Federal Employees' Group Life Insurance Program

Claim for Accidental Dismemberment Benefits

Use:

Employees use this form to claim benefits for the loss of a limb or loss of vision.

Electronic Copies:

• PDF Fillable:[165 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:

Request a paper copy of this form from your servicing Human Resources Office.

Agency field offices should order through their headquarters office and NOT 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 number is 201-395-7950 - Attention: Forms Ordering Desk. The mailing address is Office of Federal Employees' Group Life Insurance, Attention: Forms Ordering Desk, P. O. Box 2627, Jersey City, NJ 07303-2627. OFEGLI will need the form number, the quantity, the shipping address and the point of contact, in case of questions.

Agency Insurance officers may request that the forms be sent to major field installations of the agency. The quantity must be sizable (minimum order of 500 forms) to each installation. The complete address and contact information for each installation must be included.

Please note that if you want smaller quantities of the form you can download the Adobe Acrobat PDF version [288 KB] from this page and print them locally.