[104-10194-10015.pdf — page 31]
# ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGEFEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAMTO COMPLETE THIS FORM-1 FOLLOW THESE GENERAL INSTRUCTIONS:.*   Read the back of the "Duplicate" carefully before you fill in the form.*   Fill in BOTH COPIES of the form. Type or use ink.*   Do not.detach any part.2 FILL IN THE IDENTIFYING INFORMATION BELOW (please print or type):NAME (last) (first) (middle) DATE OF BIRTH (month, day, year) SOCIAL SECURITY NUMBER.CAZAZZUS Sandra B 1923EMPLOYING DEPARTMENT OR AGENCY LOCATION (City, State, ZIP Code)3 MARK AN "X" IN ONE OF THE BOXES BELOW (do NOT mark more than one):Mark here if you WANT BOTH optional and regular insurance(A) ELECTION OF OPTIONAL (IN ADDITION TO REGULAR) INSURANCEI elect the $10,000 additional optional insurance and authorize the required deductions from my salary, compensation, or annuity to pay the full cost of the optional insurance. This optional insurance is in addition to my regular insurance.Mark here if you DO NOT WANT OPTIONAL but do want regular insurance(B) DECLINATION OF OPTIONAL (BUT NOT REGULAR) INSURANCEI decline the $10,000 additional optional insurance. I understand that I cannot elect op tional insurance until at least 1 year after the effective date of this declination and unless at the time I apply for it I am under age 50 and present satisfactory medical evidence of insurability. I understand also that my regular insurance is not affected by this declina- tion of additional optional insurance.Mark here if you WANT NEITHER regular nor optional insurance(C) WAIVER OF LIFE INSURANCE COVERAGEI desire not to be insured and I walve coverage under the Federal Employees Group Life Insurance Program. I understand that I cannot cancel this waiver and obtain regular in. surance until at least 1 year after the effective date of this waiver and unless ot the time I apply for insurance I am under age 50 and present satisfactory medical evidence of in- surability. I understand also that I cannot now or later have the $10,000 additional optional insurance unless I have the regular insurance.4 SIGN AND DATE. IF YOU MARKED BOX "A" OR "C".COMPLETE THE "STATISTICAL STUB." THEN RETURN THE ENTIRE FORM TO YOUR EMPLOYING OFFICE.SIGNATURE (do not print)Sandra B. CazazzusDATE14 February 1968DUPLICATE COPY-For Agency Use 3FOR EMPLOYING OFFICE USE ONLY(official receiving date stamp)![official receiving date stamp]ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGEStatistical Stub (SF 176-T)To be completed only by employees who checked either box "A" or box "C" on the election form.The purpose of this stub is to furnish statistics on the initial registration under the liberalized life insurance program.|                                                                                                                |          || -------------------------------------------------------------------------------------------------------------- | -------- || 1. Which box did you check?                                                                                    | Box A 1  ||                                                                                                                | Box C 2  || 2. Did you have regular insurance under the Federal Employees Group Life Insurance Program on January 1, 1968? | Yes 1    ||                                                                                                                | No 2     || 3.. Your sex?                                                                                                  | Male 1   ||                                                                                                                | Female 2 || 4. Are you now married?                                                                                        | Yes 1    || horn?                                                                                                          | No 2     |