Get OPM SF 2823 1995

SF 2823 Revised April 2001 Examples of Designations 1. How to designate one beneficiary Mary E. Brown Show beneficiary s full name. Print Form Federal Employees Group Life Insurance Save Form Clear Form Designation of Beneficiary Form Approved OMB No* 3206-0136 Important Read instructions on the Back of Part 2 before completing this form* DO NOT erase or cross-out. Use a new form* A. Information About the Insured not the Assignee if there is one type or print Name of Insured Last first middle The Insured is Place an X in the appropriate box. Date of birth of Insured mm/dd/yyyy an employee Social Security Number of Insured CSI or OWCP claim number a retiree a compensationer Department or agency where the Insured works If retired last department or agency where the Insured worked Bureau or division Location city state and ZIP code First name middle initial and last name of each beneficiary Address Including ZIP code Relationship Percent or fraction designated Total Must equal 100 or 1. 0 Do not use dollar amounts Do not put a Total if you designated types of insurance. See example 4 on Back of Part 1. C. Statement of Insured or Assignee type or print Your name and address Including ZIP code Please check one I am Please check all three I have not assigned the insurance. an Assignee See Back of Part 2 for definitions Two people who witnessed my signature signed below. I did not name either witness as a I understand that if there is a valid assignment on file only the assignee has the right to designate a beneficiary. If a valid assignment is not on file but there is a valid court order on file with the agency or the U*S* Office of Personnel Management as appropriate any designation I complete for the same benefits is not valid* Employees Group Life Insurance will pay benefits according to the next most recent valid designation* If there isn t one it will pay according to the order listed on the Back of Part 2. See When Is A Designation Canceled on the Back of Part 2. I am canceling any and all previous Designations of Beneficiary under the Federal named above. Signature of Insured/Assignee Only the Insured/Assignee may sign* Signatures by guardians conservators or through a power of attorney are not acceptable. This form is not valid unless the Insured/Assignee signs in this box. Date mm/dd/yyyy D. Witnesses To Signature A witness is not eligible to receive a payment as a beneficiary. Signature of witness E* For Agency Use Only Receiving agency U*S* Office of Personnel Management FEGLI Handbook RI 76-26 Date of receipt mm/dd/yyyy Signature of authorized agency official Title Part 1 - Original NSN 7540-01-231-6228 2823-103 Previous editions are not usable. Do not write names as M. E* Brown or as Mrs. John H. Brown* If you want to designate your estate enter My estate in the beneficiary column* 000-00-0000 214 Central Avenue Munice IN 47303 Niece or 1. Read instructions on the Back of Part 2 if you need more room* Jose P. Lopez 111-11-1111 Rosa L* Rowe 222-22-2222 360 Williams Street Red Band NJ 07701 792 Broadway Whiting IN 46392 Nephew one-half Mother Someone to receive the benefits if the person you designate dies before the Insured dies John M. .