ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE - COLLINS, CHARLES P.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: COLLINS CHARLES
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001426141
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: March 20, 2008
• Case Number: F-2007-01041
• Publication Date: May 26, 1971

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.
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
EMPLOYING DEPARTMENT R AGENCY
L CATION (City, State, ZIP Code)
HAVE YOU EVER BEFORE FILED AN "ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE"? ^ YES ^ NO
If "YES," your last such form remains in effect and you should not file this new form unless you want to change the old one. (See Instructions for
Employees on page 4.)
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)
(C)
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 additions. 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. I understand also that my regular insurance is not affected by this declina-
tion of additional optional insurance.
APPROVFED FOR RELEASE
DATE: < DEC 2007
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. I understand also that I cannot now or later have the $10,000 additional
optional insurance unless I have the regular insurance.
4 DATE AND SIGN. RETURN THE ENTIRE FORM TO
YOUR EMPLOYING OFFICE.
L YL
FOR EMPLOYING OFFICE USE ONLY
(offir, as miieigiy4 dfey stamp)
R :7
STANDARD FORM No. 176
APRIL 1968
FPM Supplement 870?-1
176-102
 INSTRUCTIONS TO
1. Who must file.-SF 176 must be filed by-
? a new employee who is not excluded by law or regu-
lation from insurance. This includes one with prior
Government service that ended before February 14,
1968, and for whom no SF 176-T is on file,
? an employee appointed to a nonexcluded position
following service during which he was ineligible for
insurance,
? an employee desiring to change his insurance cover-
age.
Give a new employee copies of SF 176 and SF 176-A when
he reports for duty and ask him to return the completed
SF 176 showing his election promptly (preferably before
the end of the first day period) but in no case later than 31
days after his appointment date.
An employee with prior Government service in a non-
excluded position from which he was separated after Feb-
ruary 14, 1968, will have an SF 176 (or SF 176-T) on file
in his official personnel folder. This election, declination, or
waiver remains in effect, and he is accordingly insured, or
not insured, in his new employment. He is not required to
file anew SF 176.
Until his election, declination, or waiver can be verified,
make deductions based on his statement concerning earlier
insurance coverage in his "Declaration of Appointee"
(SF 61).
4n employee with newly acquired insurance eligibility
(e.g., one transferred or converted from an excluded to a
nonexcluded position or status), must be given the same
opportunity to complete an SF 176 as a new employee.
An employee desiring to change his insurance may at
any time file an SF 176 declining his optional insurance or
waiving his regular (and optional, if any) insurance.
EMPLOYING AGENCIES
An employee who is under age 50 may also request a can-
cellation of a waiver of regular insurance or a declination
of optional insurance any time after it has been in effect
one year. The employee is first required to submit a "Re-
quest for Insurance" (SF 51). If the Office of Federal
Employees' Group Life Insurance approves the SF 51,
notify the employee and ask him then to submit an SF 176
showing his election.
2. Employees failing to file.-If a new employee (or
newly eligible employee) does not promptly return a com-
pleted SF 176, contact him and urge him to do so even if
he does not want optional insurance. (He will, of course,
be automatically covered for regular insurance.)
If he still fails to file an SF 176 within 31 days after, ap-
pointment (or after becoming eligible), file one for him
as of that date; mark box 8, and note in the space pro-
vided for his signature "employee contacted on (date)
failed to elect optional insurance."
3. Review of completed SF 176.-Review both copies of
the SF 176 to see that it is legible, complete, and correct.
If er/ "iyee waives (marks box C) it is advisable to con-
tact him and ascertain whether this expresses his inten-
tion or is an error on his part.
4. Date of receipt and effective date.-Stamp date of
receipt by employing office in the space provided for this
purpose on both the original and the duplicate, The date
of receipt automatically determines the effective date as
shown in the table below.
5. Disposition of SF 176.-File the original SF 176 in the
official personnel folder in all cases. The duplicate may
be destroyed if not needed for payroll purposes or after
the requirements of the agency's payroll system have been
met.
TABLE OF EFFECTIVE DATES
New employee (never before filed SF 176 or SF 176-T)
EFFECTIVE DATE OF DEDUCTIONS
OPTIONAL coverage effective on date SF 176 received by
OPTIONAL and REGULAR deductions begin with pay period
employing office or on first day in duty and pay status, if
in which coverages are effective.
later; REGULAR coverage effective on first day in duty
and pay status.
Declination effective on date SF 176 received in employing
REGULAR deductions begin with pay period
coverage is
office; REGULAR coverage effective on first day in duty
effective. No OPTIONAL deductions.
and pay status.
If received during first pay period, waiver effective on receipt;
No deductions if waiver received during first
pay period;
if received after first pay period, then on last day of pay
REGULAR deductions, if begun, stop last day of pay period
period in which received.
in which waiver is received.
Present or former employee (previously filed SF 176 or SF 176-T)
PRESENT INSURANCE
COVERAGE
Waived coverage
REGULAR coverage effective on first day
in duty and
OPTIONAL and REGULAR deductions begin
pay status after date of approval of "
Request for
with pay period in which respective coverages
Insurance" (SF 51) by OFEGLI; OPT
IONAL cov-
are effective.
erage effective on first day in duty an
d pay status
after date of approval of SF 51 and r
eceipt of SF
176 by employing office.
REGULAR coverage effective on first day
in duty and
REGULAR deductions begin with pay period in
pay status after date of approval of "
Request for
which coverage is effective.
Insurance" (SF 51) by OFEGLI.
Has regular insurance
OPTIONAL coverage effective on first
day in duty
OPTIONAL deductions begin with pay period in
only
and pay status after date of appro
val of "Re?
which coverage is effective.
quest for Insurance" (SF 51) by O
FEGLI and
receipt of SF 176 by employing offic
e.
Has regular and op-
Cancellation of OPTIONAL coverage e
ffective on
OPTIONAL deductions stop last day of pay
tional Insurance
last day of pay period in which SF 17
6 received;
period in which declination is received;
REGULAR coverage continues.
REGULAR deductions continue
Has regular (or regular
W
aives insurance
Waiver of REGULAR coverage (and can
cellation of
.
REGULAR (and OPTIONAL, if any) deductions
and optional) insur?
OPTIONAL, if any) effective on last
day of pay
stop on last day of pay period in which
ance
period in which received.
waiver is received.
NOTES: 1. Approval by OFEGLI of a "Request for Insurance" (SF 51) is good for only 31 days. Regular coverage cannot become effective if employee is not in duty and pay
status within 31-day period. Optional coverage cannot become affective unless the employee is in duty and pay status and also returns an SF 176, showing an election
of optional Insurance, to his employing office within the 31-day period. If approval of SF 51 expires, new SF 51 must be submitted to OFEGLI.
2. An employee for whom the agency files SF 176 because he failed to do as is deemed to have declined optional, but not regular, insurance.
3. The effective date of regular (and optional, if not declined) coverage for an employee who has been an leave without pay for more than 12 months is the first day
he is in pay and duty status. Deductlorns are effective the same day.