Federal Employees' Group Life Insurance Program

Agency Certification of Insurance Status

Use:

Agencies complete this form when an employee's life insurance stops or is scheduled to stop, except when the employee voluntarily cancels coverage, or the employee is immediately transferring to another position which will provide eligibility for FEGLI insurance coverage.

Electronic Copies:

• PDF Fillable Version:[102 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.

Paper Copies:

Employees:

Will receive a copy of the completed form from their servicing Human Resources Office, when applicable.

Use your internal agency procedures for ordering Standard Forms.

Paper copies of this form are NOT available from OPM.