ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE - MILLS, MONTRELL EUGENE

• Document Type: FOIA
• Keywords: MILLS MONTRELL E
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001308989
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Release Date: February 19, 2008
• Case Number: F-2005-00558
• Publication Date: February 19, 1968

 (b) (3) (b) (6) ELECTION. DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM TO COMPLETE -THIS FORM- FOLLOW THESE GENERAL INSTRUCTIONS: ?  Read the back of the "Duplicate" carefully before you fill in the form. ?  Fill in BOTH COPIES of the form. Type or use ink. ?. Do not detach any part. IMPORTANT AGENCY INSTRUCTIONS ON BACK OF ORIGINAL FILL IN THE IDENTIFYING INFORMATION BELOW (please print or type): 2 NAME   (last             (first)         (middle) DATE OF BIRTH (month; day, year) SOCIAL SECURITY NUMBER `                             /~       - , ,, `'   1924:... EMPLOYING DEPARTMENT OR AGENCY                        `' LOCATION (City, State,ZlP Coda) 3 MARK AN "X" IN ONE OF THE BOXES BELOW (do NOT mark more than one): Mark here - if you WANT BOTH optional and regular insurance Mark here if you DO NOT WANT OPTIONAL but do want regular insurance Mark here if you WANT NEITHER regular nor optional insurance (A) (B) ELECTION OF OPTIONAL (IN ADDITION TO REGULAR) INSURANCE I elect the $10,000 additional optional insurance and authorize the required deductions from my salary, compensation, or annuity to pay the full cost of the optional insurance. This optional insurance is in addition to my regular insurance. DECLINATION OF OPTIONAL (BUT NOT REGULAR) INSURANCE I decline the $10,000 additional optional insurance. I understand that I cannot elect op- tional insurance until at least 1 year after the effective date of this declination and unless at the time I apply for it I am under age 50 and present satisfactory medical evidence of insurability. 1 understand also that my regular insurance is not affected by this declina- tion of additional optional insurance. WAIVER OF LIFE INSURANCE COVERAGE I desire not to be insured and I waive coverage under the Federal Employees Group Life Insurance Program. I understand that I cannot cancel this waiver and obtain regular in- surance until at least 1 year after the effective date of this waiver and unless at the time I apply for insurance I am under age 50 and present satisfactory medical evidence of in- surability. (understand also that I cannot now or later have the $10,000 additional optional insurance unless 1 have the regular insurance. 4   SIGN AND DATE. IF YOU MARKED BOX "A" OR "C", COMPLETE THE "STATISTICAL STUB." THEN  RETURN THE ENTIRE FORM TO YOUR EMPLOYING OFFICE. FOR EMPLOYING OFFICE USE ONLY `i~NtitlS~~d .~C 3~13.~0 ~~t W~ 8~~ ~~  t~ 93~ APPROVED FOR R DATE: NOV 2007 ORIGINAL COPY-Retain In Official Personnel F                     STANDARD FORM No. ?176-T JANUARY 1968 (For use only 176-lOlril 14, 1968)