ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE - BARNARD, EDWARD T.

• Document Type: FOIA
• Keywords: PERSONNEL FILES
• Keywords: BARNARD EDWARD T
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0001459659
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 2
• Document Creation Date: June 22, 2015
• Document Release Date: April 17, 2008
• Case Number: F-2007-01040
• Publication Date: February 14, 1968

ELECTION, DECLINATION, OR WAIVER IMPORTANT
OF LIFE INSURANCE COVERAGE AGENCY INSTRUCTIONS
FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM ON BACK OF ORIGINAL
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.
FILL IN THE IDENTIFYING INFORMATION BELOW (please print or type):
(b) (2)
(b) (6)
NAME (last) (first) (middle) DATE OF BIRTH (month, day, year) SOCIAL SECURITY NUMBER
Barnard Edward Townsend 10 X0/3.0
3
LOCATION (City, State, ZIP Code)
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 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.
SIGN AND DATE. IF YOU MARKED BOX "A" OR "C",
FOR EMPLOYING OFFICE USE ONLY
4
" THEN RETURN
UB
S
"
.
STATISTICAL
T
COMPLETE THE
THE ENTIRE FORM TO YOUR EMPLOYING OFFICE.
SIGNATURE (do not print)
I DATE
Official Personnel.-Folder
No.
APPROVED FOR RELEASESTANDAA.NUARYM1968176?-T
DATE: FEB 2008 (for use only 1716-10iril 14, 1968)
 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 I .Review both copies
of the SF 176-T for legibility, completeness, and con-
sistency. Reconcile with the employee any obvious major
TABLE OF EFFECTIVE DATES
DATE SF 176-T
RECEIVED BY
EMPLOYING OFFICE
Elects optional (in addition to regu-
lar) (box A).
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.
Use of SF 176-T.-SF 1767T "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.
EFFECTIVE DATE
(IF NO WAIVER, SF 53, IN EFFECT)
Coverage effective February 14,
1968.
Deductions begin 1st day of 1st
pay period beginning on or after
February 14, 1968.
Declination effective February 14,
1968.
Declines optional (but not regular)
(box B).
Waives al) regular (so mengrure wi r' c
o in which February 14, 1968 period in which February 14, 1968
opts ional) (box C). od falls. falls.
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).
Cancels previously elected optional
(but not regular) (box B).
Waives regular (so ineligible for op-
tional) (box C).
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.
Deductions for optional stop last
day of pay period in which re-
ceived.
Deductions stop last day of pay pe-
riod in which received.
Waiver effective last day of pay peri-
od 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 1.76-T 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 some day.