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Form Approved OMB No. 3206-0136 Designation of Beneficiary Federal Employees Group Life Insurance Program Group Life Insurance Warning Read instructions on back of duplicate before filling in this form Information Concerning The Insured If you have not assigned your insurance YOU are the Insured as used throughout this form. Name of Insured Last first middle The Insured is Date of birth of Insured Month day year An employee Retired or an applican.

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