Form Approved 

Designation of Beneficiary OMB No. 3206-0136 

Federal Employees Federal Employees' Group Life Insurance (FEGLI) Program Important:

Group Life Insurance Read instructions on the (DO NOT erase or cross-out. Use a new form.) Back of Part 2 before completing this form.

Name of Insured (Last, first, middle)

A. Information About the Insured (not the Assignee, if there is one) (type or print)

Date of birth of Insured (mm/dd/yyyy) Social Security Number of Insured

The Insured is:

Place an "X" in the 

appropriate box. 

an employee

a retiree

a compensationer

If the Insured is retired or receiving Federal Employees' Compensation, give CSA, 

CSI, or OWCP claim number: 

Department or agency where the Insured works (If retired, last department or agency where the Insured worked): 

Department or agency Bureau or division Location (city, state, and ZIP code)

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction 

designated 

Relationship

B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print) 

Total (Must equal 100% or 1.0) (Do not use dollar amounts) 

(Do not put a Total if you designated types of insurance. See example 4 on Back of Part 1.) 

C. Statement of Insured or Assignee (type or print) 

Your name and address (Including ZIP code) Please check one: Please check all three: 

I am: 

the Insured I have not assigned the insurance. 

an Assignee Two people who witnessed my

signature signed below. 

See Back of Part 2 for definitions I did not name either witness as a 

beneficiary. 

I understand that if there is a valid assignment on file, only the assignee has the right to 

designate a beneficiary. If a valid assignment is not on file, but there is a valid court order 

on file with the agency or the U.S. Office of Personnel Management, as appropriate, any 

designation I complete for the same benefits is not valid. 

I understand that if this Designation is valid, it will stay in effect unless it is canceled. 

(See "When Is A Designation Canceled?" on the Back of Part 2). 

I understand that if this Designation is invalid for any reason, the Office of Federal 

Employees' Group Life Insurance will pay benefits according to the next most recent valid 

designation. If there isn't one, it will pay according to the order listed on the Back of Part 2. 

I am canceling any and all previous Designations of Beneficiary under the Federal 

Employees' Group Life Insurance Program and am now designating the beneficiary(ies) 

named above. 

Signature of Insured/Assignee (Only the Insured/Assignee may sign. Signatures by guardians, conservators or through a power Date (mm/dd/yyyy)

of attorney are not acceptable.) This form is not valid unless the Insured/Assignee signs in this box. 

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D. Witnesses To Signature (A witness is not eligible to receive a payment as a beneficiary.)

E. For Agency Use Only

Signature of witness

Signature of witness

Address (Including ZIP code)

Address (Including ZIP code)

Receiving agency Date of receipt (mm/dd/yyyy) Signature of authorized agency official Title

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a 

U.S. Office of Personnel Management SF 2823

FEGLI Handbook (RI 76-26) Previous edition is usable. Revised March 2011
Examples of Designations

1. How to designate one beneficiary Show beneficiary's full name. Do not write names as M.E. Brown or as Mrs. John H. Brown. 

If you want to designate your estate, enter "My estate" in the beneficiary column.

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

Mary E. Brown 000-00-0000 214 Central Avenue

Munice, IN 47303 Niece 100%

2. How to designate more than one beneficiary Be sure that the shares to be paid to the several beneficiaries add up to 100 percent 

or 1.0. Read instructions on the Back of Part 2 if you need more room.

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

Jose P. Lopez 360 Williams Street

Red Band, NJ 07701

Domestic

Partner one-half

Rosa L. Rowe

111-11-1111

222-22-2222 792 Broadway

Whiting, IN 46392 Mother one-half

3. How to designate a contingent beneficiary (Someone to receive the benefits if the person you designate dies before the Insured

dies)

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

John M. Parrish, if living 810 West 180th Street

New York, NY 10033 Father 100%

Otherwise to: Susan A. Parrish

333-33-3333

444-44-4444 Sister 100% 810 West 180th Street

New York, NY 10033

4. How to designate different beneficiaries for Basic and Optional

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

Leroy D. White 124 Elm Street

Dayton, OH 45420 Father 100%Basic

Jane M. Smith

555-55-5555

666-66-6666 Sister 100%

Option A

421 Spring Avenue

Portland, ME 04101

Elizabeth J. Allen

Ann J. Borden

777-77-7777

888-88-8888

234 Fifth Avenue

New York, NY 10029

678 Ninth Street

Philadelphia, PA 19123 Daughter

50%

Option B

50%

Option B

5. How to designate an inter vivos trust (A trust that you set up during your lifetime)

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

Trustee(s) or Successor Trustee(s) as

provided in the John Q. Public Trust

Agreement dated 12/18/1999, if valid.

Otherwise to:

Trustee

Mary E. Brown 000-00-0000 214 Central Avenue

Munice, IN 47303 Niece

100%

100%

6. How to designate a testamentary trust (A trust that is set up when you die, according to terms in your will)

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

Trustee(s) or Successor Trustee(s) as

provided in my Last Will and

Testament, if valid. Otherwise to:

Trustee

Maria Sufuentes 999-99-9999 5909 Pacific Avenue, NW

Washington, DC 20019 Niece

100%

100%

7. How to cancel all designations of beneficiary

First name, middle initial, and last name of 

each beneficiary

Social Security Number Address (Including ZIP code) Percent or fraction

designated

Relationship

Cancel prior designations

SF 2823

Revised March 2011

You cannot designate Option C - Family.

Back of Part 1

Daughter
INSTRUCTIONS: The Insured or assignee must sign this form. Two people must witness the signature and sign as witnesses. The Insured's agency (or U.S. Office of

Personnel Management [OPM], if the Insured is an annuitant or insured as a compensationer) must receive the designation before the Insured's death. A person with a power

of attorney or other similar legal authority may not sign for the Insured or assignee. A witness cannot be a beneficiary. The agency or OPM, as appropriate, must receive

certified court orders involving FEGLI on or after July 22, 1998, and before the Insured's death.

Please read the additional instructions below before completing this form.

"You" and "your" refer to the person completing this form (the Insured or an assignee). The "Insured" is the insured employee, annuitant or

compensationer. The "Assignee" is a person(s), firm(s), or trust(s) (usually named on an Assignment form, RI 76-10) who owns and controls the

Insured's life insurance coverage. An assignment is not the same as a designation of beneficiary.

Who receives benefits when the Insured dies? By law, the Office of Federal 

Employees' Group Life Insurance (OFEGLI) pays benefits in this order: 

If the Insured assigned ownership of his/her insurance (usually by filing an 

RI 76-10, Assignment of Life Insurance), OFEGLI will pay:

First, to the beneficiary(ies) the assignee(s) validly designated; 

Second, if none, to the assignee(s).

• If the Insured did not assign ownership and there is a valid court order (see 5 

Code of Federal Regulations Part 870) on file with the agency or OPM, as 

appropriate, OFEGLI will pay benefits according to the court order. 

• If the Insured did not assign ownership and there is no valid court order on 

file with the agency or OPM, as appropriate, then OFEGLI will pay:

First, to the beneficiary(ies) the Insured validly designated;

Second, if none, to the Insured's widow or widower;

Third, if none of the above, to the Insured's child or children and the 

descendants of any deceased children (a court will usually have to 

appoint a guardian to receive payment for a minor child);

Fourth, if none of the above, to the Insured's parents in equal shares, or 

the entire amount to the surviving parent;

Fifth, if none of the above, to the court-appointed executor or 

administrator of the Insured's estate;

Sixth, if none of the above, to the Insured's other next of kin entitled 

under the laws of the State where the Insured lived.

Do I have to designate a beneficiary? No. But if you want OFEGLI to pay 

differently than listed above and you have not assigned the life insurance and there 

is no valid court order on file with the agency or OPM, as appropriate, you need to 

designate a beneficiary. 

What if one of the beneficiaries dies or is disqualified for any reason? Unless 

you indicate otherwise on your designation of beneficiary, OFEGLI will distribute 

that beneficiary's share equally among the surviving beneficiaries, or entirely to 

the sole survivor. 

What if none of the beneficiaries is living when the Insured dies? OFEGLI will 

pay the benefits according to the order of precedence listed above. 

Can I cancel or change this designation at any time? Yes, you may cancel or 

change your designation at any time, without the knowledge of or consent of the 

beneficiary(ies), unless you assigned the insurance or there is a valid court order 

on file with the agency or OPM, as appropriate. 

Is a change or cancellation of beneficiary in my last will or testament valid? 

It is valid only if you sign your will, two people who witnessed your signature 

sign your will, and your agency (or OPM, for retirees or insured compensationers) 

receives your will before the Insured's death. 

What if I don't know a beneficiary's social security number? If you don't know 

the number, leave it blank. But having the number helps speed up the payment of 

benefits. 

Can a witness receive benefits as a designated beneficiary? No. 

Who can I name as a beneficiary? You may name any person, firm, corporation 

or legal entity (except an agency of the Federal or District of Columbia 

government). 

Can I use a common disaster clause? Yes. A common disaster clause is a 

statement that says that a designated beneficiary is entitled to the benefits only if 

he/she survives the Insured by a specified minimum number of days. The number 

of days cannot exceed 30. You can name a contingent beneficiary. If you don't 

name a contingent and your beneficiary does not live long enough to qualify, 

OFEGLI will pay according to the order listed in the first column. 

Can I designate a trust? Yes. See examples 5 and 6 on the Back of Part 1. Those 

examples name a contingent beneficiary in case the trust is not valid. You don't 

have to name a contingent beneficiary unless you want to. If the trust is not valid, 

and you do not name a contingent, OFEGLI will pay according to the order listed 

in the first column. 

When is a designation canceled? A designation of beneficiary is automatically 

canceled 31 days after the Insured stops being insured. It is also canceled if either 

the Insured or assignee assigns the insurance or if the Insured or assignee submits 

another valid designation. 

What if the Insured elected a full living benefit? Then there is no Basic left. So if 

you want to designate different types of insurance to different beneficiaries (see 

example 4 on the Back of Part 1), you should only list Option A and Option B. 

Who can sign this form? The Insured or Assignee (if applicable) must sign this 

form. The signature of a guardian, conservator or other fiduciary (including, but 

not limited to, those acting according to a Power of Attorney or a Durable Power 

of Attorney) is not acceptable. 

What if I erase or cross out something on this form? You should complete 

another form. Erasures, cross-outs and alterations cause a delay in the payment of 

benefits and may make the entire designation invalid. 

What if I need more room? Write "See Attached" in Part B of the form. Use a 

blank sheet. Print your name, date of birth and social security number at the top of 

the attachment. List the information required in Part B for each beneficiary. Sign 

the form and attachment. Have the same two people witness both of your 

signatures and sign the form and attachment. 

Where can I get more information? The FEGLI Handbook (RI 76-26) and 

FEGLI Booklet (RI 76-21 or RI 76-20 for Postal employees) contain more 

information. You can read them at www.opm.gov/insure/life. 

Where should I send this form? Send it to the Insured's employing agency if the 

Insured: 

• is an employee; or 

• has been receiving compensation payments from the Office of Workers' 

Compensation Programs for less than 12 months and is still on the agency's 

rolls as an employee. 

Send it to the Office of Personnel Management, Retirement Operations Center, 

P.O. Box 45, Boyers, PA 16017-0045 if the Insured:

• is a retiree; or 

• is receiving compensation payments from the Office of Workers' 

Compensation Programs and is not still employed or has been receiving 

compensation payments for at least 12 months. 

The agency or OPM will note receipt in section E of the form and return a copy to 

you as evidence that it received and filed the original. 

Properly completed designations are not valid unless the appropriate office listed 

above receives them before the Insured's death. 

Privacy Act and Public Burden Statements

Title 5, U.S. Code, chapter 87, Life Insurance, authorizes solicitation of this information. Executive Order 9397, dated November 22, 1943, allows Federal agencies to use the Social

The Office of Federal Employees' Group Life Insurance (OFEGLI) will use the information Security Number as an individual identifier to distinguish between people with the same or

you furnish to determine your beneficiary(ies) for benefits under the Federal Employees' similar names. 

Group Life Insurance Program. OFEGLI is not a Federal agency. It is staffed by employees of

the contracted life insurance carrier. It may share this information with the Office of While the law does not require you to supply all the information requested on this form, doing

Personnel Management (OPM). Agencies and/or OPM will place this information in the so will help in the prompt processing of your designation. 

Insured's Official Personnel Folder or retirement file. OPM or OFEGLI may disclose this Agencies other than the Office of Personnel Management may have further routine uses for information to other Federal agencies or Congressional offices which may have a need to disclosure of information from the records systems in which they file copies of this form. If know it in connection with your application for a job, license, grant or other benefit. It may this is the case, they should provide you with any such uses which are applicable at the time also be shared and is subject to verification, via paper, electronic media, or through the use of you complete this form. computer matching programs, with national, state, local or other charitable or social security

administrative agencies to determine and issue benefits under their programs. In addition, to We estimate this form takes an average of 15 minutes to complete, including the time for

the extent this information indicates possible violation of civil or criminal law, it may be reviewing instructions, getting the needed data, and reviewing the completed form. Send

shared and verified, as noted above, with an appropriate Federal, state, or local law comments regarding our estimate or any other aspect of this form, including suggestions for

enforcement agency. reducing completion time, to the Office of Personnel Management, Retirement Services 

Publications Team (3206-0136), Washington, D.C. 20415-3430. The OMB number,

We also ask for the Insured's Social Security Number to use it as an individual identifier in 3206-0136, is currently valid. OPM may not collect this information, and you are not required

the Federal Employees' Group Life Insurance Program. to respond, unless this number is displayed. 

Keep Your Designation Current. Submit a New One If the Address of One of Your Beneficiaries Changes or If Your Intentions Change 

(for example, due to a change in family status, such as marriage, divorce, death, birth, etc.). 

SF 2823 

Back of Part 2 Revised March 2011