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Healthcare & Insurance Life Insurance

Statement of Claim, Option C - Family Life Insurance

Used to claim benefits for the death of family members covered by FEGLI Option C coverage.

Electronic Copies:


If you are using Adobe Reader and have a problem opening this form, please download the latest version, or do the following:

Using the RIGHT button on your mouse, click on the form link above and select "Save target as" from the resulting menu. Save the form file to your hard drive or a local network drive. Then open the file directly using Adobe Reader 5.0 or above. Doing this, you will avoid opening the file through your internet browser.

Paper Copies:


Download the form locally. However, if you can't access the Adobe-Acrobat PDF-fillable form, then request a copy from your servicing human resources office.


  • Call toll free 1-888-767-6738 (202-606-0500 in the DC Area), or
  • Send an email to, giving the number of the form that you need and your mailing address, or
  • Request a copy from a local Federal agency Human Resources Office.


We encourage agencies to download the form locally. However, if you can't access the Adobe Acrobat PDF-fillable form, you can order a limited supply 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.

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