FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM - CARANCI, JOHN C.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: CARANCI JOHN
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001411664
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: December 31, 2008
• Case Number: F-2007-00327
• Publication Date: April 22, 1970

STANDARD FORM 56
NUARY 1970
J
AGENCY CERTIFICATION OF INSURANCE STATUS (b](61
A
U,$ CIV SERVICE COMMISSION
FPlrf-SUfPLEM NT 8t0 j ra ; _ s -1.9~
(b1[31
F decal ,y,Em to tees Group Li insurance Program
1 .NAME-.... .(last).. __.._ (Q) DATIE-Q BIIhTJi.IM_a+!b,:ngy","~earL
I i
2b) SOCIAL SECURITY ACCOUNT NUMBER
,
.,Caranci ,To n C Feb 7, 1192
3 CHECK THE REASON FOR-TERMINATING INSURA ICE
(a) E Separated (includes resignations)
ceasor checked _i; 'b
Retired" your group life insurance (but
(b) Retired NOTE t the
_
,
`
'
"
"
gnd dismemberment benefits) will continue during retire-
tti.
accide
tafde
(c) Died as an employee not
-(d)~-Died as-a- reemployedannuitan't APPROVED FOR RELEASE^ DATE: 'n "Notice to Retiring Employee".,.
(e) Encl?of 12 months non-pay status
(f) 1+6&r" (specify) 10-Nov-2008
4. CHECK APPROPRIATE BOX CONCERNING SF 54, DESIGNATION OF BENEFIt-iARY -------
A-
CURRENT CURRENT SF 54' 15 A CURRENT SF 54 IS ON FILE IN
(a). (b). NOT ON FILE WITH THIS (c). THE EMPLOYEE'S OFFICIAL PERSONNEL
SF 54 ATTACHED AGENCY FOLDER (OR EQUIVALENT)
NOTE: IF EMPLOYEE (A) DIED. OR (B) ISM RETIRING OR' RECEIVING FEDERAL EMPLOYEES COMPENSATION UNDER CONDITIONS ENTITLING HIM, TO RETAIN HISiIIFE ?INSURANCE; ATTACH.
CURRENT _SF 54,' IF ANY, TO ORIGINAL SF" 56 AND CHECK BOX' 4 (a)" ON ORIGINAL AND. ALL COPIES OF SF 56`; IF NO`CURRENT SF_541 S. ON FILE CHECK BOX 4 (b) `IN ALL
OTHER CASES, SHOW WHETHER-OR NOT-CURRENT SF-,54 IS'-ON FILE BY CHECKINGBOX'4 (b)"OR`{(c)A CURRENT SF`54'IS"ONETI1AT"HAS'NOT'BEEN'CANCELED'"BY EMPLOYEE
OR AUTOMATICALLY BY TRANSFER OR PRIOR TERMINATION OF INSURANCE.
5. DATE OF EVENT CHECKED; IN. ITEM 3
6,;ANNUAL.BASIC PAY RATE,.(NOT AMOUNT OF INSUR-
7:: DID, EMPLOYEE. HAVE OPTIONAL INSURANCE ON DATE
8, DATE, OF, NOTICE OF; ,CONUERSLON
(MONTH, DAY, YEAR),
ANCE)'ONDATE IN ITEM 5., CONVERT DAILY, HOURLY,.
IN,LTEM 5? NO (J,YES~.(],,
'
PRIVILEGE. (SF 55). TO.. EMPLOYEE
'
PIECEWORK, ETC. RATE TO ANNUAL RATE.
IF YES,'GIVE RECEIPT DATE OF ELECTION'OF OPTIONAL
(MONTH,
DAY: YEAR)
A ril 22 t 9'?0
P
S:$PER ANNUM
INSURANCE (SF 176 or 176-T)
c, -7.1,
9: I CERTIFY THAT THE ABOVE INFORMATION HAS BEEN OBTAINED FROM; AND CORRECTLY:REFLECTS, OFFICIAL RECORDS ANDTHAT THE EMPLOYEE
NAMED WAS COVERED BY. FEDERAL,EMP.LOYEES,GROUP.LIFE INSURANCE ON. THE DATE SHOWN IN.ITEM 5 i??
Personal signature ofauthorized agencyofficial
Name and.address of agency, mduding_zip code
Typed name of authorized agency offical
Title
::.
_P
Date'
A G 7i
11970
As a retired' employee, your regular life insurance (riot ocddental`dkoth and disrriembem erit) Will be'continued w(thout'costtoyo;`provided i
? You do not convert to an individual policy of life insurance; and
? You' retire -with 12 or more years' creditable service of which at least 5 years are civilian service, or on account of disability; and
? You continue your regular in3uran'ce;'arid ...` `
? You have had optional insurance from the time it first became available to you; and
? Your monthly annuity is sufficient, after all other deductions, to pay the full cost; and
1, You continue, to pay the. fujl cost until youreach,oge,,,65 (the.cost will be deducted from your monthly annuity, check)..
Your" life insurance as a retired employee will be reduced by 2% each month beginning at age 65 or at retirement whichever is later: The maximum C N,- , C _,?:
You may,-if `ou' refer, convert our n'surance''fo?&n individual life`insuraric'e' h ' m'arramount not to"exceeid''Your'combined 're"'9i1Or.and'opptional
Y FS Y ~ minsurance. Or you may continue your regular insurance free after retirement, if eligible as described above, and convert only your optional insurance.
Your empJpymg office wdlimstruFt you on the procedure to follow if you want to convert only your optional insurance.
If you are eligible to continue your ltfe~'rtsurance as a retired employee, your employing agency {)as, been instructed to attach the ORIGINAL of this form
to your dpplication for'reti"cement unless you prefer to convert your regular insurance to"anlTndividuapolicy.
If you receive the-ORIGINAL copyLof thrs::Certification.aafter you file your application for retirement, and you do not want to convert your regular insur-
ance to an mdividuol polfey, forwardthe ORtGINAL,asaoon as-possible to the agency orofficetwhich admn;sters your; retirement system.
Keep the DUPLICATE copy foryourself: You will ' be notified by the Civil Service Commission of your insurance rights.;
?5r
n_ ..: .;-L1EAT'H, WITHIN 31: DAY5
Under certain conditions, life insurance is payable if death occurs within 31 days after an employee's group insurance terminates, even though the
employee had%riof"applied"for'conversion. If death occurs within this period, further iiif"oriNdtion concerning possible benefits should be obtained from
the agency ndiniedin'item above," oz ri ~. , r >,~~ is a~=_nf
:u., c; ; ; 6 ta:: r+NOTICEFQ"EMPLOYEE RECEIVING FEDERAL EMPLOYEES' COMPENSATION
While you, arec.receiying monthly,.,benefits. under,:thezFederal: Emplo",yees' cCmmpensation- low :and: are-held; by?the>Departmentt::of, Labor-to-ibe;:_unabledo
return to duty, your life insurance (not accidental death and dismemberment) may be continued. -
Instructions on how you may apply to continue your insurance coverage while receiving Federal employees' compensation are contained on the back of
PART 1-the ORIGINAL copy of this Certification, which is to be sent to the U. S. Civil Service Commission, Bureau of Retirement, Insurance, and
the .Dl''1pG~CA E ce'?" "fora of FSelf:'
Occupational Health, Washington, D. C. 20415. Keep
py" Y ?
 IMPORTANT-tNFORMATION?`ON-CONVERS1O
Any individual, policy purchased under aicconversion privilege is a prnvat 6usipess transactrwn {bel een rev nrtctzrtkealellig 6lesinsw4m?e i
company you select. Here are some important: things-you sbouid know e : c E2 Cis g; ,g cV1; 3
tlonal insurance...
n z. t?Cip lns0?Wceat.olf t4~lf'7fisaGi r ainfl
You must pay, the, premium applicable to ;the:type-Ot.,,, : s; .,,,deaths as i dis emfiierrme {ben tit ,a eu sXs ew"
policy'' you, select and, your__:age-and; class o rrsk. r:. ..smut' o her, qe uoy iaaa,i 3c c aer; i~
fo ci uc t a h I,r;,
The Government will not,pay any part of he pre, , ,\ Jr I Armed S,al 'examinafi ona is r,
q~u}re d o ? IIr9 # of i s w-w
TYPES O'F POLICIES. -,The type'of Fridividurrt policy yolk-iePect`='sfioud'b^e=?deteimrired by frtds' rpose''"wfiir`I f`f61 #1Sy i te= e `
?? `.# ??? ????_ ~???? #- ?? - r - ,js-z s L f PJ9 Yt o l6 ti~rls#Si:6` A4 1"'i"t5A8t. Idi L` f 3#d WOXWflIid'
in3urance policies are primarily colkiafion or modificafons of these threes] The rth ee b s c, o de escrl a elow
~t q
- oL er one, two, or three years.
'return for premium payments throughout your. entire life. The oohcy, builds a caash~value aft
;,You may withdraw this cash if you "d`ecide-to"stop paying premiums. Also, lyou may borrow upon it atany time for any
;.purpose., } c} _,j e ..,. a I , ,s:u z~ nt ' c .ou.accofll~ of go
s SOST QF INDIVIDUAL POLICY-Life insurance policies are issued ion; a part~icipPtlnlra fQr . 60 X94 00 _ ?, 37
951.000 6 U
44.00 `^ > 5
z s 4u1 sir. Qk: c ;i t t W ".h 1' S+A" 2C Ivr 2EC71it~Lt YCGC~11 1 I=
ri0_W TO.; CONVERT To'convert todo Individual p2shcy, fotlow^fh instrrrcYrags-tttre bdaffi . this
.. .v .:wa tt ` MY tKw '~o N1 ti'UnLO C'G 14 +3 #
Ierrincation;
-E 2J '1Z
02' '~ WC Y.11