ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE - CARANCI, JOHN CHARLES

Document Type: 
Keywords: 
Collection: 
Document Number (FOIA) /ESDN (CREST): 
0001498523
Release Decision: 
RIPPUB
Original Classification: 
U
Document Page Count: 
2
Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
Sequence Number: 
Case Number: 
F-2007-00327
Publication Date: 
February 27, 1968
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PDF icon DOC_0001498523.pdf157.31 KB
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(bli61 (b1I31 FOLLOW THESE GENERAL INSTRUCTIONS: ? Read the back of the "Duplicate" carefully before you fill in th ? Fill in BOTH COPIES of the form. Type or use ink. ? Do not detach any part. TO COMPLETE THIS FORM- IMPORTANT AGENCY INSTRUCTIONS ON BACK OF ORIGINAL APPROVED FOR RELEASED DATE: 12-Nov-2008 FILL IN THE IDENTIFYING INFORMATION BELOW (please print or type): L /?A )\ C_. / ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM DATE OF BIRTH (month, day, year) 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) (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 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. I 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. I understand also that I cannot now or later have the $10,000 additional optional insurance unless I 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. SIGNATURE (do not print) DATE ORIGINAL COPY-Retain in Official Personnel Folder STANDARD FORM No. 176-7 JANUARY 1968 (For use only until April 14, 1968) 176-101 INSTRUCTIONS TO EMPLOYING AGENCY 1. Who must file.-All employees not excluded by law or regulation from insurance coverage, including those who have previously waived coverage, are required to com- plete and file Standard Form 176-T. Employees who are in the service on February 14, 1968, as well as those who are appointed after that date but before April 14, 1968, must file the form. 2. Automatic cancellation of previously filed waiv- ers.-All "Waivers of Life Insurance Coverage" (SF 53) on file are automatically canceled as of the first day of the first pay period beginning on or after February 14, 1968. Payroll offices are to begin regular insurance deductions on the automatic cancellation date for employees who do not file a new waiver, i.e., those who do not check box C of SF 176-T, on or before that date. 3. Employees failing to file.-If an employee does not return a completed SF 176-T, 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 in- surance). If he still fails to file SF 176-T by April 14, 1968, or 31 days after appointment, whichever is later, file one for him as of that date: mark box B, and note in the space provided for his signature "employee con- tacted-failed to elect optional insurance." See note 2 below. 4. Review of completed forms.-(a) Review both copies of the SF 176-T for legibility, completeness, and con- sistency. Reconcile with the employee any obvious major discrepancy such as a mark in more than one box. (b) If the employee marked box A or box C, make sure the Statistical Stub is complete. Then detach and mail stubs, in a bundle, weekly to : Office of Federal Employees' Group Life Insurance (Statistical Study) 4 East 24th Street New York, New York 10010 (c) If the employee marked box B, detach and destroy the stub. 5. Date of receipt and effective date.-(a) Stamp date of receipt by employing office in the space provided for this purpose on both the Original and the Duplicate. (b) The effective date is determined from the table be- low. 6. Disposition of forms.-(a) File the Original SF 176-T in the official personnel folder in all cases. (b) Any necessary payroll change, with effective date, may be posted in the space reserved on the Duplicate for employing office. (c) The Duplicate may be destroyed, if no payroll action is required, or after the requirements of the agency's payroll system have been met. 7. Use of SF 176-T.-SF 176-T "Election, Declination, or Waiver of Life Insurance Coverage" should not be used after the initial filing period (after April 14, 1968). A revised edition will be available for use after that date. DATE SF 176-T RECEIVED BY EMPLOYING OFFICE After February 14 but not later than April 14, 1968. Elects optional (in addition to regu- lar) (box A). Declines optional (but not regular) (box B). Waives regular (so ineligible for optional) (box C). Elects optional (in addition to regu- lar) (box A). Declines optional (but not regular) (box B). Cancels previously elected optional (but not regular) (box B). Waives regular (so ineligible for op- tional) (box C). EFFECTIVE DATE (IF NO WAIVER, SF 53, IN EFFECT) Coverage effective February 14, Deductions begin 1st day of 1st 1968. pay period beginning on or after February 14, 1968. Declination effective February 14, 1968. Waiver effective last day of pay peri- Deductions stop last day of pay od in which February 14, 1968 falls. period in which February 14, falls. 1968 Coverage effective on date of receipt. Deductions begin 1st day of 1st pay period beginning on or after date of receipt. Declination effective on date of re- ceipt, but employee loses auto- matic optional protection on Feb- ruary 14, 1968. Cancellation effective last day of pay period in which received. Waiver effective last day of pay peri- od in which received. Deductions for optional stop last day of pay period in which re- ceived. Deductions stop last day of pay pe- riod in which received. NOTES: 1. Because regular insurance coverage and deductions are automatic unless waived (by checking box C), A and B elections do not affect regular insurance effective dates. 2. An employee for whom the agency files SF 176-T because he failed to file is deemed to have declined optional, but not regular, insurance. 3. An employee with an uncanceled waiver (SF 53) on file cannot be insured any earlier than the first day he is in duty and pay status in a pay period beginning on or after February 14, 1968; filing of an SF 176-7 before that date will not cancel an SF 53 any earlier. Deductions begin the day he becomes insured. 4. The effective date of regular (and optional) insurance coverage for an employee who has been on leave without pay for more than 1 year is the first day he is in pay and duty status. Deductions are effective the same day.