U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

SF 2819

May 1995

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]

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

Paper Copies:

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.