deduction should begin with the pay for the month when a service member elects to have his/her spouse covered. (Note: If the spouse
dies between the time the form is submitted to OSGLI and the time it is returned marked “APPROVED,” the insurance will be paid. If the
form is returned marked “DISAPPROVED,” the insurance will not be paid.) If the request for insurance is disapproved, OSGLI will return
the form with a letter of explanation to the Commanding Officer. The member should be notified that he/she may write to OSGLI or call
1-800-419-1473 for further explanation.

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Directions To Service Member
1. Type or print in ink except where otherwise noted.
2. Complete Parts I and II.
3. Your spouse must complete Part III if increasing, restoring, or applying for spouse coverage.
4. You must read, sign, and date Part IV. An authorized agent of the uniformed services must witness your signature.
Important Information
Spouse coverage is granted under the Servicemembers’ Group Life Insurance provisions of title 38, United States Code, and is
subject to this law and the regulations pertaining to this law.
Periods of Coverage
Coverage for spouses began on November 1, 2001, for service members insured under SGLI who were married as of that date.
Otherwise, coverage for spouses begins on the date of marriage to the insured service member, unless your spouse is also a member
of the uniformed services and you were married on or after January 2, 2013. In those instances spouse coverage is not automatic.
Coverage for spouses ends 120 days after any the following events: 1) The date a service member elects in writing to terminate
the spouse coverage. 2) The date a service member elects in writing to terminate his or her own coverage. 3) The date of a service
member’s death. 4) The date a service member separates or is released from uniformed service. 5) The date of divorce from a
service member.
An insured spouse may elect to convert his or her coverage to a commercial policy within 120 days following one of the events listed
above. The service member or spouse must contact the Office of Servicemembers’ Group Life Insurance as soon as possible after the
event to get a list of participating companies and more information on converting. A list of participating companies can also be found
at www.benefits.va.gov/insurance.
Information about Dependent Child Coverage
By law, if you are insured under SGLI, each of your dependent children is automatically insured for $10,000. Coverage for dependent
children of service members insured under SGLI began on November 1, 2001. For natural children born after November 1, 2001,
coverage begins on the date of birth of the child. Coverage for those who are not natural children of the insured service member begins
on the date when the child becomes a qualified dependent of the member. Dependent children include, but are not limited to, natural
born children, legally adopted children, and stepchildren who are members of the service member’s household, who are under the age
of 18, or who became permanently incapable of self-support prior to age 18, or who are under age 23 and are full-time students. For a
more complete definition of dependent children, please refer to title 38 USC, the first sentence of section 101(4)(A).
Coverage for children ends 120 days after any of the following events: 1) The date a service member elects in writing to terminate his
or her own coverage. 2) The date a service member separates or is released from the uniformed service. 3) The date of a service
member’s death. 4) The date the children no longer qualify as insurable dependents of the service member.

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Provisions for Payment of Insurance
The service member will receive the proceeds upon the death of his or her spouse or child. Payment of the proceeds for the death of a
spouse will be made through the Alliance Account®, check, Electronic Funds Transfer (EFT), or 36 equal monthly payments.* Payment
of the proceeds for the death of a child will be made through the Alliance Account, check, or Electronic Funds Transfer (EFT). If two
insured service members are married, the proceeds paid from the death of a child will be paid to the member who was eligible for
SGLI coverage the longest. If an insured service member is separated or divorced from another insured service member, insurance
proceeds from the death of a child will be paid to the member who has custody of the child.
How to File a Claim
Upon the death of your spouse or child, you should notify the Casualty Office within your branch of service. The Casualty Office will
submit a Report of Death of Family Member (SGLV 8700), a copy of the death certificate, and this form to the Office of Servicemembers’
Group Life Insurance.
Cost of Coverage – Premiums for Spousal Coverage
Spouse’s age

Monthly rate
per $10,000

Monthly cost for
$100,000 coverage

Under 35

$0.50

$5.00

35–39

$0.65

$6.50

40–44

$0.85

$8.50

45–49
50–54
55–59
60 & older

$1.30
$2.50
$3.70
$5.00

$13.00
$25.00
$37.00
$50.00

The Office of Servicemembers’ Group Life Insurance (OSGLI) administers Servicemembers’ Group Life Insurance and Veterans’ Group Life
Insurance under the supervision of the Department of Veterans Affairs. OSGLI is a division of The Prudential Insurance Company of America.
*The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America,
located at 751 Broad Street, Newark, NJ 07102-3777. Draft clearing and processing support is provided by The Bank of New York Mellon. Alliance Account balances are not insured by
the Federal Deposit Insurance Corporation (FDIC). The Bank of New York Mellon is not a Prudential Financial company.

18788661

SGLV 8286A

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