[104-10225-10003.pdf — page 318]
# INSTRUCTIONS TO EMPLOYING AGENCY1.  Who must file. All employees not excluded by law or regulation from insurance coverage, including those who have previously waived coverage, are requited to com- plete and file Standard Form 176 T. Employees who are in the service on February 14, 1968, as well as those who are appointed after that date but before April 14, 1968, must ble the form.2.  Automatic cancellation of previously filed wate ers. All "Waivers of Life Insurance Coverage" (SF 53) on ble are automatically canceled as of the first day of the first pay period beginning on or after February 14, 1968. Payroll offices are to begin regular insurance deductions on the automatic cancellation date for employees who do not file a new waiver, te., those who do not check box C of SF 176-T, on or before that date.3.  Employers falling to file.--If an employee does not return a completed SF 176-T, contact him and urge him to do so even if he does not want optional insurance (he will, of course, be automatically covered for regular in- surance). If he still fails to file SF 176-T by April 14, 1968, or 31 days after appointment, whichever is later, file one for him as of that date: mark box B, and note in the space provided for his signature "employee con. tacted--failed to elect optional insurance." See note 2 below.4.  Review of completed forms.-(a) Review both copies of the SF 176-T for legibility, completeness, and con- sistency. Reconcile with the employee any obvious major discrepancy sach as a mark in more than one box.(b) If the employee marked box A or box C. make sure the Statistual Such is complete. Then detach and mail stube, in a bundle, wewaly to:Office of Federal Employees' Group Life Insurance(Statistical Shah)4 East 24th SovetNew York. New York 100010(c) If the emplowe market hos 8. detach and destroy the stub5.  Date of recript and effective date.--(a) Stamp date of receipt by emphwing office in the space provided for this purpose on both the Original and the Duplicate.(b) The effective date is determined from the table be- low.6.  Disposition of foress.-(a) File the Original SF 176-T in the official personnel folder in all cases.(b) Any necessary purell change, with effective date, may be posted in the space reserved on the Duplicate for employing office.(c) The Duplicate may be destroyed, if no payroll action is required, or after the requirements of the agency's payroll system have been met.7.  Use of SF 176-T.--SF 176-T "Election, Dev lination, or Waiver of Life Insurance Coverage" should not be used after the initial Sling period (after April 14, 1968). A revised edition will be available for use after that date.TABLE OF EFFECTIVE DATES| DATE SF 176-T RECEIVED BY EMPLOYING OFFICE           | EMPLOYEE'S DECISION                                                         | EFFECTIVE DATE (IF NO WAIVER SF 53, IN EFFECT)                                                                   |                                                                                    |     || ---------------------------------------------------- | --------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------- | --- ||                                                      |                                                                             | OF DECISION                                                                                                      | OF DEDUCTIONS                                                                      |     || On or before February 14, 1968.                      | Elects optional (in addition to regu lar) (box A).                          | Coverage effective February 14 1968                                                                              | Deductions begin ist day of Ist pay period beginning on or after February 14, 1968 |     ||                                                      | Declines optional (but not regular) (box).                                  | Declination effective February 14 1968.                                                                          | Deductions stop last day of pay pered in which February 14, 1968 falts             |     ||                                                      | Walves regular (so ineligible for: optional) (box C).                       | Warver effective last day of pay pen ad in which february 14, 1968 falis.                                        |                                                                                    |     || After February 14 but not later Than April 14, 1968. | Elects optional (in addition to regu Coverage effective on date of racerpt. |                                                                                                                  | Deductions begin 1st day of Ist pay period beginning on or after Gate of receipt   |     ||                                                      | lar) (box A).                                                               |                                                                                                                  |                                                                                    |     ||                                                      | Declines optional (but not reguler) (bax B).                                | Dectination effective on date of ro. coipt. but employee loses 3. matic options! protection ca february 14, 1958 | Deductions hy optional stop last dey of pay period to which re coved               |     ||                                                      | Cancels previously elected optional (but not regular) (bax 8)               | Cancellation effective last day st pey period in which received                                                  |                                                                                    |     ||                                                      | Waives regular (so ineligible for op. tronal) (bos C)                       | Warver effective last day of pay pen od is which recarved                                                        | Dotertions deg last der of pay pe deadh Foreved                                    |     |NOTES Duse regular arccord datortions are ambagheuelarved by thesting bes and traAs popieren for show the agonyfing SF 176-1 borone bo tarted to file is écsmod te how hand opt-ong1248 14 سال به ده, Ring ad on St 176-1 bare that date 31 ang Dedented4 The affate de dragter adaptanal) werererage farge sopares alas base is thestate Gatoffactise the some fa