Name of Insured (please print): ______________________________________

Social Security Number of Insured: ___________________________________

INTER VIVOS TRUSTEE DESIGNATION

TO BE ATTACHED TO AND MADE PART OF DESIGNATION OF BENEFICIARY DATED______________________________________

I request that the amount payable under the FEDERAL EMPLOYEES' GROUP LIFE INSURANCE PROGRAM (Proceeds) be paid to the Trustee(s) or Successor Trustee(s) as provided under (Name of Trust Agreement) __________________________________ bearing the date of ______________ executed by me.

I further request that in the case of the failure of said Trustee(s) to be appointed as such or to qualify as such for any reason, or the termination for any reason of the trust prior to my death that the Proceeds shall be paid to:

Name Address  Relationship Share
_________________ __________________ _________________ ______________
_________________ __________________ _________________ ______________
_________________ __________________ _________________ ______________

 The Office of Federal Employees' Group Life Insurance (OFEGLI) shall not be responsible for the application or disposition of the proceeds by said Trustee and the receipt by said Trustee shall fully discharge OFEGLI's liability under the FEDERAL EMPLOYEES' GROUP LIFE INSURANCE PROGRAM.

____________________________________ ______________________________
Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power of attorney are not acceptable.) Date of execution (Month, day, year)

Two Witnesses to Signature (A witness is not eligible to receive payment as a beneficiary):

__________________ ________________________ _______________________________
Signature of witness Number and street City, state and ZIP code
__________________ ________________________ _______________________________
Signature of witness  Number and street City, state and ZIP code