Student 2015 Non-Tax Filers Statement
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4Statement of Claim — Option C
Family Life Insurance
Federal Employees' Group Life Insurance Program
Instructions
General
The Office of Federal Employees’ Group Life Insurance (OFEGLI) pays claims under the Federal Employees’ Group Life Insurance
Program.
“We” and “our” on this form refer to OFEGLI.
“I” and “you” refers to the individual completing this form.
How do I complete this form?
• Read the instructions carefully.
• Please type or print legibly in ink.
• Complete parts A, B and C.
What else do I have to send with this claim form?
In addition to this claim form, you must send a certified copy of the deceased’s death certificate that contains the cause and
manner of death. You can get the certificate from your city’s or state’s Bureau of Vital Statistics or equivalent agency. We
cannot accept a photocopy of the death certificate. We will let you know if we need anything else.
What should I do if I need help completing this form?
If you need help in completing this form, you may contact our customer service representatives, toll-free, at 1-800-OFE-GLIA
(1-800-633-4542).
Where do I send this form and other documents?
Please do not send your claim form and other documents directly to OFEGLI.
• If you are an active employee, send everything to your employing office.
• If you are retired or receiving Federal Workers' Compensation benefits, send everything to:
Office of Personnel Management (OPM)
Retirement Operations Center
Attention: FE6-DEP
Boyers, PA 16017
What should I do if I no longer want Option C — Family Life Insurance?
• If you are an active employee, contact your employing office.
• If you are retired or receiving Federal Workers' Compensation benefits, write to:
Office of Personnel Management (OPM)
Retirement Operations Center
Attention: Annuity Adjustment Section
Boyers, PA 16017
Please include your retirement or compensation claim number and be sure to sign your letter.
Instructions to the employing agency/retirement system
• Complete Part D of this claim form.
• If the claim requires that you determine eligibility for foster children or disabled children older than age 22, first review the definitions
on page 4 and then complete Part D of this claim form. Please note that OFEGLI does not need the background documentation.
• Send the completed claim form and certified death certificate to:
OFEGLI
P.O. Box 2627
Jersey City, NJ 07303-2627
Do not use previous editions
Page 1
Form FE-6 DEP
Revised April 2004
OFEGLI Form in Adobe Acrobat PDF (04/04)
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