Fillable Printable SF 2821
Fillable Printable SF 2821
SF 2821
U.S. Office of Personnel Management
The FEGLI Handbook for Personnel and Payroll Offices NSN 7540-01-231-5587 Previous editions are not usable
14b. Effective date of election
Death as a reemployed annuitant
End of 12 months non-pay status
Other (Specify)
Separation (includes resignation)
Retirement
Death as an employee
Had employee filed Application for Retirement
(SF 2801 or SF 3107) with OPM?
Agency Certification of Insurance Status
Federal Employees' Group Life Insurance Program
To Agency: See reverse for information and instructions
1. Name of employee (Last, first, middle) 2. Date of birth (Month, day, year) 3. Social Security number
4a. Event requiring certification 4b. Employee's retirement system 5. Disposition of Designations of Beneficiary
(SF 54, SF 2823)
4c. OWCP number (if applicable)
CSRS/FERS
TVA
DCRS*
FSRS
CIA
FICA
Other (Specify)
Attached
None
on file with this agency
On file in employee's Official Personnel
Folder
6. Did the employee assign his/her
insurance?
No
Yes (attach RI 76-10)
7. Did the employee elect living benefits?
Amount elected (check one and attach EOB)
No
Yes
Partial (post-election BIA $ )
Full
8. Date of event checked in item 4a
9. Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose
coverage as an employee terminates, including all retiring employees)
*D.C. Police & Fire/Public School Teachers
10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert
hourly, daily, piecework, etc., rate to annual rate)
11. Effective date of continuous coverage under the FEGLI Program (If any
break in service, list dates)
12a. Did employee have Option A - Standard Insurance on date in item 8? 13a. Did employee have Option C - Family Insurance on date in item 8?
No
Yes
12b. Amount of Option A
12c. Effective date of election
No
Yes
14a. Did employee have Option B - Additional Insurance on date in item 8?
No
Yes
13b. Effective date of election
14c. Number of multiples on date in item 8 14d. Lowest number of multiples during
last 5 years
15. Personnel records certification (This form will not be accepted without both personnel and payroll certification.)
I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal
Employee's Group Life Insurance on the date in item 8.
No
Yes
15a. Signature of certifying official (Facsimile not acceptable)
15b. Typed name of certifying official
15c. Title
15d. Date 15f. Telephone number (Including area code)
15e. Name and address of agency (Including ZIP Code)
16. Payroll records certification (This form will not be accepted without dual certification.)
I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree.
Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code
(Insurance code and SF 50 equivalent) on the date in item 8.
Alpha code
16a. Signature of certifying official (Facsimile not acceptable)
16b. Typed name of certifying official
16c. Title
16d. Date 16g. Payroll office number
16f.
Name and address of payroll office (If different from that given in item 15e)
Remarks (For agency use only) OPM use only
Standard Form 2821
Revised May 1995
PART 1 - Original
16e. Telephone number (Including area code)
PRINT
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U.S. Office of Personnel Management
The FEGLI Handbook for Personnel and Payroll Offices NSN 7540-01-231-5587 Previous editions are not usable
14b. Effective date of election
Death as a reemployed annuitant
End of 12 months non-pay status
Other (Specify)
Separation (includes resignation)
Retirement
Death as an employee
Had employee filed Application for Retirement
(SF 2801 or SF 3107) with OPM?
Agency Certification of Insurance Status
Federal Employees' Group Life Insurance Program
To Agency: See reverse for information and instructions
1. Name of employee (Last, first, middle) 2. Date of birth (Month, day, year) 3. Social Security number
4a. Event requiring certification 4b. Employee's retirement system 5. Disposition of Designations of Beneficiary
(SF 54, SF 2823)
4c. OWCP number (if applicable)
CSRS/FERS
TVA
DCRS*
FSRS
CIA
FICA
Other (Specify)
Attached
None on file with this agency
On file in employee's Official Personnel
Folder
6. Did the employee assign his/her
insurance?
No
Yes (attach RI 76-10)
7. Did the employee elect living benefits?
Amount elected (check one and attach EOB)
No
Yes
Partial (post-election BIA $ )
Full
8. Date of event checked in item 4a
9. Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose
coverage as an employee terminates, including all retiring employees)
*D.C. Police & Fire/Public School Teachers
10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert
hourly, daily, piecework, etc., rate to annual rate)
11. Effective date of continuous coverage under the FEGLI Program (If any
break in service, list dates)
12a. Did employee have Option A - Standard Insurance on date in item 8? 13a. Did employee have Option C - Family Insurance on date in item 8?
No
Yes
12b. Amount of Option A
12c. Effective date of election
No
Yes
14a. Did employee have Option B - Additional Insurance on date in item 8?
No
Yes
13b. Effective date of election
14c. Number of multiples on date in item 8 14d. Lowest number of multiples during
last 5 years
15. Personnel records certification (This form will not be accepted without both personnel and payroll certification.)
I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal
Employee's Group Life Insurance on the date in item 8.
No Yes
15a. Signature of certifying official (Facsimile not acceptable)
15b. Typed name of certifying official
15c. Title
15d. Date 15f. Telephone number (Including area code)
15e. Name and address of agency (Including ZIP Code)
16. Payroll records certification (This form will not be accepted without dual certification.)
I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree.
Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code
(Insurance code and SF 50 equivalent) on the date in the item 8.
Alpha code
16a. Signature of certifying official (Facsimile not acceptable)
16b. Typed name of certifying official
16c. Title
16d. Date 16g. Payroll office number
16f. Name and address of payroll office (If different from that given in item 15e)
Remarks (For agency use only) OPM use only
Standard Form 2821
Revised May 1995
16e. Telephone number (Including area code)
PART 2 - Enrollee/Assignee
U.S. Office of Personnel Management
The FEGLI Handbook for Personnel and Payroll Offices NSN 7540-01-231-5587 Previous editions are not usable
14b. Effective date of election
Death as a reemployed annuitant
End of 12 months non-pay status
Other (Specify)
Separation (includes resignation)
Retirement
Death as an employee
Had employee filed Application for Retirement
(SF 2801 or SF 3107) with OPM?
Agency Certification of Insurance Status
Federal Employees' Group Life Insurance Program
To Agency: See reverse for information and instructions
1. Name of employee (Last, first, middle) 2. Date of birth (Month, day, year) 3. Social Security number
4a. Event requiring certification 4b. Employee's retirement system 5. Disposition of Designations of Beneficiary
(SF 54, SF 2823)
4c. OWCP number (if applicable)
CSRS/FERS
TVA
DCRS*
FSRS
CIA
FICA
Other (Specify)
Attached
None on file with this agency
On file in employee's Official Personnel
Folder
6. Did the employee assign his/her
insurance?
No
Yes (attach RI 76-10)
7. Did the employee elect living benefits?
Amount elected (check one and attach EOB)
No
Yes
Partial (post-election BIA $ )
Full
8. Date of event checked in item 4a
9. Date of SF 2819, Notice of Conversion Privilege - Issuance Is Mandatory (Prepare SF 2819 for each employee whose
coverage as an employee terminates, including all retiring employees)
*D.C. Police & Fire/Public School Teachers
10. Annual basic pay (not basic insurance amount) on date in item 8 (Convert
hourly, daily, piecework, etc., rate to annual rate)
11. Effective date of continuous coverage under the FEGLI Program (If any
break in service, list dates)
12a. Did employee have Option A - Standard Insurance on date in item 8? 13a. Did employee have Option C - Family Insurance on date in item 8?
No
Yes
12b. Amount of Option A
12c. Effective date of election
No
Yes
14a. Did employee have Option B - Additional Insurance on date in item 8?
No
Yes
13b. Effective date of election
14c. Number of multiples on date in item 8 14d. Lowest number of multiples during
last 5 years
15. Personnel records certification (This form will not be accepted without both personnel and payroll certification.)
I certify that the above information was obtained from, and correctly reflects, official personnel records, and that the employee was covered by Federal
Employee's Group Life Insurance on the date in item 8.
No Yes
15a. Signature of certifying official (Facsimile not acceptable)
15b. Typed name of certifying official
15c. Title
15d. Date 15f. Telephone number (Including area code)
15e. Name and address of agency (Including ZIP Code)
16. Payroll records certification (This form will not be accepted without dual certification.)
I certify that I have compared the annual basic pay shown in item 10, above, with current payroll records and the figures agree.
Payroll deductions were being made or would have been made if the employee had been in pay status for the alpha code
(Insurance code and SF 50 equivalent) on the date in the item 8.
Alpha code
16a. Signature of certifying official (Facsimile not acceptable)
16b. Typed name of certifying official
16c. Title
16d. Date 16g. Payroll office number
16f. Name and address of payroll office (If different from that given in item 15e)
Remarks (For agency use only) OPM use only
Standard Form 2821
Revised May 1995
16e. Telephone number (Including area code)
PART 3 - File Copy
Instructions To Employing Agencies
Completion of Certification
1. This certification must be completed in triplicate whenever an employee's
insurance terminates or is scheduled to terminate due to:
a. Death
b. Retirement
c. Completion of 12 months in non-pay status including those cases where the
employee will be continuing all or some of his or her insurance while in
receipt of workers' compensation.
d. Any other reason, except under the following circumstances:
(1) Employee waived or declined all insurance on his or her most recent
SF 2817.
(2) If it is known that, within 3 calendar days after the insurance
terminates, the employee will return to Government service in the
same position or another position and he or she will be eligible to
reacquire insurance coverage.
2. In item 4b, indicate the retirement system under which the employee is covered.
If other than those shown, please specify. In item 4c, indicate the insured Office
of Workers' Compensation Programs case file number, if applicable.
3. In item 6, indicate whether the employee completed an Assignment of Federal
Employees' Group Life Insurance form (RI 76-10). If yes, attach the form. If the
assignee(s) subsequently reassigned the insurance, attach the applicable RI 76-10
form(s).
4. In item 7, indicate whether the employee elected living benefits. If yes, attach the
Explanation of Benefits (EOB) which was returned to the personnel office by
OFEGLI, and indicate whether full or partial benefits were elected. If partial,
indicate the dollar amount.
5. In item 9, give the date of the Notice of Conversion Privilege (SF 2819). In case of
death in service, where employee had no Option C coverage, leave this item blank.
6. In item 11, "effective date of continuous coverage under the FEGLI Program"
means the date the employee began FEGLI coverage without a break for any
reason, except separation from the Federal service or exclusion by law or
regulation. In addition to the effective date of continuous FEGLI coverage,
indicate the dates of any break in service.
7. In item 12, indicate the dollar amount of Option A. In most cases, this will be
$10,000. However, the amount may exceed $10,000 if the combined total of the
maximum basic insurance amount and the $10,000 for this option is less than the
employee's annual basic rate of pay (the rate actually payable).
8. In item 12, 13, and 14, "effective date of election" means the date the employee
began the optional FEGLI coverage without a break for any reason, except
separation from the Federal service or exclusion by law or regulation.
9. Appropriate officials must certify that the employee's personnel and payroll
records are consistent with the information reported on this form. The two
certifications (in items 15 and 16) may not be made by the same official;
however, a payroll certification may be made by a personnel officer who has
access to payroll records.
10. If this certification is prepared for reasons other than separation for retirement,
death, or end of 12 months in non-pay status, Do Not send the SF 2821 to OPM.
Give or mail the original (Part 1) and duplicate (Part 2) to the employee or
assignee(s), if applicable, with the SF 2819, for conversion purposes. However,
if the employee is receiving compensation benefits, and employment terminates
prior to the end of 12 months in non-pay status, check Other in item 4a and
forward the original (Part 1) of the SF 2821 to the Office of Personnel
Management, Retirement Operations Center, Boyers, PA 16017.
11. Important: When a duplicate SF 2821 is issued to replace one which is lost, it
must be clearly marked
"DUPLICATE".
Disposition of Certification
1. Death of Employee
a. Send duplicate (Part 2) of the SF 2821 to the Office of Federal Employees'
Group Life Insurance (OFEGLI), 200 Park Avenue, New York, NY
10166-0188.
b. Keep the original (preferably in the Official Personnel Folder or its
equivalent) for attachment to a claim for death benefits (Form FE-6) when
received.
c. If no claim is received, send the original (Part 1) SF 2821, upon request, to
OFEGLI.
d. If the deceased employee has any designation of beneficiary forms (SF 54
or SF 2823) on file, you must attach them to the original SF 2821 when it
is sent to OFEGLI.
e.
If the deceased employee has an Assignment of Federal Employees' Group
Life Insurance form (RI 76-10) on file, you must attach it to the original SF
2821 when it is sent to OFEGLI. If the employee elected Living Benefits,
attach the Explanation of Benefits (EOB) which was returned to the
personnel office by OFEGLI.
2. Retirement of Employee
a. If the retiring employee is applying for an immediate annuity and is eligible
and will be continuing all life insurance into retirement, attach the original
SF 2821 (Part 1), all designations of beneficiary (SF 54 or SF 2823), if any,
and all life insurance elections (SF 176 or SF 2817), to the Application for
Retirement and send these documents to OPM. Give the duplicate (Part 2)
of the SF 2821 to the employee. (Note: In a disability retirement case
where the retirement application has already been sent to OPM, attach the
original SF 2821 and the other insurance forms to the "final" Individual
Retirement Record [SF 2806/SF 3100 or equivalent].) If the retiring
employee has an Assignment of Federal Employees' Group Life Insurance
(RI 76-10) on file, you must attach it to the original SF 2821. If the retiring
employee elected Living Benefits, attach the Explanation of Benefits
(EOB) which was returned to the personnel office by OFEGLI.
b. If the employee is continuing Basic Life insurance into retirement, have
him or her complete SF 2818, Continuation of Life Insurance Coverage.
Attach the complete SF 2818 to the original (Part 1) SF 2821.
c. A retiring employee who will continue Basic Life insurance, but cancel
(and therefore NOT CONVERT) one or more of the options for which he
or she would otherwise be eligible, must complete SF 2817, Life Insurance
Election, declining those options. However, if the employee has assigned
his/her insurance, he/she may not cancel any insurance. Only the
assignee(s) may do so. If the effective date of the change in coverage
comes before the separation for retirement, process the SF 2817 as usual
and attach the original, with all other life insurance elections, to the
Application for Retirement. However, if the effective date of the change in
coverage falls after the date of separation for retirement, indicate as such in
item 6 of the SF 2817 designated Agency Remarks, give the employee his
or her copy, and attach both the original and Part 2 to the SF 2821. In either
event, OPM must have the executed SF 2817. The SF 2821 should be
completed to reflect the retiring employee's insurance status at the time of
separation for retirement and attached to the Application for Retirement.
d. If the retiring employee will continue Basic Life insurance, but convert
(and therefore NOT CANCEL) one or more of the options, complete the
SF 2821 and submit the original (Part 1) with the Application for
Retirement, as indicated in item 2a, above. However, if the employee has
assigned his/her insurance, he/she may not convert any insurance. Only the
assignee(s) may do so. The employee or assignee(s), if applicable, should
submit the duplicate SF 2821 (Part 2) with a completed SF 2819, indicating
which options he or she wishes to convert, to OFEGLI. Do Not have the
employee or assignee(s), if applicable, complete an SF 2817, Life
Insurance Election, declining the options being converted.
e. If the retiring employee or assignee(s), if applicable, prefers to convert (and
therefore NOT CANCEL) both Basic Life and all optional insurance(s) to
an individual policy, give him or her the original and duplicate (Parts 1 and
2) of the SF 2821 and an SF 2819. Retain designations of beneficiary (SF
54 or SF 2823), if any. Do Not have the employee or assignee(s), if
applicable, complete an SF 2817, Life Insurance Election, declining the
options being converted.
f. If the retiring employee is not eligible to continue life insurance coverage
into retirement, give him or her or assignee(s), if applicable, the original
and duplicate (Parts 1 and 2) of the SF 2821 and an SF 2819. Retain
designations of beneficiary (SF 54 or SF 2823), if any.
3. Employee is Receiving Compensation Benefits
a. Before completing items 12 through 14, contact the district Office of
Workers' Compensation, if necessary, to confirm whether the employee
still has any optional insurance.
b. A compensationer is considered a retired employee for purposes of life
insurance. Therefore, follow items 2a - 2f above.
4. All Other Cases
Give or mail the original and duplicate (Parts 1 and 2 of the SF 2821) to the
employee and/or assignee(s), as applicable.
5. In All Cases
Retain the file copy (Part 3) of the SF 2821 in the employee's Official Personnel
Folder or its equivalent.
Prompt Certification Required
The time in which an employee or assignee(s), if applicable, may convert group life
insurance to an individual policy is limited. This SF 2821 must be completed and
delivered or mailed promptly.
