Federal Employees' Group Life Insurance Program

Notice of Conversion Privilege

Use:

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.

Electronic Copies:

• PDF Fillable Version [76 KB]

To use the Adobe Acrobat forms you need the commercial Acrobat software or the free downloadable Acrobat Reader. You can fill in this form on your computer screen before you print it.

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 Insurance
P.O. Box 2627
Jersey City, NJ 07303-2627

Employees:

Will receive a copy from their servicing Human Resources Office when their life insurance coverage ends, except by voluntary cancellation.

Agencies:

Use your internal agency procedures for ordering Standard Forms.

Paper copies of this form are NOT available from OPM.