Document Type: 
Document Number (FOIA) /ESDN (CREST): 
Release Decision: 
Original Classification: 
Document Page Count: 
Document Creation Date: 
June 22, 2015
Document Release Date: 
April 17, 2008
Sequence Number: 
Case Number: 
Publication Date: 
August 18, 1970
PDF icon DOC_0001459657.pdf148.94 KB
sTANOARO PoRM sa JANUARY 1970 ~"``~, ,~~EN~Y CE~rIF1CATlON OF ' - 1NSU_RA!`~I~~ STA7U~ ~ ~; (]~) (6) ( ~ ' U. S. CIVIL SERVICE COMMISSION ~ t~= ~sar7rae~~e PC?gr~~ Fer~~r~ m ~a~ ~~s ~f'~89 FPM SUPPLEMENT 870-1 56-;09 ~ ~ ~ i. NAME (Last) (First) (,~,4iddta) 2(a). DATE OF BIRTH. (Month, Day,'leari 2(b). SOCIAL SECURITY ACCOUNT NUMBER a 3. CHECK THE REASON FOR TERMINATING INSURANCE (a) ? Separated (includes resignations) (b) ~ Retired NOTE: if the reason ehec{ced is "b; Retired" your group life insurance (bui (c) ~ Died as an ampioyee not accidental death and dismemberment benefits) will continue during retire- (d) ~ Died as a reemployed annuitant ment if you meat the conditions described in "Notice to Retiring Employee" below. (e) ~ End of 1 2 months non-pay status (f) ~ ether (specify) 4. CHECK APPROPRIAi E BOX CONCERNING Sr" i4, L'ESIGNAI lON OF BENEFICIARY A CURRENT SF 54 IS ~ CURRENT 5F 54 f5 GN F3LE IN r CURRENT ,a). C---~ (b). NOT ON F!Lf WITH THi5 lc)? { THE EMPLOYEE'S OFFICIAL PERSONNEL j SF Sd ATTACHED i A.GENCY ~ rOLDER (OR EQUIVALENT) NOTE: IF EMPLOYEE (A) DIED OR (B) IS RETIRING CR RECEIVING FEDERAL EMPLOYEES' COMPEi~lSAT1CN UNDER CONDITIONS ENTITLING H(M TO RETAIN HIS L!fE INSURANCE, ATTACH CURRENT SF S4, IF ANY, TO ORIGINAL SF Sb AND CHECK $OX 4 (a) CN ORIGINAL AND ALL COPIES OF 5'r Sb; IE NO CURRENT SF 54 IS ON FILE, CHECK" $OX 4 (b). IN AlL OTHER CASES, SHOW WHETHER OR NCT CURRENT SF 54 IS CN PILE BY CHECKING BOX 4 (6J CR (c). A CURRENT SF 54 IS CNE THAT HAS NOT BEEN CANCELED $Y fMPLOYEE OR AOTOMATICALLY BY TRANSFER CR PRIOR TERtflINATiON CF INSURANCE. S. DATE OF [VENT CFIECXED IN ITEM 3 6. APINUAI BASIC PA'I RATE INOT AMOUNT OF INSUR- 7. DID 5'APLOYEE HAVE OPTIONAL INSURANCE ON DATE 8. DATE CF NOTICE OF .CONVERSION (MONTH, DAY, '!EAR) ONCE) ON DATE IN ITEM 5. COtJVERT DAILY, HOURLY, IN REiM S? NO ~ YES [; PRIVILEGE ISF 55) TO EMPLOYEE PIECEWORK, ETC. RATE i0 .4NNUAL RATE. IF YES, GIVE RECEIPT DATE OF ELECTION OF OPTIONAL (MONTH,. DAY, YEAR) -y:?.;~ ~? U 31 ~ ~'~ ~. ~ ~ i' ~~' GS~i? $ PER ANNUM iNSURANC"t (Sf 17b ar ll6-T): 9. I CERTIF'f THAT THE ABOVE INFORIJ;APON HAS BEEN OESTA.INED FROM, AND CORRECTLY REFLECTS, OFfiC1AL RECORDS AND THAT THE EMPLOYEE NAAAED WAS COVERED BY FEDERAL EMPLOYEES GROUP LIFE iNSL'RANCE ON 7HE DATE SHOWN IN ITEM S. Personals t ri d a ene official Name and address of agency, including zio code Typed name or authorize agency o icial 'a~I ~~.S ii? so'~ G 1A. ~~ , ~~, I~ J ~ ~- Title Phone number, including area code. Date. A .i.n:"`l3i`cr.'i:~` ii~~w~ :].~I.s~~?ii.~,b~ 1 f~ `-~~1 s~~ aTH~~ s)aE ~oR If~15TRt,?CTlONS TO ~M~tQYiNG AGE3~iGY APPROVED FOR RELEASE DATE: FEB 2008 CO1~i~LETION OF CERTEFIC/~.TkOE~E 1. This Certifcation must be completed in triplicate whenever an employee's insurance terminates for. a. Death. b. Retirerent an an immediate annuity with 12 or mare years' creditable service, of which at !east 5 years are civilian servicz, 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.) !n a disability retirement cast, do not cornpiete SF 56 until a ending of disability has been cfficially made and the employee's separation is in ardor. 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. d. Any other reason, if the employee desires to convert his life insurance, except under the following circumstances (i) Employee waived or declined on SF 176 (or SF 1 76-T1; (2) If it is known that, within 3 calendar days after the date the insurance terminated, the employee v,.ill return to Government service- in the same or another position in which he will be eligible to reacquire Federal Employees Group Life Insurance; (3) More than 7S 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 6nsurance. 2. If insurance terminated on account of death, indicate in item 3(a} whether-the ernplayee heed flied an A.pplicatiesn fcsr Retirement (5F 2801) with the Civil Service C?mrnission. 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 replacz 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 (prefercbiy in 'she Official Personnel Folder or its equivalent) for attochn-iert to a claim for death benefits (Form FE-b) when received. c. Ir' no claim is received, send original SF 56, upon request, to the Office of Federal Employees' Group Life insurance. d. If the deceased employee has a current Designation of Beneficiary (SF 54) on Ile, the SF 54 must be attached to the original SF 56 when it is sen'r is ?he Office of Federal Employees' Group Life Insurance. 2. Retirement of employee- a. If the employee is applying for an immediate annuity with 12 or more years' cred?,table service (of ~a~hich at least 5 years are civilian service] or for disability; attach the ariginal SF 56 and current Designation of Beneficiary (SF 54), if any, to the t.pp!ication for Retirement and give duplicate of SF 56 to the employee, [f~OTE: in a disability refirement case v.~here the retirement application has already been Beni tc the Civil Service Commission, attacF~ the ariginal SF 56 (and Sr 54, if any) to the "FINAL" Individual Retirement Record (SF 2806).) b. ff the employee ~a~ants to continue only his regular insurance; have him complete a S'r 176 declining his aptianal insurance. If he v,-ant: to convert only his optional insurance, prepare a statement (see belo~al, in dupiicat~, for him to sign, attach both copies of the starement to the original SF 56, and submit with application for retirement as instrucred in 2e above. Illustrative Statement "I want to continue my regular insurance after retirement but would like additional information an converting my optional insurance." (Employee's signature) (Address-print or type} (Date} c. If the employee prefers to convert both his regular-and optional insurance to an individual policy, give him the original and duplicate copy of the SF 56, P.etairi SF 54, if any. 3. If employee is receiving compensation benefits- a. Before completing item 7 contact the local Bureau of Employees' Compensation Cffice, if necessary, to confirm whether the employee still has optional insurance. b. Have the employee complete appropriate box op reverse side of the original SF 56. Send original SF 56 and current Designation of Beneficiary (SF 54), if any, to the. U. S. CIVIL SERVICE COMh1iSSION, BUREAU OF RETIREMENT; INSURANCE, AND OCCUPATIONAL HEALTH, WASHINGTON, D. C., 20415, and give duplicate copy cf SF 56 to the employee. c. If the employee prefers to convert his group insurance to an individual policy, give him the original -and dupli- ~ copy of the SF 56. Retain SF 54, if any. 4. All other cases- Upon request, give the employee the .ariginal and duplicate copy of the SF 56 or mail them to him. 5. In all cases- Retain file copy of the SF 56 in the employee's Official Personnel Fo{der ar its equivalent. PROr'J-PT CERTIFICATION REQI~'?FD The time in which an emp ee may convert his ,group life insurance to an ini.`_ :val policy is limited. This 'SF 56 must be completed and delivered or mailed to him promptly.