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Claim for Accidental Dismemberment Benefits

Claim for Accidental Dismemberment Benefits

Employees use this form to claim benefits for the loss of a limb or loss of vision.

Electronic Copies


Paper Copies


Request a paper copy of this form from your servicing Human Resources Office.


Agency field offices should order through their headquarters office and NOT from OFEGLI.

Agency headquarters insurance officers order FE forms directly from OFEGLI. OFEGLI accepts orders by fax and mail only - no telephone orders. The fax numbers are 315-792-6603 or 315-792-6802 - Attention: Forms Ordering Desk. The mailing address is Office of Federal Employees' Group Life Insurance, Attention: Forms Ordering Desk, P.O. Box 6512, Utica, NY 13504-6512. OFEGLI will need the form number, the quantity, the shipping address and the point of contact, in case of questions.

Agency Insurance officers may request that the forms be sent to major field installations of the agency. The quantity must be sizable (minimum order of 500 forms) to each installation. The complete address and contact information for each installation must be included.

Please note that if you want smaller quantities of the form you can download form FE-7  and print them locally.

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