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Fillable Printable Form FE-7

Fillable Printable Form FE-7

Form FE-7

Form FE-7

Claim for Dismemberment Benefits
Federal Employees’Group Life Insurance (FEGLI) Program
Instructions
Form FE-7
Do NOT use previous Revised December 2013
OFEGLI Form in Adobe Acrobat PDF ( 12/13)
“You”, “your” and “I” refer to the insured employee.
Who completes this form?
Employees enrolled in the FEGLI Program who lose a limb or eyesight
complete this form.
How do I complete this form?
Complete Part Aand ask your physician or other healthcare provider to
complete Part C. Then give the form to your human resources office.
Should I attach anything to this form?
Yes. Attach copies of all medical reports from treatment you received for this
accident. Also attach any police, traffic or other reports about this accident.
How can I get help completing this form?
Contact your human resources office or call the Office of Federal
Employees’Group Life Insurance (OFEGLI) at 1-800-633-4542.
Can someone complete this form on my behalf?
Yes. If you are physically or mentally unable to complete this claim
form, someone else can complete it for you and attach a short explana-
tion of the reason you are unable to complete this form. Items 1-8 of
Part Aand all of Parts B and C should be about you, but the person
completing this form should sign his/her name and give his/her address
and telephone number.
Part A- Employee’s Statement
1. Your name (Last, first, middle)2. Date of birth (mm/dd/yyyy) 3. Social Security number
4. Your department or agency, including bureau or division
5. Location of employment (City, state and ZIP code)
6. Date of accident (mm/dd/yyyy)
7. Place of accident (City and State)
8. Give a brief description of the accident.
All statements I made on this claim form are true. I have not knowingly left out anything related to this claim. I authorize my physician or other healthcare provider to release any
information requested about this claim.
Your SignatureAddress
Telephone numberDate (mm/dd/yyyy)
(day)
(evening)
Employing Agency’s Instructions
Please help the employee complete this claim form, if necessary. The employee should return this form after the physician or other health care provider com-
pletes Part C. Complete Part B and send this form to:
Office of Federal Employees’Group Life Insurance
PO Box 6080
Scranton, PA 18505-6080
Part B - Agency’s Certification
1. Annual rate of basic pay for Basic Life insurance purposes on the date of the accident$
2. Was the employee covered by Option Aon the date of the accident? NOYESIf “YES,”
I certify that this information correctly reflects official records and that the employee was covered by Federal Employees’Group Life Insurance on the date of the accident.
Signature of authorized agency officialName of agency
Name of authorized agency official (type or print)Mailing address of agency, including ZIP code
Title
Date (mm/dd/yyyy)Telephone numberFax number
()()
Area codeArea code
Date of election(mm/dd/yyyy)
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Complete for Loss of Vision Only
13. Give the date of exam and vision before the accident.
Date: (mm/dd/yyyy)
14. State the loss of vision.
15. Give the date you first determined vision was irrecoverably reduced to
20/200 (Snellen Notation) or less with correction, and the vision
remaining in each eye on that date.
Date: (mm/dd/yyyy)
16. Give the date and vision found on last eye examination.
Date: (mm/dd/yyyy)
17. Is recovery of useful vision possible by operation or treatment?
Right eye
Left eye
18. If eye is enucleated, give date.
19. If fields of vision are contracted, show contraction on chart below.
Left EyeRight Eye
OperationTreatment
OperationTreatment
Part C - Physician’s Statement
1. Name of patient2. Date of Birth (mm/dd/yyyy)
3. Date of accident (mm/dd/yyyy)4. Date first consulted because of this injury (mm/dd/yyyy) 5. Date of last treatment (mm/dd/yyyy)
6. Describe the exact nature, location, and extent of all injuries sustained. (Attach all medical reports relevant to the treatment of the injury)
7. Were the injuries described solely responsible for the loss of limb or eyesight?YES
NOGive the particulars of any cause or causes (including
disease) which contributed to the loss, in the space to the left.
(Explain on a separate sheet if necessary)
FE-7 (0509) Printed in U. S. A.
Reverse of FE-7
Revised December 2013
OFEGLI Form in Adobe Acrobat PDF (12/13)
Complete for Limb Amputations Only
8. Which limbs were severed or amputated?
9. On what date(s) did the severances or amputations occur?
10. State the exact point where the amputation was performed or where the severance
occurred for each limb lost. If the severance or amputation was below the elbow or
knee joint, indicate in item 12 on the chart below the exact point of severance.
11. Reason for amputation(s)?
I certify that all of my statements are true to the best of my
knowledge and belief.
Physician’s Signature Date
(mm/dd/yyyy)
Physician’s Name (type or print)
Office address - number and street
City, state and ZIPcode
Telephone numberFax number
()()
Area codeArea code
Uncorrected Corrected
Right
eye
Left
eye
(Snellen
Notations)
Uncorrected Corrected
Right
eye
Left
eye
(Snellen
Notations)
Uncorrected Corrected
Right
eye
Left
eye
(Snellen
Notations)
RIGHTLEFT
RIGHTLEFT
CHART
RIGHTLEFT
90º
80º
70º
60º
50º
40º
30º
20º
10º
10º
20º
30º
40º
50º
60º
70º
80º
270º
80º70º60º50º40º30º20º10º 10º20º30º40º50º60º60º50º40º30º20º10º 10º20º30º40º50º60º70º80º
120º60º
120º60º
150º30º
330º
300º240º300º240º
210º
180º
90º
80º
70º
60º
50º
40º
30º
20º
10º
10º
20º
30º
40º
50º
60º
70º
80º
270º
Yes NoYes No
12.
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