FOIA
ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE - COLLINS, CHARLES P.
Document Type:
Keywords:
Collection:
Document Number (FOIA) /ESDN (CREST):
0001426143
Release Decision:
RIPPUB
Original Classification:
U
Document Page Count:
2
Document Creation Date:
June 22, 2015
Document Release Date:
March 20, 2008
Sequence Number:
Case Number:
F-2007-01041
Publication Date:
February 12, 1968
File:
| Attachment | Size |
|---|---|
 DOC_0001426143.pdf | 194.56 KB |
Body:
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 any part.
IMPORTANT
AGENCY INSTRUCTIONS
ON BACK OF ORIGINAL
2 FILL IN THE IDENTIFYING INFORMATION BELOW (please print or type):
NAME (last) (first) (middle)
DATE OF BIRTH (month, day, year)
SOCIAL SECURITY NUMBER
LOLL NI S, Charles P.
Dec. 28, 1916
EMPLOYING DEPARTMENT OR AGENCY
LOCATION (City, State, ZIP Code)
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
ELECTION, DECLINATION, OR WAIVER
OF LIFE INSURANCE COVERAGE
FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM
(A)
(B)
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.
APPROVED FOR RELEASE
DATE: DEC 2007
(C)
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.
(b) (2)
(b) (6)
FOR EMPLOYING OFFICE USE ONLY
73NNOSd3d -4O 3313.dQ
896 NY 41 1/ 01 93j
ORIGINAL COPY-Retain in Official Personnel Folder
STANDARD FORM No. 176-T
JANUARY 1968
(For use only until April 14, 1968)
176-101
.INSTRUCTIONS TO EMPLOYING AGENCY
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.
Automatic cancellation of previously filed waiv-
ers.-All "Waivers of Life Insurance Coverage" (SF 53)
onfile 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.
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"ilia space provided for his signature "employee con-
tacted-failed to elect optional insurance." See note 2
below..
Review of completed forms.- (a) Review both copies
of the SF 176-T for legibility, completeness, and con-
s istericy.. Reconcile with the employee any obvious major
TABLE OF EFFECTIVE DATES
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