SF2821
Agency Certification of Insurance Status - Federal Employees' Group Life Insurance Program
Standard Form 2821 (SF 2821), Agency Certification of Insurance Status, is a Federal Employees' Group Life Insurance (FEGLI) Program form. Its footer names the U.S. Office of Personnel Management (OPM) and The FEGLI Handbook for Personnel and Payroll Offices, Revised May 1995. GSA hosts a copy in its forms library.
The Instructions To Employing Agencies say the certification is completed in triplicate whenever an employee's insurance terminates or is scheduled to terminate due to death, retirement, completion of 12 months in non-pay status, or any other reason, with two exceptions they list. The agency's personnel office and payroll office each certify the entries, and the form says it will not be accepted without both certifications.
The form records the event, the retirement system, beneficiary designations, any assignment and living benefits, annual basic pay and each type of coverage. You can fill it out free in your browser on this page and download the result without an account.
Name, date of birth, Social Security number, the event requiring certification, whether an SF 2801 or SF 3107 was filed with OPM, retirement system, OWCP number, and where designations of beneficiary (SF 54, SF 2823) are.
Whether the employee assigned the insurance (attach RI 76-10), and whether living benefits were elected, full or partial with the post-election BIA amount, attaching the EOB.
Date of the event, date of the SF 2819 (the form prints Issuance Is Mandatory), annual basic pay converted to an annual rate, and the effective date of continuous FEGLI coverage with any breaks.
Option A, Standard, with its amount and election date; Option C, Family, with its election date; and Option B, Additional, with its election date, multiples on the event date and lowest multiples in the last 5 years.
Personnel and payroll certifications, each with signature, typed name, title, date and telephone number, plus agency address, payroll office address if different, and payroll office number.
A Remarks box for agency use only and a box marked OPM use only. The instructions to employing agencies are printed on the reverse.
Check the event in item 4a, the retirement system in item 4b (specify if other) and, if applicable, the Office of Workers' Compensation Programs case number in item 4c.
If the employee completed an RI 76-10, attach it in item 6. If living benefits were elected, attach the Explanation of Benefits (EOB) returned by OFEGLI and give the dollar amount for a partial election.
For item 12, the instructions say the Option A amount in most cases will be $10,000, though it may exceed $10,000 in the case they describe. Effective date of election means the start of coverage without a break.
A personnel official signs item 15 and a payroll official signs item 16. The form says it will not be accepted without dual certification, and a facsimile signature is not acceptable.
The Disposition of Certification instructions cover death of an employee, retirement, an employee receiving compensation benefits, and all other cases. In all cases the file copy (Part 3) stays in the Official Personnel Folder.
The instructions say that when a duplicate SF 2821 is issued to replace one that is lost, it is clearly marked DUPLICATE.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
For a retiree continuing all life insurance, the original (Part 1), any designations of beneficiary (SF 54 or SF 2823) and life insurance elections (SF 176 or SF 2817) are attached to the Application for Retirement and sent to OPM. The duplicate (Part 2) goes to the employee.
The duplicate (Part 2) goes to OFEGLI, 200 Park Avenue, New York, NY 10166-0188. The original is kept for attachment to a claim for death benefits (Form FE-6), and sent to OFEGLI on request if no claim is received.
If employment terminates before the end of 12 months in non-pay status, the instructions say to check Other in item 4a and forward the original to the Office of Personnel Management, Retirement Operations Center, Boyers, PA 16017.
The instructions say not to send the SF 2821 to OPM, and to give or mail Parts 1 and 2 to the employee or assignees with the SF 2819 for conversion purposes.
The form says the time to convert group life insurance to an individual policy is limited, so the SF 2821 is to be completed and delivered or mailed promptly.
SF2819
22 fields, 3 pages
SF2817
37 fields, 5 pages
SF2818
30 fields, 5 pages
SF2823
64 fields, 3 pages
SF2801
454 fields, 21 pages
SF3107
470 fields, 14 pages
The instructions are addressed to employing agencies. The employee or assignee receives copies in some cases.
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The footer names the U.S. Office of Personnel Management and The FEGLI Handbook for Personnel and Payroll Offices, Revised May 1995. GSA hosts a copy in its forms library.
The instructions say whenever an employee's insurance terminates or is scheduled to terminate due to death, retirement, completion of 12 months in non-pay status or any other reason, except when the employee waived or declined all insurance on the most recent SF 2817, or will return to Government service within 3 calendar days and be eligible to reacquire coverage.
No. The instructions say the personnel and payroll certifications may not be made by the same official, though a payroll certification may be made by a personnel officer who has access to payroll records.
Item 9 asks for the date of the SF 2819, Notice of Conversion Privilege. The instructions say to leave it blank in case of death in service where the employee had no Option C coverage.
The duplicate (Part 2) goes to OFEGLI, 200 Park Avenue, New York, NY 10166-0188, and the original is kept for a claim for death benefits (Form FE-6).
The instructions say a duplicate SF 2821 issued to replace a lost one is clearly marked DUPLICATE.