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Agencies give this form to employees and assignees when the employee's life insurance coverage ends due to separation, resignation, retirement, death, or the end of 12 months in non-pay status. The form notifies employees or assignees of their rights to convert to an individual insurance policy.
NOTICE: The address given on this form for submission of the completed form is no longer correct. The form should be sent to:
Office of Federal Employees' Group Life InsuranceP.O. Box 8149Long Island City, NY 11101-8149.
For overnight deliveries only (such as express mail): OFEGLI, FEGLI Conversion Team, 5th Floor, 27-01 Queens Plaza North, Queens, NY 11101.
Will receive a copy from their servicing Human Resources Office when their life insurance coverage ends, except by voluntary cancellation.
Use your internal agency procedures for ordering Standard Forms. Paper copies of this form are NOT available from OPM.