Notice Of Conversion Privilege Federal Employees Group Life Insurance Program {SF 2819}

Federal Employees Group Life Insurance Notice of Conversion Privilege Federal Employees' Group Life Insurance Program Part A - Instructions to Employing Agency Complete Part A of this form whenever an employee's life insurance coverage terminates due to separation, resignation, retirement, death or end of 12 months in non-pay status. On the date insurance terminates (except by waiver), give this notice to every employee and/or the assignee(s), if applicable, and to the family of each deceased employee who had the Option C-Family coverage. Also, upon request, give this notice to the family of an eligible employee who does not convert his or her Option C-Family insurance. If this notice is prepared for a retiring employee, forward Part 2 (duplicate) to OPM with the employee's retirement papers. Otherwise, place Part 2 (duplicate) in the employee's Official Personnel Folder. 1. Name of employee 4. Was employee insured for Option C-Family insurance on date in item 3? 2. Date of birth (mo., day, yr.) Yes 3. Date insurance terminated No Agency Certification I certify that the above information has been obtained from, and correctly reflects, official personnel records. 6. Name and mailing address of agency 5. Signature of authorized agency official 7. Typed name of authorized agency official 8. Title 9. Telephone number 10. Date of this notice (mo., day, yr.) Part B - Conversion Information for Employees, Assignees, and Family Members Who are Losing FEGLI Coverage If you are eligible and you will be carrying all of your Federal Employees' Group Life Insurance (FEGLI) coverage into retirement, do not apply for conversion. Employees (and assignees, if applicable) and their family members who are losing FEGLI coverage, however, may be eligible and wish to convert some or all of their coverage to an individual direct-pay policy. Employees - If you have not assigned your FEGLI coverage, you are entitled to convert to an individual direct-pay policy unless, within 3 calendar days after the date your insurance terminates, you return to a Government position that qualifies you to reacquire FEGLI coverage. You may purchase an individual policy in an amount equal to or less than your Basic life insurance plus any optional coverage you may have. Assignees - You are entitled to convert your share of the insured's FEGLI coverage to an individual direct-pay policy unless, within 3 calendar days after the date the insured's insurance terminated, he/she returns to a Government position that qualifies him/her to reacquire FEGLI coverage. If that is the case, his/her previous assignment is still valid. You may purchase an individual policy in an amount equal to or less than the amount of insurance which the insured assigned to you. Family members - If, upon termination of the employee's FEGLI coverage, he/she does not convert Option C-Family coverage (if any), you, as an eligible family member, may do so. Spouses may convert up to $5,000, and eligible children up to $2,500 each. Eligible family members are the employee's spouse and unmarried dependent children under age 22 (including adopted children, stepchildren who lived with the employee in a regular parent-child relationship, and recognized natural children) and unmarried dependent children over age 22 who are incapable of self-support because of a mental or physical disability that existed before they reached age 22. Your time to convert is limited - You must mail your request for information regarding conversion within 31 days of the date in item 3 of Part A above, or within 31 days of the date you receive this notice, whichever gives you more time. If you fail to request conversion information within the 31-day time limit due to a cause beyond your control, you may be allowed to convert your life insurance within six months after the date in item 3, provided you attach a full explanation of what prevented you from making a timely request. If approved, the effective date of the conversion policy will be retroactive to the day following the day group coverage ended. Note: Under certain circumstances, life insurance is payable if death occurs within 31 days after the group life insurance terminates, regardless of whether conversion has been requested. However, extension of the conversion privilege beyond 31 days does not extend coverage under any circumstances. If death occurs within the 31-day period, further information concerning possible benefits may be obtained from the agency named in item 6 above. General information about conversion If you have assigned your FEGLI coverage, you can only convert your Option coverage (if any). Your assignee(s) retain(s) the right to convert your other coverage(s). No medical examination is required. You or the assignee(s), if applicable, must pay the premium applicable to the individual policy. The government will not pay any part of the individual policy premium. The individual policy will be issued by an insurance company you select from the list of eligible companies you will receive if you apply for conversion. The individual policy may be an ordinary life policy or a variation of ordinary life (see Part D). It must be a type of insurance customarily issued by the insurance company you select. However, it cannot be term insurance or universal life insurance or any other form of life insurance that has an indeterminate premium. It cannot have disability or accidental death and dismemberment benefits. How to convert 1. Complete the appropriate eligibility statement on the reverse side of this form and mail it to the Office of Federal Employees' Group Life Insurance (OFEGLI), 200 Park Avenue, New York, NY 10166-0188. 2. If you have an SF 2821, Agency Certification of Insurance Status, attach the original (Part 1) to this form when you mail it to OFEGLI. Note: Retiring employees (and assignees of those employees) who are continuing Basic Life insurance but converting one or more of the options should submit their duplicate (Part 2) of the SF 2821with this form to OFEGLI. The original (Part 1) of the SF 2821 should be submitted with the retirement application. OFEGLI will mail you detailed information on how to apply for conversion, together with a list of eligible insurance companies. You have 31 days (from the date in item 3 of Part A above, or the date you receive this notice, wh ichever gives you more time) to request conversion information from OFEGLI. 3. In the event you do not have an SF 2821, you shou