Fillable Printable Request for Insurance
Fillable Printable Request for Insurance
Request for Insurance
Request
For
Insurance
Federal
Employees'
Group Life Insurance
(FEGLI)
Program
SF 2822
Instructions
(page 1
of 2)
Revised December 2013
Instructions
for
Employees
When
should
I
complete
this
form?
You should complete this form if:
•
you are in a position that makes you eligible for FEGLI
coverage (ask your human resources office if you don't
know), AND
•
at least one year has passed since the effective date of your
most recent waiver of Basic, Option A and/or Option B life
insurance, AND either:
you are not enrolled in the FEGLI Program, but would
like to be, OR
you are enrolled in the FEGLI Program, but you have
less than the maximum life insurance available and you
want more life insurance.
What is a waiver of life
insurance
coverage?
A waiver means you:
•
did not elect life insurance coverage when it was available to
you, OR
•
cancelled coverage you previously had, OR
•
elected less than the maximum coverage.
Can
I
use results
of a
physical
I
had last year for
another reason?
No. OFEGLI cannot accept a previous physical. Your physician
or other healthcare provider must perform the physical for the
purposes of this request for life insurance. OFEGLI must receive
this form within 60 days of the date of the physical.
What is
Basic insurance?
It is life insurance based on your annual salary, rounded up
to the nearest thousand dollars (if it is not already an even
thousand), plus $2,000. It includes accidental death and
dismemberment coverage (payment of more life insurance if
you die in an accident or lose a limb or eyesight.)
Basic also includes an Extra Benefit if you are under age 45 when
you die. The amount of Basic payable upon your death will be
double the regular amount if you are age 35 or under when you
die. Starting at age 36, the Extra Benefit reduces by 10 percent
per year, until at age 45 there is no Extra Benefit.
What is
Option A?
It is life insurance equal to $10,000. It is also called Standard
Optional insurance. Option A also includes accidental death and
dismemberment coverage.
Ask your human resources office if you don't know the effective
date of your last waiver, if any.
What
coverage
can I
get by
completing
this form? You
can get Basic, Option A, and Option B, if the Office of Federal
Employees' Group Life Insurance (OFEGLI) approves your
physical. OFEGLI is an administrative unit of Metropolitan
Life Insurance Company that processes these requests and
pays claims for the FEGLI Program.
You cannot get Option C by completing this form.
How do I
complete
this
form?
•
Ask your human resources office to complete Part A.
•
You must complete Part C. Answer all of the questions, or
mark N/A (for not applicable). Do not leave an answer
blank.
•
Bring this form to your physician or other healthcare
provider.
•
Sign in Part C, in the presence of your physician or other
healthcare provider.
•
Ask him/her to complete Part D.
•
Ask him/her to mail the completed form directly to OFEGLI.
•
OFEGLI must receive the form within 60 days of the date of
the physical.
Do
I
have to pay for this
physical?
Yes, you must pay any fee for the physical. Your agency or
OFEGLI cannot pay for it.
What is
Option B?
It is life insurance equal to 1, 2, 3, 4 or 5 times your annual salary
(after rounding your salary up to the nearest thousand dollars, if it
is not already an even thousand). It is also called Additional
Optional insurance.
What is
Option C?
It is life insurance for your family, available in 1 to 5 multiples.
Each multiple equals $5,000 for your spouse and $2,500 for each
eligible dependent child. It is also called Family Optional
insurance. You cannot elect Option C by completing this form.
You can only elect Option C during an open enrollment period or
if you have a life event (marriage, divorce, death of spouse, or
adding an eligible child to your family) and you already have
Basic.
When is
coverage effective?
Basic will be effective on the first day you are in a pay and duty
status on or after OFEGLI's approval date.
Option A and/or Option B will be effective on the first day you
are in a pay and duty status on or after OFEGLI's approval date
and on or after the date your agency receives your SF 2817, Life
Insurance Election.
However, if you are not in a pay and duty status within 60 days
after the approval date you will not have Basic insurance (unless
you already had it when you filled out this form), and you cannot
elect Option A or Option B. If you do not submit an SF 2817
within those 60 days, you cannot elect Option A or Option B.
What is pay and duty status
?
This means you are on duty, receiving pay. You are not on
annual leave, sick leave, administrative leave or otherwise absent
from duty.
SF 2822
Instructions
(page 2
of 2)
December 2013
Instructions
for
Employees
(continued)
How will
I
know if
OFEGLI
approves
my
physical?
Your human resources office will tell you. OFEGLI contacts
your human resources office as soon as it approves or denies your
request. You should contact your human resources office if it is
more than 2 weeks after the date your physician or other
healthcare provider performed the physical and you do not yet
know whether OFEGLI approved your physical.
My
agency
told me that
OFEGLI
approved
my
request.
What do I
do?
If you just want Basic insurance, you do not have to do anything.
You will automatically have it on the first day you are in a pay
and duty status on or after the date of OFEGLI's approval (as
long as you are in a pay and duty status within 60 days of
OFEGLI's approval.)
If you want Option A and/or Option B, you must complete
SF 2817, Life Insurance Election. Your human resources office
must receive your form within 60 days after OFEGLI's approval.
Sign for Basic and for Option A and/or Option B. Be sure to
mark the number of Option B multiples you want to have.
Approval of your physical allows you to elect up to a total of 5
multiples of Option B.
Each SF 2817 you complete replaces the previous form. You
must sign for all coverage you currently have and wish to keep,
AND you must sign for all new coverage you wish to elect. If
you have coverage now and do not sign for that coverage, you
have cancelled that coverage.
My
agency
told me that
OFEGLI
denied
my
request.
Can
I
appeal?
OFEGLI's decision is final. There are no formal appeal
procedures. You or your physician or other healthcare provider
may call OFEGLI at 1-800-633-4542 and ask why it denied your
request for insurance. Depending on the reason for the denial,
you may be able to submit additional medical evidence.
OFEGLI may have denied your request because you didn't wait
until at least one year after the date of your last waiver of
insurance. If so, you can wait until that year has passed, complete
another SF 2822, and have another physical. OFEGLI can
discuss your options.
Where can I
get more
information about
the FEGLI
program?
You can find more information on the FEGLI website at
www.opm.gov/insure/life. Read the FEGLI Booklet (FE 76-21
or FE 76-20 for Postal employees) and/or the FEGLI Handbook
(RI 76-26) (available in electronic format only).
Privacy Act
Statement
Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance,
authorizes the solicitation of this information. The Office of Federal Employees'
Group Life Insurance and your agency will use the data you furnish to determine
your eligibility to receive benefits under the FEGLI Program. This information
may be shared and is subject to verification, via paper, electronic media, or
through the use of computer matching programs, with national, state, local or
other charitable or social security administrative agencies in order to determine
benefits under their programs or to obtain information necessary for
determination or continuation of benefits under this program.
It may also be shared and verified with law
enforcement
agencies
when they are
investigating a violation or potential violation of 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. If you don't furnish the
requested information, you may not have the level of insurance protection you
want.
Request
For
Insurance
Federal
Employees'
Group Life Insurance
(FEGLI)
Program
Read instructions
before
completing
this
form.
Part A
Employing
Agency
1.
Employee's name
(last, first,
middle)
2.
Date of
birth
mm/dd/yyyy)
3. Social Security
number
4.
Employing
department/agency
(including bureau or
division)
5.
Work location (city
and
state)
6.
Employee's daytime
phone
number
( )
7. Has more than 1 year
passed
since the effective date of the
employee's
last w aiver or
cancellation
of FEGLI
coverage?
Yes
No
9.
Signature
of certifying
agency
official
11. Title of certifying
agency
official
8. Has the
employee
had any
continuous absence
of
at
least 3
weeks because
of
sickness
or injur y during
the
past
year?
Yes
13.
Name and mailing
address
of
agency
(type
or print)
To:
No
10.
D a t e
(mm/dd/yyyy)
12.
A g e n c y
telephone number
( )
14. Email
address,
if you
want
OFEGLI to email its
decision
15.
F A X
number,
if you
want
OFEGLI
to fax its
decision
( )
Part B OFEGLI
1.
To the
employing agency:
We
approve
this
request.
We den y this
request.
2. OFEGLI
Reviewer
3. Date
(mm/dd/yyyy)
Instructions
for
Agencies
When do we
complete
this
form?
Complete Part A of this form whenever an employee asks you to, IF the employee
is eligible for life insurance (see below). Be sure to include a complete, legible
address where OFEGLI can send you its approval/denial. OFEGLI will not retype
this address. It will fold this form and put it in a window envelope if you do not
give an email address or fax number. That is why it is vital that your address is
clear and complete.
When is an
employee eligible?
An employee is eligible if:
•
he/she is in a position that allows FEGLI coverage, AND
•
at least one year has passed since the effective date of his/her most recent
waiver or cancellation of life insurance coverage.
What do we do with the form after
completing
Part
A?
Give the form to the employee. The employee and his/her physician or other
healthcare provider must complete the rest of the form and send it to OFEGLI.
OFEGLI will consider the results of the physical and either approve or deny the
request for insurance.
How will we
receive
OFEGLI's
decision?
OFEGLI will send you its decision in one of three ways: by email, fax or regular
mail. If you give an email address in Block 14 above, OFEGLI will email its
decision to you. If you don't give an email address, but do give a fax number in
Block 15 above, OFEGLI will fax its decision to you. If you only give a mailing
address, OFEGLI will mail its decision to you.
When will we
receive
OFEGLI's
decision?
You should receive OFEGLI's decision within 2 weeks after it receives the form
from the employee's physician or other healthcare provider. If you have any
questions about the status of the decision, please call OFEGLI at 1-800-633-4542.
(Note: since this is Personally Identifiable Information (PII), you may need to
log in to MetLife’s secure email server to access the decision.)
U.S. Offi ce of
Personnel Management
FEGLI
Handbook
N S N
7540-01-231-5588
What if
OFEGLI
approves
the
request?
If the employee is not already enrolled in Basic, enroll the employee in
Basic, effective on his/her first day in pay and duty status on/after the date of
OFEGLI's approval.
•
•
Void the approval if the employee is not in a pay and duty status within 60
days of OFEGLI's approval. The employee does not have Basic unless
he/she already had it before completing this form.
•
Notify the employee of OFEGLI's approval immediately and tell the
employee to submit an SF 2817 within 60 days of OFEGLI's approval, if
he/she wants to elect Option
A and/or
Option B. Coverage is effective on
his/her first day in pay and duty status on or after you receive the SF 2817.
If the employee is not in a pay and duty status or doesn't submit an SF 2817
within 60 days of OFEGLI's approval, OFEGLI's approval is void. The
employee will not have Option A or Option B unless he/she already had
that
coverage
before completing this form.
•
File the form in the employee's official personnel folder or its equivalent.
What if
OFEGLI
denies
the
request?
•
Immediately contact the employee. Tell the employee that he/she doesn't
have Basic (unless he/she already had it before completing this form) and
cannot elect Option A or Option B. The employee will only have the
coverage
he/she
had before completing this form (if any).
•
File the form in the employee's official personnel folder or its equivalent.
SF 2822
2822-103
D o N o t U s e
Previous
Editions.
R e v i s e d D e c e m b e r
2013
Part C
Employee
1a.
Your
address
(number,
street, city, state, ZIP
code)
2.
Have y ou had any
change
in health in the past 5
years?
1b.
(
Daytime
telephone
number
)
3.
Have y ou
sought med ical
advice or
been treated
by a clinic,
hospital, physician,
or
healer
within the past 5
years?
4.
Have y ou ever
been denied
life or health
insurance,
or offered it at higher than normal
rates?
No Yes, give
details:
No Yes, give
details:
5.
No Yes, give
details:
Have you ever had or were you ever told you had the following?
Check
"Yes" or
"No"
.
If
"Yes",
e x p l a i n i n
5a.
Chest
p a i n , s w o l l e n
ankles,
or
disease
of heart or blood
vessels?
High blood
pressure?
How
high?
Asthma,
emphysema,
chronic
bronchitis
or
other
lung
diseases?
Liver
conditions, ulcers, or gastrointestinal
(G.I.)
conditions?
Disease
of kidney,
bladder,
m a l e o r f e m a l e
organs,
or albu min
or
sugar
in the urine?
Unconsciousness, para lysis, epilepsy,
or
other nervous
or m ental
disorder?
Cancer,
tumor, polyp, or
disease
of the
blood, spleen, or
lymph
glands?
Diabetes, tuberculosis,
or dr ug
habit?
Biopsy,
surgical operation,
or
radiation treatment?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Arthritis or any
muscular weakness
or
disorder?
Yes
No
In the last 5
years,
has any
physician
or health
professional
diagnosed, treated
you
for,
tested
you f or, or given you
medical
advice on injuries or
illnesses
not
shown
on this form?
If "Yes",
give details in 5a. Do not include colds or minor
injuries/illnesses
that
lasted
less than 5
days.
Yes
No
5a.
Briefly
state condition, dates,
duration,
and
kind
of
treatment.
Also
state names and
locations
of
doctors and
hospitals.
(Use a blank
sheet
if you
need
more
room.)
I
certify
that my
answers
are true and
complete
to the
best
of my
knowledge
and
belief.
6. Your
signature
(You must sign in the
presence
of
the
examining physician).
7. Date
(mm/dd/yyyy)
Part D Examining
Physician
or Other
Healthcare Provider
•
This examination is for Federal Employees' Group Life Insurance
•
Fully complete, sign and date this part.
purposes. We cannot accept an earlier exam.
DO NOT RETURN THIS FORM TO THE EMPLOYEE.
•
•
The employee must pay any fee for this examination. Do not
MAIL IT TO:
perform any special examinations or incur any unusual expense.
Office of Federal Employees' Group Life Insurance
•
Ask the employee to sign Item 6 in Part C in your presence.
P.O. Box 6080
Scranton, PA 18505-6080
1. Print
employee's
full
name
(last,
first,
middle)
2.
Gender
Two
readings,
sitting Systolic
Diastolic
General movements, strength, stamina,
responsiveness,
coordination,
etc.?
Yes
No
Nervous
systems and
reflexes?
Heart,
arteries,
or
veins?
Respiratory
system?
Yes No
Skin
and
glands?
Yes
No
G.U.
system?
Yes No
Any
murmurs
present?
Yes
No
Yes
No
Yes
No
Yes
No
3. Date of birth
(mm/dd/yyyy)
Male
Female
6.
Pulse (at
rest)
centimeter
or feet
and
inches
4.
Height
5.
Blood
pressure
First
reading
6a.
If
over 96, take
pulse a fter
Diastolic
at
7.
Weight
5
minutes
kilograms
or
pounds
5th
phase
Second
reading
8. Does
examination
reveal
abnormality of:
9.
Fully
describe
abnormalities.
(Use
a
blank
sheet
if you
need
more
room.)
Eyes,
ears, nose, throat?
Yes No
G.I.
system?
Extremities and
skeletal
or
muscular
system?
Yes
No
10.
I
certify that the
employee signed
Part C in my
presence;
that
I
have carefully
examined
the
employee;
and that
I
correctly
recorded
my
complete finding s.
Signature
of
examining physician
or other
healthcare
provider Date of
examination (mm/dd/yyyy)
11.
Name and
address
of
examining physician
or
other
healthcare provi der
Telephone number
( )
Back of
SF 2822
