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.
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.