Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
December 31, 2008
Sequence Number: 
Case Number: 
Publication Date: 
December 23, 1970
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DEC EDE T iohu C. Caranci DATE OF I TH 2/722 Ib1161~ 151131 CERTIFICATION OF IN ' NCE STATUS OF . DECEASED ANNUITANT .On .:OMPENSATIONER FEDERAL EMPLOYEES GROUP LIFE INSURAN.CE.PROGRAM^ CSI 1 255 367 ITO: OFFICE OF FEDERAL EMPLOYEES' GROUP LIFE INSURANC This certification is invalid if your records show a conversion after the date insurance coverage as an employee :terminated. A. CERTIFICATION REGARDING DECEASED ANNUITANT, NOTE TO EXAMINER: Certify a deceased compensationer as an insured annuitant. lr tai annuity use slluwri lle 1J V4LLGCW16C,:: eligible for insurance as a retired employee and (b) the amount of insurance is the same regardless of annuitant or compensationer status. 1. (a) TYPE OF RETIREMENT DISABILITY ^ NON-DISABILITY 1. (b) DATE OF SEPARATION 1. (d) 12/1667 OR LATER ^ 9/23/59 TO 12/15/67 ^ BEFORE 9/23/59 c3 The deceased was retired under the Civil Service Retirement System or system named in attached SF 49, and at time of death: ? was insured for regular insurance only. ^ was insured for regular and optional insurance. ^ canceled optional insurance during retirement. The deceased's annual pay as shown on SF 56 is consistent with data on ri i''? lable to the Commission. ava ^ on records available to the Commission. SF 56 has been amended to show torte rateas$ If deceased attained age 65 prior to August 29, 1954, annual pay on,August D 2. ^ The deceased was not an insured annuitant at the time of his death (and insurance as a compensationer is not involy+ed coverage. ^ He converted his insurance after separation for reti`rem ^ Other (specify). DECEASED EMPLOYEE APPROVED FOR RELEASE DATE: 1O-Nov-2008 ^ He died in service without filing for retirement.:' ^ Other (specify). B. CERTIFICATION REGARDING DECEASED COMPENSATIONER The deceased was receiving employees' compensation and held to be unable to return to duty. He was insured on that bast at the time of his death for- 0 Regular insurance only. ^ Regular and optional insurance. ^ Canceled optional insurance during retirement. 2. ^ The deceased was not an insured compensationer at the time of his death (explain under "D. Remarks"). DESIGNATION OF BENEFICIARY - SF 54: EF Attached - Rec'd in CSC prior to death. ^ Attached - Rec'd in CSC after date of death from ^ Claimant ^ Agency. ^ No SF 54 on file in CSC. SF 56 - Agency Certification of Insurance Status. Death Certificate. (3Attached ^Not on file in CSC. FE 6 s Claim Rfor D ath B oyee's Insurance Certificate. SF 49 - Certification of Insured Employee's Retired Status _ ^ Other (specify). D. REMARKS AND SIGNATURE (Adjudicator will show any unusual annuity claim circumstances that may affect OFEGLI's payment and enter other pertinent, re marks: here. If additional space is needed, use reverse side of this form.) Please expedite payment of this insurance as soon as possible. ance, and occupational Health U.S. Civil Service Commission ^ His retirement was not based on at least 12 years creditable service or disability (separation on or after September 23, 1959). ^ His retirement was not based on at least 15 years creditable service or disability (separation before September 23, 1959). ^ His retirement was not on an immediate annuity. ^ He waived insurance coverage as an employee. ^ He was separated before the insurance law went, into effect. Date BRI 46-19$' AUGUST 13989:;::