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Get Certification Of Insured Employee's Retired Status - Opm

D instructions on the Back of Part 3 before completing this form. A. Agency Report of Insurance Coverage 1. Name of retired employee (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security number 4. Mailing address (including ZIP code) 5. Plan or system under which retired 6. Retirement claim number (if any) 7. Annuity commencing date (mm/dd/yyyy) 8. Did employee retire on an immediate annuity? Yes 9. Did employee have Basic life insurance for the 5 years immedia.

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