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Fillable Printable SF 2822

Fillable Printable SF 2822

SF 2822

SF 2822

Request
For
Insurance
Federal
Employees'
Group LifeInsurance
(FEGLI)
Program
SF2822
Instructions
(page1
of 2)
RevisedDecember2013
Instructions
for
Employees
When
should
I
complete
this
form?
Youshouldcompletethis form if:
youareina positionthat makesyoueligibleforFEGLI
coverage(askyourhuman resourcesofficeif youdon't
know),AND
at leastoneyear has passedsince the effective date ofyour
mostrecentwaiverofBasic,OptionA and/orOptionB life
insurance, ANDeither:
youarenotenrolledintheFEGLIProgram,butwould
like to be,OR
youareenrolledintheFEGLIProgram,butyouhave
less thanthe maximumlife insuranceavailable andyou
wantmorelife insurance.
Whatisa waiver oflife
insurance
coverage?
A waivermeansyou:
didnotelectlife insurancecoveragewhenitwasavailable to
you,OR
cancelled coverageyou previously had,OR
elected less thanthe maximumcoverage.
Can
I
useresults
of a
physical
I
had lastyear for
anotherreason?
No. OFEGLIcannotaccept a previousphysical. Yourphysician
orotherhealthcare providermustperform the physical forthe
purposes ofthis requestforlife insurance.OFEGLImustreceive
thisform within60 days ofthe date ofthe physical.
Whatis
Basicinsurance?
It is life insurancebased onyour annualsalary, roundedup
to the nearest thousanddollars(if it is notalready an even
thousand),plus $2,000. It includesaccidentaldeathand
dismembermentcoverage(paymentofmorelife insuranceif
you diein an accident orlose a limboreyesight.)
BasicalsoincludesanExtraBenefitifyouareunderage 45 when
youdie.TheamountofBasicpayable uponyourdeathwillbe
double theregularamountifyouareage35 or under whenyou
die.Starting at age 36,the Extra Benefit reducesby 10percent
peryear,untilatage 45 thereisnoExtraBenefit.
Whatis
OptionA?
It is life insurance equalto $10,000. It is also called Standard
Optionalinsurance. OptionA alsoincludesaccidentaldeathand
dismembermentcoverage.
Askyourhumanresourcesofficeifyou don't know theeffective
date ofyourlastwaiver,if any.
What
coverage
can I
get by
completing
thisform?You
can get Basic, OptionA, andOptionB, if the Office of Federal
Employees'GroupLife 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.
Youcannotget OptionC by completingthis form.
How do I
complete
this
form?
Askyourhuman resourcesofficetocompletePart A.
YoumustcompletePart C.Answerallofthe questions,or
markN/A(fornotapplicable).Donotleave ananswer
blank.
Bringthis form toyourphysician orotherhealthcare
provider.
SigninPart C, inthe presenceofyourphysician orother
healthcare provider.
Askhim/hertocompletePart D.
Askhim/hertomailthecompletedformdirectlytoOFEGLI.
OFEGLImustreceive the form within 60days ofthe date of
the physical.
Do
I
have topay forthis
physical?
Yes,youmust payany feeforthe physical.Youragencyor
OFEGLIcannotpay forit.
Whatis
OptionB?
Itislife insurance equal to 1, 2,3, 4 or 5 timesyour annual salary
(afterroundingyoursalary up tothenearestthousanddollars,ifit
is notalready an eventhousand). It is also called Additional
Optionalinsurance.
Whatis
OptionC?
It is life insuranceforyour family,available in 1 to 5 multiples.
Eachmultiple equals $5,000 foryourspouseand$2,500 foreach
eligible dependentchild. It is also called FamilyOptional
insurance. YoucannotelectOptionC by completingth is form.
YoucanonlyelectOptionC duringanopenenrollmentperiodor
ifyouhave a life event(marriage,divorce,death of spouse,or
addinganeligiblechildtoyourfamily)andyou already have
Basic.
Whenis
coverageeffective?
Basicwill be effective onthe first day you are in a pay and duty
status onorafter OFEGLI's approvaldate.
OptionA and/orOptionB will be effective onthe first day you
are in a pay anddutystatus onorafter OFEGLI's approvaldate
andonorafterthe date youragencyreceives yourSF 2817, Life
Insurance Election.
However,ifyouarenotina pay and dutystatuswithin60 days
afterthe approvaldateyouwillnothaveBasicinsurance(unless
youalready haditwhenyoufilled outthisform),andyoucannot
electOption A orOptionB.Ifyou donot submitanSF 2817
withinthose60 days,youcannotelectOptionA orOptionB.
Whatispay anddutystatus
?
Thismeansyouareon duty,receivingpay.Youarenoton
annualleave,sickleave,administrativeleaveorotherwiseabsent
from duty.
SF2822
Instructions
(page2
of 2)
December 2013
Instructions
for
Employees
(continued)
How will
I
know if
OFEGLI
approves
my
physical?
Yourhuman resourcesofficewilltellyou.OFEGLIcontacts
yourhuman resourcesoffice as soonas it approvesordenies your
request. Youshouldcontact yourhuman resourcesofficeif itis
morethan 2 weeksafterthe date yourphysician orother
healthcare provider performedthephysicalandyoudo notyet
knowwhetherOFEGLIapprovedyour physical.
My
agency
told methat
OFEGLI
approved
my
request.
Whatdo I
do?
Ifyou justwantBasicinsurance,you donothavetodo anything.
Youwill automaticallyhaveit onthe first day youarein a pay
and dutystatus on or afterthe date ofOFEGLI's approval(as
longas you are in a pay andduty status within 60 days of
OFEGLI's approval.)
IfyouwantOption A and/orOptionB, youmustcomplete
SF 2817, Life InsuranceElection. Yourhuman resourcesoffice
mustreceiveyourformwithin60daysafterOFEGLI's approval.
SignforBasicandforOptionA and/orOptionB.Be sureto
markthe number ofOptionB multiplesyouwanttohave.
Approvalofyourphysical allows youtoelectup toa totalof 5
multiplesofOptionB.
EachSF 2817 youcompletereplacesthe previous form.You
mustsignforallcoverageyoucurrentlyhaveandwishto keep,
ANDyoumustsignforallnewcoverageyouwishtoelect. If
youhavecoveragenowanddonotsignforthat coverage,you
havecancelled that coverage.
My
agency
told methat
OFEGLI
denied
my
request.
Can
I
appeal?
OFEGLI'sdecisionisfinal.Therearenoformal appeal
procedures. Youoryourphysician orotherhealthcare provider
maycallOFEGLIat 1-800-633-4542 andaskwhyitdeniedyour
requestforinsurance.Dependingonthe reasonforthe denial,
youmaybeableto submitadditionalmedicalevidence.
OFEGLImayhave denied yourrequestbecause you didn't wait
until atleastoneyear afterthe date ofyourlastwaiverof
insurance. Ifso,youcanwait until that year haspassed,complete
anotherSF 2822, andhaveanotherphysical.OFEGLIcan
discussyouroptions.
Where canI
get more
informationabout
the FEGLI
program?
Youcanfindmoreinformation onthe FEGLIwebsite at
www.opm.gov/insure/life. ReadtheFEGLIBooklet (FE 76-21
orFE 76-20 forPostal employees)and/orthe FEGLIHandbook
(RI 76-26)(available in electronic format only).
Privacy Act
Statement
Chapter 87, title 5,U.S.Code,Federal Employees' GroupLifeInsurance,
authorizes thesolicitationof thisinformation.The Office of Federal Employees'
GroupLife Insurance and your agency will use thedatayou furnish todetermine
your eligibility toreceivebenefitsunder theFEGLIProgram.Thisinformation
maybeshared and issubjecttoverification,via paper, electronic media, or
through the use of computer matchingprograms,with national,state,localor
other charitableorsocialsecurity administrativeagenciesinordertodetermine
benefitsunder their programsortoobtaininformationnecessaryfor
determination or continuation ofbenefitsunder thisprogram.
Itmayalsobeshared and verifiedwithlaw
enforcement
agencies
whentheyare
investigatinga violationorpotentialviolation of civilorcriminallaw.Public
Law 104-134
(April
26,
1996) requiresthatany persondoingbusiness withthe
Federal governmentfurnish a SocialSecurity number ortax identification
number. Thisisan amendment totitle 31, Section 7701. Ifyou don't furnish the
requestedinformation,youmaynothavethelevel of insurance protectionyou
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 waiver 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 injury during
the
past
year?
Yes
13.
Name and mailing
address
of
agency
(type
or print)
To:
No
10.
Date
(mm/dd/yyy y)
12.
Agency
telephone number
( )
14. Email
address,
if you
want
OFEGLI to email its
decision
15.
FAX
number,
if you
want
OFEGLI
to fax its
decision
( )
Part B OFEGLI
1. To the
employing agency:
We
approve
this
request.
We deny 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. Office of
Personnel Management
FEGLI
Handbook
NSN
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 statuson 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
Do NotUse
Previous
Editions.
Revised December
2013
Part C
Employee
1a.
Your
address
(number,
street, city, state, ZIP
code)
2.
Have you had any
change
in health in the past 5
years?
1b.
(
Daytime
telephone
number
)
3.
Have you
sought medical
advice or
been treated
by a clinic,
hospital, physician,
or
healer
within the past 5
years?
4.
Have you 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",
explain in
5a.
Chest
pain, swollen
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,
maleor female
organs,
or albumin
or
sugar
in the urine?
Unconsciousness, paralysis, epilepsy,
or
other nervous
or mental
disorder?
Cancer,
tumor, polyp, or
disease
of the
blood, spleen, or
lymph
glands?
Diabetes, tuberculosis,
or drug
habit?
Biopsy,
surgicaloperation,
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 for, 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 after
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 findings.
Signature
of
examining physician
or other
healthcare
provider Date of
examination
(mm/dd/yyyy)
11.
Name and
address
of
examining physician
or
other
healthcare provider
Telephone number
( )
Back of
SF 2822
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