FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM - COLLINS, CHARLES P.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: COLLINS CHARLES
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001426142
• 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: June 11, 1971

STANDARD FORM 56
JANUARY 1970
-AGENCY CERTbfCATION= OF 4'( INSURANCE STATUS -' (b) (3 )
UTVI
COMMISSION
(b) (6)
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87070-1 56-1 109
FPM SUPPLEMENT
era
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oyees
Group L1 e
insurance Program
1. NAME (Last) (First) (Middle) -).,DATE OF BIRTH (Month, oay, Year) 2(b). SOCIAL SECURITY ACCOUNT NUMBER
COLLINS,, Charles ,P. Z Dec 19.16
3. CHECK THE REASON. FOR TERMINATING INSURANCE
(a) [8 Separated (includes resignations)
(b) Retired NOTE: If the reason checked is "b; Retired".your group life insurance (but?
(c) E Died as an employee not accidental death and dismemberment benefits) will continue during retire-
(d) Died as a reemployed annuitant:- ment if you meet the conditions described in "Notice to Retiring Employee"
below.
(e) End of 12 months non-pay status
(f) Other (specify)
4. CHECK APPROPRIATE BOX CONCERNING SF 54, DESIGNATION OF BENEFICIARY
CURRENT A CURRENT SF 54 IS A CURRENT SF 54 IS ON FILE IN
(?) (b). X 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) IS RETIRING OR RECEIVING FEDERAL EMPLOYEES' COMPENSATION UNDER CONDITIONS ENTITLING HIM TO RETAIN HIS LIFE 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 54 IS ON FILE, CHECK BOX 4 (b).-1N`-ALL
OTHER CASES, SHOW WHETHER OR NOT CURRENT SF 54 IS ON FILE BY CHECKING BOX 4 (b) OR (c). A CURRENT SF 54 IS ONE THAT 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 CONVERSION
(MONTH, DAY, YEAR)
ANCE) ON DATE IN ITEM S. CONVERT DAILY, HOURLY,
IN ITEM 5? NO fl YES )
PRIVILEGE (SF 55) TO EMPLOYEE
PIECEWORK, ETC. RATE TO ANNUAL RATE.
IF YES, GIVE RECEIPT, DATE Of ELECTION OF OPTIONAL
(MONTH, DAY, YEAR)
28 May 1971
$ L9 PER ANNUM
S~JA
INSURANCE (
F'br Tq'6 8
9. I CERTIFY THAT THE ABOVE INFORMATION HAS BEEN OBTAINED FROM, AND CORRECTLY REFLECTS, OFFICIAL RECORDS AND THAT THE EMPLOYEE
NAMED WAS COVERED BY FEDERAL EMPLOYEES GROUP LIFE INSURANCE ON THE DATE SHOWN IN ITEM 5.
Personal signat
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Name and address of agency, including zip code
Central Intelligence
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I dYI 1971
 INSTRUCTIONS TO EMPLOYING AGENCY
COMPLETION OF CERTIFICATION
1. This Certification must be completed in triplicate whenever an employee's insurance terminates for:
a. Death.
b. Retirement on an immediate annuity with 12 or more years' creditable service, of which at least 5 years are civilian
service, or on account of disability. (An immediate annuity is one which begins to accrue not later than 1 month after
the date the insurance would normally cease.) In a disability retirement case, do not complete SF 56 until a finding of
disability has been officially made and the employee's separation is in order.
c. Completion of 12 months in a non-pay status or separation, and the employee is receiving benefits under the Federal
Employees' Compensation law, and held unable to return to duty.
._.Any.other._reason.,_ifJhe_employee-.desires-.Lo_.converthis-life insurance, except under the.,following..circurnstances:
(1) Employee waived or declined on SF 176 (or SF 176-T);
(2) If it is known that; within 3 calendar days after the date the insurance terminated, the employee will return to
Government service in-theiirne or'an'other'posttron in which he will be eligible to reacquire Federal Employees
Group Life Insurance;
(3) More than 75 days have elapsed from the date insurance terminated unless specific request is made therefor by
the Civil Service Commission or the' Office of Federal Employees' Group Life Insurance.
2. If insurance terminated on account of death, indicate in item 3(a) whether the employee had filed an Application for
Retirement (~~~180~)w(tYi the Civic-Servwe mission. " ?_ - ``- '"`"- ""`
3. In item 8, give date of Notice of Conversion Privilege (SF 55), except that if this form (SF 56) is issued in lieu of SF 55, give
current date. In case of death, leave this item blank.
4. It is important whenever a duplicate SF 56 is issued to replace one which has been lost, that it be clearly marked "DUPLICATE".
DISPOSITION OF CERTIFICATION
1. Death of employee
a. Send duplicate of SF 56 immediately to the Office of Federal Employees' Group Life Insurance.
b. Keep the original (preferably in the Official Personnel Folder or its equivalent) for attachment to a claim for death benefits
T ,(FoIrn;FE-6) -when-received
c if no claim is received send original SF 56, upon request, to the Office of Federal Employees' Group Life Insurance.
If the deceased employee has a current ,Designation of Beneficiary i(SF 54) on file, the SF 54 must be "attached to the
'original tSF 56"wrhenit is sent to the Office of Federal Employees' Group Life Insurance.
[jXbq cans o,,c+2u~Retrremeat rof employee-
applying a ie emplo'yeeis "loran `immediate annuity with 12 .or. more. years; creditable service, (of which at least 5
years are civilian service) or for disability, attach the original SF 56 and current Designation of Beneficiary (SF 54), if
.'t .~:
,an t. o tJie' Application for Retirement and give di u of SF 56 'to the employee, ee, NOTE: In a disability retirement
case where the retirement application has already been sent to the Civil Service Commission, attach'the original SF-56
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