Fillable Standard Form 2819 - Notice Of Conversion Privilege printable pdf download

Notice of Conversion Privilege

Federal Employees' Group Life Insurance Program

Federal Employees

Group Life Insurance

Part A - Instructions to Employing Agency

C-Family coverage. Also, upon request, give this notice to the family of an eligible

Complete Part A of this form whenever an employee’s life insurance coverage

terminates due to separation, resignation, retirement, death or end of 12

employee who does not convert his or her Option C-Family insurance.

months in non-pay status. On the date insurance terminates (except by

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

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

(duplicate) in the employee’s Official Personnel Folder.

1. Name of employee

2. Date of birth (mo., day, yr.)

3. Date insurance terminated

Yes

4. Was employee insured for Option C-Family insurance on date in item 3?

Agency Certification

I certify that the above information has been obtained from, and correctly reflects, official personnel records.

5. Signature of authorized agency official

6. Name and mailing address of agency

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

General information about conversion

Insurance (FEGLI) coverage into retirement, do not apply for conversion. Employees (and

If you have assigned your FEGLI coverage, you can only convert your Option

assignees, if applicable) and their family members who are losing FEGLI coverage,

coverage (if any). Your assignee(s) retain(s) the right to convert your other

however, may be eligible and wish to convert some or all of their coverage to an individual

coverage(s).

direct-pay policy.

No medical examination is required.

You or the assignee(s), if applicable, must pay the premium applicable to

Employees - If you have not assigned your FEGLI coverage, you are entitled to convert to

the individual policy.

an individual direct-pay policy unless, within 3 calendar days after the date your insurance

The government will not pay any part of the individual policy premium.

terminates, you return to a Government position that qualifies you to reacquire FEGLI

The individual policy will be issued by an insurance company you select

coverage. You may purchase an individual policy in an amount equal to or less than your

from the list of eligible companies you will receive if you apply for

Basic life insurance plus any optional coverage you may have.

conversion.

Assignees - You are entitled to convert your share of the insured’s FEGLI

The individual policy may be an ordinary life policy or a variation of ordinary

coverage to an individual direct-pay policy unless, within 3 calendar days after the date the

life (see Part D). It must be a type of insurance customarily issued by the

insured’s insurance terminated, he/she returns to a Government position that qualifies

insurance company you select. However, it cannot be term insurance or

him/her to reacquire FEGLI coverage. If that is the case, his/her previous assignment is still

universal life insurance or any other form of life insurance that has an

valid. You may purchase an individual policy in an amount equal to or less than the amount

indeterminate premium. It cannot have disability or accidental death and

of insurance which the insured assigned to you.

dismemberment benefits.

Family members - If, upon termination of the employee’s FEGLI coverage,

How to convert

he/she does not convert Option C-Family coverage (if any), you, as an eligible family

1. Complete the appropriate eligibility statement on the reverse side of this

member, may do so. Spouses may convert up to $5,000, and eligible children up to $2,500

form and mail it to the Office of Federal Employees' Group Life Insurance

each. Eligible family members are the employee’s spouse and unmarried dependent

(OFEGLI), 200 Park Avenue, New York, NY 10166-0188.

children under age 22 (including adopted children, stepchildren who lived with the

2. If you have an SF 2821, Agency Certification of Insurance Status, attach

employee in a regular parent-child relationship, and recognized natural children) and

the original (Part 1) to this form when you mail it to OFEGLI. Note: Retiring

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.

employees (and assignees of those employees) who are continuing Basic

Life insurance but converting one or more of the options should submit their

Your time to convert is limited - You must mail your request for information

duplicate (Part 2) of the SF 2821with this form to OFEGLI. The original

regarding conversion within 31 days of the date in item 3 of Part A above,

(Part 1) of the SF 2821 should be submitted with the retirement application.

or within 31 days of the date you receive this notice, whichever gives you more time. If you

OFEGLI will mail you detailed information on how to apply for conversion,

fail to request conversion information within the 31-day time limit due to a cause beyond

together with a list of eligible insurance companies. You have 31 days (from

your control, you may be allowed to convert your life insurance within six months after the

the date in item 3 of Part A above, or the date you receive this notice,

date in item 3, provided you attach a full explanation of what prevented you from making a

wh ichever gives you more time) to request conversion information from

timely request. If approved, the effective date of the conversion policy will be retroactive to

OFEGLI.

the day following the day group coverage ended.

3. In the event you do not have an SF 2821, you should request a completed

form from the employing agency before the expiration of your 31 day time

Note: Under certain circumstances, life insurance is payable if death occurs within 31 days

limit and forward it to OFEGLI at the address given in item 1 above.

after the group life insurance terminates, regardless of whether conversion has been

However, don't delay sending the SF 2819 requesting conversion

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 to OFEGLI -- send it anyway while you await the SF 2821.

information concerning possible benefits may be obtained from the agency named in item 6

4. If you are using this form to convert some of your life insurance coverage,

above.

but not Option C, have your employing office prepare another SF 2819 for

your family members.

Part 1 - Employee/Assignee/Family Member

Standard Form 2819

Office of Personnel Management

Rev. May 1995

FEGLI Handbook for Personnel and Payroll Offices

NSN 7540-01-231-5586

2819-102

Previous editions are not usable

Standard Form 2819 - Notice Of Conversion Privilege

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