METROPOLITAN LIFE INSURANCE COMPANY

—_—

GROUP POLICY No. 17000-G bearing date of August 29, 1954 ang issued to
UNITED STATES CIVIL SERVICE COMMISSION
{Herein calles the Policynolcer)
pursuant To chapter 87 of titie 5, United States Code, is hereby emenced as follows:
AMENDMENT $4 .

Eftective July 1, 1972, by inserting "(1) For Any Policy Year beginning Prior to
duty: 1, 1972" as a@ caption immegiately after The heading “Schecule of Maximum Exsense anc
Risk Charges” in the tchedule following the fifth paragraph et Section (5 thereot, as
amenced, ang by adding To s: scneduie, the tol towing:

"(2) For Any Policy Year teoinning on or Subsequent _to July 1, 1972

item Mast mum Cha:

(a) Expense Crarges
(i) Taxes The actual accrued amount of taxes directly srtributacie to

the premiues, amounts of Insurance in force, or reserves under
tmis Policy, as cetermines by The tnsurance Company.

(il) Expense of The amount of all expenses incucred by the Insurance Company
acministration in aaainistering this Policy, Including the expense of mainte-

nance and operation of the Office and al! otner expenses at-
tributadie To this Policy, a8 determined by the Insurance
Company. Subpart 8 of Part !5 of Chapter | of Title 32, Code
ot Federal Regulations jail be used as a guice in the caterni-
nation of types of expense which are acceptanie as expenses of
acainistration and If, on audit, any item of expense of adminis-
tration is found to be based on @ type of expense which uncer
The above regulations is an unacceptable type of expense, sn
appropristeé adjustment will be made in @ subsequent contract
term accounting statement.

{b) Risk Charge (1) The sum of 0.4% of that part ot Preniums for the policy
year which Is not in excess of 3125 mitlion, and 0.2% of that
part of Premiums for tne policy year which Is in excess of
3125 miilion, of (if) $850,000, wnichever is less.”

The foregoing amendment is to be attached to and mace part of seid Group Polley.

Signed at _agsningron, 0.¢. this ____2nd aay of November 19.7

iki STATES CIVIL SERVICE COMMISSION
(Policyhoiger)

By Robert £. Hamoton
(Space Below For Use of Metropolitan Life Insurance Company Only)

Signed at New York NewYork this 29mm Gay of __ November 197,

. METROPOLITAN LIFE INSURANCE COMPANY,
——Wn B_hiaver to
Registrar) QA32QQ
Cone A Coat
Vice-Preswsem and Secretary

Form G.1985-29

COPY


@® " OSKER JONES 01-90

. Hamlin Ave. ; 090¢
Gogol toes ° . a La fe0 Tf 21/710
4 ~ BRANCH S600
! —
Geet 12S 7 CARD Is 50. 06
LILLY, Lath LE LOO se Dolla

'@) FIRST CHICAGO BAI
‘4 ‘The First National Bank of Chic



METROPOLITAN LIFE INSURANCE COMPANY

Senn eT
GROUP POLICY No. 17000-G bearing tate of August 29. 1954 and issued 10

UNITED STATES CIVIL SERVICE COMMISSION

( WEREIN CALLED THE POLICY MOLDER)

pursuant 10 the Federal Employees’ Group Life Insurance Act of 1954, is hereby amended as follows:

AMENDMENT 26 by s0b-
Effective as of the date of issue of said Group Policy. wl
sttuting for the liat of Retirement Systems in Schedule B artached

to said Group Folicy a3 a part thereof, the following list:

“(11 Cuil Service Revirement System
(2) System for Board of Governors of the Federal Reserve

System .
(31 Svatem for Public School Teschers of the District of
Columbia .
{4) Tennessee Valley Authority System
(5) System for Civil af the Naval Academy
(8) Forcum Service Revrement System ;
(7) System for Policemen and Firemen of the District of
luni
(8) Old Age and Survivors Insurance System (Social Se-
curity)
19) Coaat and Geodetic Survey System .
(10) System for Officers of the Public Health Service
(12) Lighthouse Retirement Systent
(12) EeeralJurbetary Renrement System (28 U.S.C,
71(a))
(13) Tuilicwey of the Territories Retirement System (28
73)"

AMENDMENT 27

. y subatituting “As amemied to and ins
. 1960" for “as amentied September 25, 1989" and
Ie 1, 180" for “aiter September 23, 19597 in Section 23
thereat, as amended

AMENDMENT 2
Effective July 10. 1960,

\. By adding immediately aiter the second paragraph of Section
I thereof, as amended, the following paragraph:

“The term ‘Employee’ shail also include any person
who, under condinans of eligibility pre-crihed by the
Polieyholsler pursuant to subsection (U1 of Section 2 of

+ the Federal Employees’ Group Life Insurance Act of
1954, a amended. comes within the purnew of aid .\et.”

B, By deleting the period at the end of the first paragraph of
Section 2 thereof, as amended. and by adding to sa:d paragraph,
the following:

+ and except that in the case of persons who. under cone
ditions of eligibility preseohed! hy the Folievholder pur>
tuant to siinecuon (di of Sectwn 2 ui the Feeleral Rims
ployees’ Group Life Insurance <Act af 1984, as ainended,
come within the purview of said Act. the ‘effective date’

shall be the date oe dates on of aiter July 10, 1950 pre-
scribed hy the Policyhudler ior any grep of auch persons.”
C. By deleting the perind at the enti of item (5) of the second
maph a §
item. the following:
and far any grep ai persons 4
cot eligibii

IJ thereni, as amended, and hy adding to said

nuler cenditions
prescnihed by che alievholler pursuant to
(dt of Section 2 af the Federal Employees”
mep Life Insurance Act of 1484, as amemied, cme

within the purview of said Act.”

AMENDMENT
4 uvenber 27, 1900,

ALB:
the following
“The term ‘renewal slate’ as tsed in this Mulicy shall
meas the last premium sive date i the month af Nevem=
her in each ai the calendar vears 1955 through 1900, bach
inclunve, antl [uly tot am the calendar year [M1 and in
cach sulmeyuent calendar year.”
B. By adding ta Section [4 therent, the folluwing sulsection (E)

“(Ki Discontinnunce of Colievonin the event of the
lisenntinuance ai this Pulicy in accordance with the provi-

3 of Section 16 hereui. of hy reson of non-renewal in
accordance with the provisions nf Section 17 hereof, the
Polivyholder shall he liable to the Insurance Company for
the jayment of the pro-rata premium accruing for any
period this Policy continues im force on and subsequent 10
the «due date of the last due and unpaid premium, and the
Insurance Company shall reiund to the Policyholder the
[ro-rata premium for any perxt subsequent to the effec-
tive «late of such discontinuance for which prenuums were
praxl by the Policyhoider.”

The foregoing amendments are to be attached to and made part of ssid Group Policy.

Mary J. Angluin

ehinchens Re Ge ___ this Tyertyaninth.__.___day of ___!

aaneen 9.80,

‘Wied

{SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)

UNITED STATES CIVIL SERVICE COMMISSION

BY mee rnnnee PRE IE. Ha. TONE

Chairman

anwday of. December, wat 9, 8,

METROPOLITAN LIFE INSURANCE COMPANY,

Mae. Stabe

Secretary


3. Upon information and belief, Maxine Jones (“Maxine”) is a resident of Illinois.
She was married to the Insured at the time of his death.

4. Upon information and belief, Osker K. Jones is a resident of Illinois, He is the
son of the Insured, but not the son of Maxine. Instead, he is the son of Vera Jones (“Vera”) who,
on information and belief, was married to the Insured prior to Maxine. On information and
belief, Vera died on or about September 15, 1994, predeceasing the Insured.

JURISDICTION AND VENUE

5. This Court has jurisdiction over this matter pursuant to 28 U.S.C. §§ 1331 and
1335, in that it is an interpleader action and the benefits are payable under a statute of the United
States, to wit, FEGLIA.

6. Venue in this District is proper pursuant to 28 U.S.C. §§ 1391(b) and 1335, in that
both defendants reside in this district, and a substantial part of the events giving rise to this
action occurred in this district.

FACTS

7. The payment of proceeds pursuant to the FEGLI Policy is governed by the
language of the FEGLI Policy, the FEGLIA statute (5 U.S.C. §§ 8701-8716), and federal
regulations (5 C.F.R. Part 870).

8. The FEGLIA statute provides, in pertinent part:

The amount of group life insurance and group accidental death
insurance in force on an employee at the date of his death shall be
paid, on the establishment of a valid claim, to the person or persons

surviving at the date of his death, in the following order of precedence:


CAME! Fo 1005 94S

| Sigh [6 Jove!

4 Vere a oe eee
GL
Dove



AMENOMENT $8 (Continued)

(B) Aaplicabie After the Emoloyee's Ratirement:—-The amount of Lite
insurance hereuncer on any Emptoyee after retirement shall de the basic
amount of Life insurance reduced by 2% thereof each month deginning with
the etfective reduction cate, subject To a minimum amount of Life Insurance
retirement of 25% of the basic amount of Lite Insurance. The terms
basic amount of Lite Insurance" and “effective raduction cate” are detined
in the following paragraphs of this subsection (B). in the case of an Em
Pioyee whose retirement occurs on or after December 16, 1967, the amount of
Life tnsurance at any time atrer retirement shail de separstely determined,
as nereinatrer specified, in respect of (I) Life Insurance exciusive of
optional Lite insurance, anc (2) optional Lite insurance, if any.

With rasoect to an Employee whose retirement occurs on or after
Decemoer 16, !967, “Sasic amount of Life Insurance” means, as to Life Insur=
ance exclusive of cotional Life Insurance, the amount of Lite Insurance in
accorsance with Part 1! of the Schedule of Insurance in subsection (A) of
this Section pased on the amount of his annual compensation on The date
his insurance would otherwise have ceased decause of The happening of the
event specifies in eitres of items (1) of (2) of the first paragraph of
Section 3 hereot; and “ettective reduction cate” means the first day of tne
second calendar montn after (1) such gate, or (2) his 65th birthday, which=
ever is later. The basic amount of Lite Insurance for the purposes of This
paragraph snail de determined as set forth etove without regard to the speci=
tications in Part 11 of the Schedule of Insurance in subsection (A) of this
Section relating to tne period tor which such scneduie is effective.

with respect to an Employee wnose retirement occurs on or after

February 14, 1968, “basic amount of Life Insurance” means, as to optional
Lite insurance, so much of the amount of optional Life Insurance in force
on his account on the date his insurance would otherwise nave ceased des
cause of the happening of the event soecitied in ner of items (1) of (2)
ot tne first paragraph of Section 3 nereot, in accoraance with Part 111 of
the Schedule of Insurance in subsection (A) ef this Section, which hag been
In torce tor not less tnan

(a) the full period or periods of service during which
optional insurance was availanie to him, or

(b) the twelve years of service immedi ly preceding
such date and during which the optional insurance was
avaitable to hia,

Form G.1985-33


Do 7 tae _ .
ANENOMENT 63 (Continued) “

annual compensation on the date his insurance would otherwise have
Ceased because of the happening of the event specified in either of
items (1) or (2) of the first paragreph of Section 3 hereof. The basic
amount of Life Insurance for the purposes of this paragraph shall be
determined as set ferth above without regard to the specifications in
Part Il of the Schedule of Insurance in subsection (A) of this Section
relating to the period for which such schedule is effective.

With respect to en Employee whose retirement occurs on or after February
14, 1968 out prior to Hovenber 2, 1978. ‘basic amount of Life Insurance’
meens, as to optional Life Insurance, se much of the amount of optional
Life Insurance in force cn his account on the date his insurance sould
otherwise have ceased decause of the hepoening of the event specified in
either of items (1) er (2) of the first peragraph of Section 3 hercof,
in accordance with Fart III of the Schedule of insurance in subsection
{A) of this Section, which had been in force for rot less than

(a) the full period or pericds of service during which optional
Insurence 3s available to him, er

{b) the tuelve vears of service imnediately preceding such date
and during which the optional insurence was available to hia,

whichever fs shorter. For the purposes of this paragraph, in the case
of an Employee who was on the roll of his employing cffice on February
14, 1968 ang who was insured for optional insurance on April 14, i833 or
the date of his retirement, if earlier, such optional insurance shalt be
deemed to have been in force for the fvll period or periods of service
during which optional insurance was evailable to hin prior to such
earlier date. If the Policyholder receives written notice frou the En-
ployee that optional Life Insurance on his acceunt is not to be cone
tinued after retirement, the provisions of this paragraph shall be null
and voic and of no effect and no optional Life Insurance shall be pro-
vided for the Employee after.retirement. .

With respect to an Employee those retirement occurs on or after December
16, 1957 but prior to February 14, 1968, ‘basic emount of Life Insur-
ance’ means, as to optional Life Insurance, en amount of optional Life
Insurance in accorcance with Part III of the Schedule of Insurance in
Subsection (A) of this Section based cn the anount of nis annual ccupen-
sation on the date his insurance would otherwise have ceased because of
the happening of the even: specified in either of {teas (1) or (2) of
the first paragrapil of Section 3 hereof. The basic anount of Life In-

surance for the purposes of this paragraph shall be determined as set
forth above without regard cs the specifications in Part III of the
Schedule of Insurance in subsection (A) of this Section relating to the

Form 6.1985-38


APELICATION,

Pursuant to the Federal Employees' Group Life Insurance Act of
1954, application is hereby sade to

METROPOLITAN LIFE LISURANCE COMPANY

for the insurance provided by Group Policy No. 17000-G, the
form of which hes been prepared and designated by Metropolitan
Life Insurance Company as "Fora G.1985", the terms of which
are hereby approved end accepted. A copy of such Fora duly
executed by Metropolitan Life Insurance Company together with
a copy of this application duly executed by the Policyholder
and attached to said copy of such Form shall constitute the
Group Policy hereby applied for.

This application supersedes the preliminary application
Signed at Washington, District of Columbia, September 10, 1954.

. wv
REY at bashington, District of volunbia, this _/O day
of CYLIET:.4 » 195k.

VUTTED STATES CIVIL SERVICE COMMISSTON
. {Policyholder)

Fora 6.4921
» Sept. 195%

(12)


14/26/2081 18:42 47736261522 DELORES WILLIAMS Pace @5
Ootezs~OL 09:33 PM LPHILLTFS 1778

~~ 6 0705 905. tal He, Ce Yee?

Pees Carb pthis yp

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Agr. wees

‘ $ th ’ ,


10.23.
IMPORTANT INFORMATION ABOUT
MONEY MARKET ACCOUNTS
AUTOMATIC “
+ If we are paying you $7,500 or more, we will automatically open a money market aeeunt i in your name and
mail you the checkbook.

ae)
2 Psy

SAFE
+ The account earns interest starting the first day we open it.
* Metropolitan Life Insurance Company guarantees the full amount in the account, including all interest.

FREE
* You pay nothing for this account. There are no monthly service charges or charges for checks.
* You can write checks from $250 up to the full balance at any time.

FLEXIBLE
+ You can withdraw all or part of your money at any time, with no penalty.
+ You can name a beneficiary for your funds, in case something happens to you.

We will send you detailed information about the account when we open one in your name.

SPECIAL NOTE

Please complete, in ink, the information below and sign your name in the first box. We need this
information to open a money market account. Even though you may be giving the same information elsewhere
on this form, you must also /\ it here. We cannot process your claim without this information.

= eran a

Your name (Please prin

MAX. a NE Johps

Address (Number, street, apt. no.)

£217 _W. VAN Buega

“CHicnes, LL Go 4
‘Your Sactal Seourity Nunaber va 3 =>|D _ lo | An ae

Estate/Trust Identification Number

Date (m ilo OB telephone no. Evening telephone no.
ODabl3R7 | (2B AULI47S

Form FE-6
Revised Anril 2001



& . S
METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 1700-6 bearing date of August 29, 1954 ond Issued -to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyhoicer)

pursuant to chapter 87 of title 5, United States Code, is hereby emended as follows:

AMENOMENT_ 61

Effective May 17, 1976, by substituting for the provisions added to
Said Group Polley by Form G.1985-32 (Amenament 57), The tol lowing:

“During the pertormance of this contract, the contractor agrees
as tollows: .

(1) The contractor will not discriminate against any enployee or
appiicant for employment because of physical or mental handicap in re-
gard to any position for which the employee or applicant for employment
is quatitiad. The contractor agrees to take affirmative action to en
Ploy, advance In employment and otherwise treat handicapped individuals
without discrimination based upon their physical or mental handicap in
atl employment practices such as the tollowing: employment, upgrading,
demotion or transter, recruitment, or recruitment advertising, tayott
or termination, cates of pay or other forms of compensation, and setec=
tlon tor training, including apprenticeship.

(2) The contractor agrees to comply with the rules, regulations,
and relevant orders of the Secretary of Labor issued pursuant to the
Renabilitation Act of 1973, Section 503(a) of Title V, Public Law 93-112,
as amended by Public Law 93-3516.

{3) In the event of the contractor's Pencomp| lance with the require~
ments of the non-discrimination clauses of this contract, actions for non-
compliance may be taken In accordance with the cules, regulations, and
relevant orders of the Secretary of Labor In 20-CFR Ch VI, Part 741.

(4) The contractor agrees to post In conspicuous places, avaliable
to enployees and applicants for employment, notices, tn a form to be
prescribed by the Director, Office of. Federal Contract Comp! lance: Programs,
United States Oepartment of Labor, provided by or through the contracting
otticer. Such notices shail state the contractor's obligation under the
taw to take affirmative action to employ and advance in employment qual lq
fled handicapped employees and applicants for employment, and the rights
Of applicants ang employees. - oe

Form 6.158536


METROPOLITAN LIFE INSURANCE COMPANY

—_—
GROUP POLICY No. 17000-G bearing dote of August 29, 1954 and insved to

UNITED STATES CIVIL SERVICE COMMISSION
{Herein called the Policyhoider)

puriwent to the Federal Employees’ Group Life Insurance Act of 1954, is hereby amended as follows:
AMENDMENT 36

Effectiveas of the date of issue of said Group Policy, by substituting for the last para=
groph of Section 11 thereof, the following porographs:
"If any person otherwise entitled to payment under Section 5 hereof or
this Section does not make claim therefor within one year after the death of
the Employee, or if payment to such penton within that period is prohibited
by Federal storute or regulation, poyment may be made in the order of pre-
cedance es if such person hod predeceased the Employee. Payment to any
person by virtue of the preceding sentence shall be a bor to recovery by ony
other persion.

If, within two years after the decth of the Employee, no claim for pay=
ment hes been filed by ony person entitled thereto under Section 5 hereof or
the order of precedence set forth in this Section, and neither the Policyholder
nor the Office hes received any notice that eny such claim will be mode, poy=
ment may be made to a claimant os may in the judgment of the Polic:
equitably entitled thereto, and such payment shall be o bar to rei
other person. If, within four yeors ofter the death of the Employee, payment
hes not been made purivant to Section 5 hereof or this Section ond no claim
for payment by cny person entitled thereto under said Section 5 or this Section
is pending, the cmount payable shall escheat te the credit of the fund creared
by subsection (c) of Section 5 of the Federal Employees’ Group Life insuronce
Act of 1954,°

AMENDMENT 37

Effective August 28, 1962, by substituting the dote “August 28, 1962" for the date
“July 1, 1960" in the two places in which it cppears in Section 23 thereof, os amended.

The foregoing amendments are to be attached to and made port of said Group Policy.

Signed ot_ Washington, 0. C. this 17th doy of Decender, 1962
Relea D. Unriz UNITED STATES CIVIL SERVICE COMM
(Wimess) i
By Jomn W. Macy, Jr.
. irman
(Space Below For Use of Metropoliten Life Insurance Company Oniy}
Signed at__nev york, Nev York this ith day of Jemary 1963

METROPOLITAN LIFE INSURANCE COMPANY,
Keane. Kithubeck
Seereery

ce Sz paringhane
Form G .}985~14 | GC 0) iP) Y -


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY NO. 17000-G bearing date of August 29, 1954 and issued to

OFFICE OF PERSONNEL MANAGEMENT

(Herein called the Policyholder)
pursuant to chapter 87 of title $, United States Code, is hereby amended as
follows:

AMENDMENT. 67

Effective July 10, 1984, by substituting for Section 12 of said Group Policy,
the following:

"Section 12. ASSIGNMENTS ~- The Eaployee's certificate {is non-a signable and
the insurance and benefits are non-assignable prior to a loss, excepe that a
Judge may trrevocably ign the inaurance and benefits wich respect to the
Basic Life Insurance, Option A-Standard Life Insurasce and Option B-Additional
Life Insurance under the Group Policy. No assignment is valid for any purpose
unless {t meets the following criteris:

A) For assignments signed before publication of the Policyhelder’s Final
Regulacions promulgated to implemenc section 208 of Public Law 98-353,

1. the assignment muse be signed; and

2. the assignment sust be received in the Judge's exploying office
before death; and

3. the assignment aust convey ovnership of all insurance: Basic Life
Insurance, Option A - Standard Life Insurance and Option B -
Additional Life Insurance, which the Judge may have; and

4. che assignment must not attempt to convey stated dollar amounts to
any assignee or assignees.

3B) For assignments signed after publication of the Policyholder's Final
Regulations promulgated to implement section 208 of Public Law 98-353,
the assignment sust comply vith auch regulations and any applicable
Tegulations which amend or modify or replace such Final Regulations.

‘Judge’ seans an individual appointed as a Federal justice or judge under
article I and Article III of the Conacitution.

Form 6.198542



METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 22, 1954 and tawed bb

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Pollcyholder)

punwvont to the Faders! Empicyees' Group Life Insurance Act of 1954, 1s hereby anended a follows:

AMENCMENT 44
Effective December 6, 1966, by odding to Section 5 thereof, the following subsection (C):

"(C) Special Provisions Applicable to Reemployed Retired Employeest=if the Life
Insuronce on c retired Employee cacses becouse of oppointment of the retired Employee
to @ pesition such thet he again falls within the definition of the term 'Employee' in
Section | hereof, then ot the subsequent death of the Employee while Insured hereunder,
the emount peyoble pursuant to the preceding subsection (A) on occount of weh decth
shell not be less than the amount thet weuld hove been poyoble hereunder hod the Em=
ployee's Ufe Insurence hereunder a a retired Employee not cacsed because of such
appointment, or, In the event that such death results from bodily injuries ond Is thereby
© loss for which benefits ore pcycble pursvont to the preceding subsection (B), the total
mount peysble purivant te sald subsections (A) and (8) on account of such death shail
not be less than the excess, If any, of (1) the cmount that would hove been payable
hereunder hed the Employee's Ufe Insurance hereunder os ¢ retired Employee not ceased
becowe of such appointment, over (2) the oggregate amount payable pursuant to sold
subsection (8) for cil losses, other than loss of Itfe, suffered as o result of such injuries.”

The foregoing anencment Is te be cHoched to ond mode part of seid Group Policy.

Signed ot Washington, D.C. _this___—_—Zard day of Februery 19.48
Helen R. Hill UNITED STATES CIVIL SERVICE COMMISSION
(Witmess) ey! 7)
by John W. Macy, Jr.
_ Specs Below For Use of Metropolitan Life Insurance Company Only)
Signed ot ___ New York, N.Y. this twelfth _day of March 1968_
METROPOLITAN LIFE INSURANCE COMPANY,
Wm. H. Mayer, Jr. ME. Hathabecie
Tagistree) —
Form G 1985-19

COPY


AMENOMENT_37_2 (Continued)

(4) The contractor agrees to compty with the rules and regulations of
the Secretary of Labor in 20 CFR Ch VI, Part 74h,

. (5) In the event of the contractor's noncompliance with the recuirements
of the nondiscrimination cisuses of this contract or with any of such rules,
reguiations or orders, this contract may be cancelled, terminated or suspenced
in whole or In part.

(6) The nondiscrimination clauses of this contract shell be Included in
ell subcontracts over $2,500.

(7) The contractor agrees

(a) to establish an affirmative action program, including
appropriate procedures consistent with the guidelines
and the rules of the Secretary of Labor, which will
provide the affirmative action regarding the employment
and advancement ct the handicapped required by Section 503(a)
of Title V of Public Law 93-112, the Rehadl Ii tation Act of
1973,

(b) to publish the program In his employee's personne! handbook
or otherwise distribute a copy to al! personnel,

(a) to review his program on or before March 3ist of each year
and To make such changes as may be appropriate, and

(a) to designate one of his principal officials to be respon=
sible tor the establishment and operation of the program.

(8) The contractor agrees to permit the examination by appropriate
contracting agency officials or the Assistant Secretary for Emioyment
Standards or his designee of pertinent books, documents, papers end
fecorss concerning his employment and the advancement of the handicapped.

(9) The contractor agrees to post in conspicuous places, available
to employees and applicants tor employment, notices, in a form to be
prescibed by the Assistant Secretary for Employment Standards, provided
by the contracting officer stating the contractor's obligation under the
few to take affirmative action to employ and advance In employment quale
Uf led handicapped employees and applicants for employment and the rights
and remedies availabdie.

Form 6.198532 G 0) [P Y


METROPOUTAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G becring dete of Augist 29, 1954 and lasved to

UNITED STATES CIVIL SERVICE COMMISSION
{Herein called the Pollcyhoider)

pursuant to the Federal Employees’ Group Life Insurance Act of 1984, Is hereby amended os folicws:
AMENDMENT _ 40

Effective April 6, 1964, by substituting “4 East 24th Street, New York, New York 10010"
for "25 East 24th Street, New York 10, N.Y." as the post office address of the Office of Federal
Employees’ Group Life Insuronce oppearing in the fourth peragroph of Section } thereof, as omended,
AMENDMENT 41

Effective Jonucry 1, 1965,

A. By substituting for the words “in any of the groups of employees specified In Schedule A
attoched hereto as o port hereof” In the first porograph of Section |} thereof, os amended, the following:

excluded by section 870.202 of the Polleyholder's regulations".

B. By deleting Schedule A ottoched to said Group Policy as @ part thereof.

The foregoing amendments cre to be attached to ond made port of sold Group Policy.

Signed et Washington, 0. C. this 22nd day of December 19.65
Mory V. Wenzel UNITED STATES CIVIL SERVICE COMMISSION
(Witness) (olleyholder)
by. John W. Macy, Jr.
(Spece Below For Lite of Metropolitan Life Insurance Company Only)
Signed at New York, N.Y. this__ fourteenth _day of January 1966
. METROPOLITAN LIFE INSURANCE COMPANY,
; Neat. Hethubecke
Seowery

Wm. H. Mayer, Jr.
(Registrar)

Forn G.1985-17 GC 0) P Y .



AMENCMENT 38 (Continued)

PART 11 = SCHEDULE OF INSURANCE, EXCLUSIVE OF OPTIONAL INSURANCE,
CN ANO AFTER FIRST DAY OF FIRST PAY PERIOD “HICH BEGINS ON OR AFTER
FEBRUARY 14, 1968

Insurance for Death

Lite or Dismemberment by
Insurance Accidents! Means
The amount of the Employee's Lite The amount of the Employee's
Insurance shall be an amount equal Insurance tor Oeatn or Oisnemberment
to tne sum of (a) $2,000, and (bd) by Accidental Means shal! Se an
tne Employee's Annual Compensation amount equal to the smount of
(as fixed by law or regulation). . . his Life Insurance.

Such amount of Lite Insurance snali
be subject to (i) a minimum amount
of Life insurance of $10,000 and (ii)
a maximum amount of Lite Insurance
equal to the Annual Compensation -
rate tor positions at Level !! of

the Executive Schedule uncer

section 5313 of title 5, United
States Code, as in effect from time
to tima, plus $2,000. If the Annual
Compensation referred to is not a
multiple of $1,000 it snail de taken
To the next higher multiple of $1,000
tor the purpose of this provision,

PART [11 + SCHEDULE OF OPTIONAL INSURANCE ON ANO AFTER
FIRST DAY OF FIRST PAY PERIOO WHICH BEGINS ON OR AFTER
FESRUARY 14, 1968

The amount of optional Lite Insurance and the amount of optional insurance

tor Death or Oismemoerment by Accidenta! Means is the greater of (a) $10,000,
or (b) The excess, if any, of the amount of the Empioyee's annua! compensation
Cif not a multiple of $1,000, such annual compensation to be taken to the next
lower multiple of $1,000) over tne amount of Lite Insurance or the amount of
Insurance for Ceatn or Olsmemberment by Accidental Means, respectively, in
accordance with Part I! above.

Form G.1985-33


Administrative lav judges, bankruptcy judges and magistrates are not judges

for the purposes of assignment.”

The foregoing amendment is to de attached to and made part of said Croup

Policy. .
Signed at _ Washington, D.C. this 20th day of February. 1986
- OFFICE OF PERSONNEL MANAGEMENT.
(Policyholder)
By. Jean McBarber
(Space Below for Use of Metropolitan Life Tasurance Company Only)
Signed ac New York, New York this 9th day of May 1986

METROPOLITAN LIFE INSURANCE COMPANY

(Registrar) mara

Sherron Willfanson 4 Lig,
7 Cory

Form 6.198$-42



18/26/2081 18:42 17736261522 DELORES WILLIAMS PAGE 23
°

CT-25-81 12:02 FM LPHILLIPS 1 773 768 3226 P.e2

PAGE 2 OF 2 OF Letter dated October 25, 2004

OSKER K. JONES
312 Chicago Avenue , Unit 2-4
Oak, Park, tifinols 60302
Telephone # 708-783-0813

eb

RE: DECEASED INSURED Mr. Osker Jonas - CSA#A3788243 - CLAIM # 20010708945

As | previously stated in my letter of October 7, 2001, my father was out of town September 5,
2000, and did not sign this beneficiary form at any time. Also! am again indicating thet Mr.
Osker Jones, would not have signed any form/s/ without the benefit of a Notary seal.

My correspondence of October 7, 2001 included @ copy of my father’s signature for
comparing with that signature which appeared on the Beneficiary form of September 5, 2000.

Please note that the copy of the beneficiary form which was sent to me from your office
reflects the name of the "named beneficiary”, Maxine Jones. Pisase note that the name of
Maxine Jones was “whited out”, | am assuming that this was done to protect the privacy of
the “named” benefictary, however If you hold the document over an electric light fixture you
are able to see her namo appearing as the beneficiary to recolved 100% of the benefits.
Again, | am stating that this Is « fraudulent document.

| AM AGAIN REQUESTING THAT YOUR OFFICE INVESTIGATE THIS CLAIM BEFORE PAYING
ANY PROCEEDS. PLEASE DO NOT PAY ANY PROCEEDS TO MAXINE JONES, AS THE
BENEFICIARY FORM THAT WAS EXECUTED ON SEPTEMBER 5, 2000, THAT WAS
SUBMITTED BY MAXINE JONES 18 FRAUDULENT, AND OOES NOT BEAR THE ACTUAL
SIGNATURE OF MY FATHER, OSKER JONES. ALSO, THE WITNESSES OF THIS DOCUMENT
SHOULD ALSO BE QUESTIONED, AS THEY DID NOT WITNESS THE SIGNING OF THIS
DOGUMENT BY MY FATHER, MR. ONKER JONES, THESE WITNESSES ARE PERSONAL
FRIENDS OF MAXINE JONES, SHE 18 ALSO EMPLOYED BY THERE WITNESSES,

Please notice the printing and all of the “supposed signaturos” on the beneficiary form. The
completion of this form appears to have been completed by tho same person. Ldo.not

balinve that this ix a colncident that all of the Information that required a printed or curalye
response, appears to have been made by the sume person.or by poraona with jdantical
handwilting,

Please honor the original beneficiary named by my father on November 2, 1989, which is
myself, Ovkor K. Jones. Ploase contact me by letter or telephone at your earllost regarding
this matter. .

Very truly yours,
Ch. Khe

Osker K. Jones
Enc.: letter dated 10-7-01 & returned canceled checks for Osker Jones


w4e

AMENOMENT 46 (Continued)

“PART I-SCHEDULE OF INSURANCE, EXCLUSIVE OF OPTIONAL
INSURANCE, PRIOR TO FIRST DAY OF FIRST PAY PERIOD WHICH
BEGINS ON OR AFTER FEBRUARY 14, 1968",

ond by odding immediately after sald schedule, the following:

“PART 1l-SCHEDULE OF INSURANCE, EXCLUSIVE OF OPTIONAL
INSURANCE, ON AND AFTER FIRST DAY OF FIRST PAY PERIOD
WHICH BEGINS ON OR AFTER FEBRUARY 14, 19768

Annvel Compensation Insyrence for Death
Greater But Not Ufe or Dismemcerment by
Thon Grecter Thon Insurance Aceidentc! Means
0 $ 8,000 $10,000 $ 10,000
$8,000 9,000 11,000 11,000
9,000 10,000 12,000 12,000
10,000 11,000 13,000 - 13,000
11,000 12,000 14,000 14,000
12,000 13,000 1§,000 15,000
13,000 14,000 16,000 16,000
14,000 1$,000 17,006 17,000
15,000 16,000 18,000 18,000
18,000 17,000 19,000 19,000
17,000 18,000 20,000 20,000
18,000 19,000 21,000 21,000
19,000 20,000 22,000 . 22,000
20,000 21,000 23,000 23,000
21,000 22,000 24,000 24,000
22,000 23,000 25,000 25,000
23,600 24,000 26,000 26,000
24,000 25,000 27,000 27,000
25,000 26,000 28,000 28, 000
26,000 77,000 29,000 27,000
7,000 28,000 30,000 30,000
28, 000 2, 31,000 31,000
29,000 - 32,000 32,000

PART IIl-SCHEDULE OF OPTIONAL INSURANCE ON AND AFTER
FEBRUARY 14, 1968

The omount of optional Life Insurance and the amount of optional Insurance

for Deoth or Dismemberment by Accidental Means Is the greater of (a) $10,000,
ond (b) the excess, If any, of the omount of the Employee's annual compensation
over the omount of Life Insurance of the amount of Insurance for Death or Dismem=
berment by Accidental Mecns, respectively, In accordance with Pert II above.”

Form G.1985-21


emest oF entitiement zo benesizs
4, United States Code, eleccs to have
ed in accordance with either Elecrios 2 oz
cancel the ssouns cf Yasic Lite
eston 3 and thereaftes bes /bee

ection ra sucs Esplovee say,
insurance provided br eis!
e lis i

selecsec

The amoust of Opeion A = sandase Lise Insurasce bereunder, ‘{f any, o3 asy
tizement or estitlensst to beresits under subchapter i of

chap te 5, Usired Stazes Code shall be che amount of Option 2 -
Szaacarée Les insuzancea reduced dy 2% ©: ef each month begiscing wich e
att d@uezios dase, subdjecs to a einisus anount of Option A - Standard

Lise Issuzasce after re enent oz esticlenent to benefits under subchapter 1 of

chapter 61 of title S$, Unized States Code of 252 of the amount of Option a -
Standard Life Issurance.

The asouns of Option 2 - adéisiosal Life Insurance hereunder, if any, after -
retirement or entitlement to benetics under subchapter 1 of chapter 81 of title
$ e¢ States Code shall de reduced by 2% chereot each month begicning vith
active reduction cate and contisuing for 50 aonths.

Life Insurance (exclusive of Option A - Standard Lite Insurance and Optics 3 -
Addizional Lite Insurance) means so much of the azount of such Life Insurance ia
force on his/her account on the dave his/her insurance vould otherwise have
ceased because of the happening of che event specified in either of.irems (1) or
(2) ef the first paragcaph of Section 3 hereof, 42 accordance with Part ILa* of
the Schedule of Insurance in subsection (A) of this Section which had been in
force fo> not less than

(a) che full period er periods of service during vhich such insurance vas
available to him/her, or

(b) she five years of sezvice imediacely ding the date of the Employee's
retiresent oz the dace of she isploye estitlezent to Senefits under
subchaptes 1 of chapters 81 of ticle S, United States Code and ‘during vhich
such iasurance ** was svailabdle to hin/hes,

whichever is shorter.

Qpcton A = Standard Life Insurance means so much of the amount of Opsion A-
Stancard Life Insurance in force on his/her account on the date his/her
insurance vould othervise have ceased because of the happening of the event
speciiied in either of itezs (1) or (2) of the first paragraph of Section 3.
heseof, tn sccordance with Parts Ii] and/or IV of the Schedule of Insurance ‘a
subsection (A) of this Section which had been in force for not less thas

* Parte ITA, ot I73, whichever is applicable to the Ezployee, - on and after che
fisst day of the firsc pay period which begins on o> after October 1, 198).

** socludes insusance set forth in Fart Il and/or Parc Ila.

=~ COPY


lelow surviving at the date uf the Eimplayer's death, ins the fullerw~
jog under of precedence:

(1) Ta the witkiw up widower uf the Employer:

12) [neither of the alaeve, ts the chiki ur children of such Esn-
ployee and deweaants of deveased chikicen hy representas
ting:

(31 Ti nane of the alee, 0 the parents of auch Eapluyee of the
survivor oF then

we al the aluve, te the thily ayyadnted executer ue atl

(5) Hh nune of the almve, iether next of kin of such Enyphoyee
y le sleterutined liy the CHtice to he entithed under the
jhe al 9

m ‘ island Leo-slni

ake vlaine therclur withit wee year aiter the death vi the

SSSIGNMENT.—The Eanluyee's certifieate is

Tec reemenniggtiable

SEE AMND.67 SEE AMEND. 36.

FORDS=INFORMATION TO WE FUR:
TERMINATION RY THE POLICYHOLDER,
=The Palicyhokler shall nssiniain we catbe to be maintained records
from which way be determined the names of all Kanpluyees insured
hereunder and the amemne of insurance in furce on each of such
cyhuliler shall furnish of couse ty be furnished

p wployers insured here=

cratnn oi the inwurance lereuner. The records of the
icyhubice as have a bearing on the insurance hereunder shall be
tapen (or inspection by the fice at any rensunable time.

For the purpnes uf this Mulicy, determination by the Policy
holder of the following shall be conclusive:
(1) The classification of any perun as heing within the detini«
tion oi the term “Employee” in Section 1 hereot.
(2) The fact and date of (i) separative of an Employee from
the service, (ii) a pay stars or non-pay status of an Em-
Woyee, and (iii) cessation of an Employee's classifieation
as an Fanployre as detinal in Section 1 hereol.

Eanytuyer at the time of hin death. ”

(3) The “annual compensation”-of any Employee as of any
na date,
S (4) Fae ferrin ther eny-tinmpefeeie-envisied-te-end-hee-met
8 for retirement on immediate annuity. (ii)
a ia retired for disability of the
: ixilian service of any such

s Employee is at least fifteen, and (a?~that_any such Em-
a ployee's annuity has terminated and the dat tere
: ination

oye .
a AMEND. 5, 28 a

Section 14, PREMIUMS—GRACE PERIOD—(A) Basic
Tables of Premium Reter—The initial Schedules of Basse Bi-
weekly Premium Rates for Life Insurance and for Insurance for
Death or Dismemberment by Accidental Means are set forth in
Section 21 hereof. Such Schedules are applicable to the first palicy
year, and shall be continued for subsequent pniicy years, except that
they may be readjusted for any subsequent policy year, based on
the experience under this Policy, such readjustment to be made by
the Insurance Company on a basis determiner by the Policyhoider
in advance of such year to be consistent with the general practice
of life insurance companies under policies of group ti
and group accidental death and dismemberment insurance issued to
large employers.

E.xcepe as otherwise provided in subsection (B) of this Section,
the Insurance Company shall compute an average basic bi-weekly
Gronp Life Insurance premium rate per $1,000 of Lile Insurance
for the first and exch subsequent policy year as uf the first day of
auch policy year by applying the Schetlule in Section 21 herect
applicable to such policy yer to the distribution hy age of the
amounts of Life Insurance in force hereunder on the first day of

+ mach policy year.

‘The term “policy year” as used in this Pulicy means the period

hexinnina with the date of issue of this Palicy, or with a subsequent
renewal «date, and enling with the oy wecliately preceding the
neat following renewal date.

(W) Tentative treraye Group Life Innmarce Prominin Ratem
in the event the Pulicyhulder determines that ascertaining the actual
age distribution of the amounts of I ife Inutrance in furce hereunder
on the date of issue of this Policy or at the encl of the first or any
aubvexyvent policy year would not he possible except at a dispro-
portionately high expense, the Policyhulder may approve the de-
termination of a tentative bi-weekly average Geoup Life Insurance
premium rate per $1,000 of Life Insurance for the tirst or any aub-
seyuent policy year, in lieu of using the actual aye distribution. Such
tentative premium rate shall then becunse the premium rate in effect
hereunder per $1,000 of Life Insurance. Upon request by the Insur-
ance Company the Policyhoider shail redeterntine the tentative
average premium rate as of any premium due date during any
policy year if experience indicares that the assumptions made in
tktermining the tentative average premium for that policy year
were incorrect.

{C) Payment of Preminus—Premiums under this Policy shall
he due as of the date of issue hereot and bi-weekly thereafter on the
same day of the week as the date of issue (herein called the due
date). The prensiam payable on any due date shall be either

a ‘The sum of (i) the amount of Life Insurance in force on

ance with subsection (A) of this Section in effect on such
due date and (ii) the amount of Group Insurance for Death
or Dismemberment by Accidental Means in foree on such
due date multiplied by the bi-weekly premium rate for such
insurance in effect on such due date. or
(2) Ifa tentative bi-weekly average Group Lile Insurance pre-
mium rate has been determined in accordance with subsec-
Form G.1985

(3) Aug. 1984


Proceeds of the FEGLI Policy. After payment of the funeral home bill, there remains
$43,053.58 in the Insured’s account (the “Remaining Proceeds”).

18. MetLife is ready, willing and able to pay the Remaining Proceeds of $43,053.58,
plus all applicable interest, now payable as a consequence of the Insured’s death, to the party or
parties entitled thereto. MetLife is prepared to pay immediately into this Court, or as this Court
otherwise directs, the total Remaining Proceeds payable, plus applicable interest.

19. MetLife is a mere stakeholder, has no interest in the Remaining Proceeds and
respectfully requests that this Court determine to whom said benefits should be paid.

20. Accordingly, MetLife will deposit into the registry of the Court the Remaining
Proceeds, plus applicable interest, which are now due and owing in accordance with the terms of
the Policy, for disbursement in accordance with the judgment of this Court.

21. MetLife has not brought this Complaint of Interpleader at the request of any or all
of the Defendants; there is no fraud or collusion between MetLife and any or all of the
Defendants; and MetLife brings this Complaint of its own free will and to avoid being vexed and
harassed by conflicting and multiple claims.

22. Until this Court rules on the issue of whether the Second Form is valid and
effective, MetLife cannot safely determine the beneficiary of the Proceeds without risking
exposure to multiple liability.

WHEREFORE, plaintiff, Metropolitan Life Insurance Company, requests this
Court to enter judgment against Defendants, Maxine Jones and Osker K. Jones, as follows:
A. Restraining Defendants Maxine Jones and Osker K. Jones by Order and
Injunction of this Court from instituting any action against MetLife for the
recovery of the Remaining Proceeds;

B. Requiring Defendants Maxine Jones and Osker K. Jones to answer this
Complaint;


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 29, 1954 ond Issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyhaider)

pursuant to the Federal Employees’ Group Life Insurance Act of 1954, Is hereby omended os follows:
AMENOMENT 46 ,

Effective December 16, 1967,

A. By adding to Section 1 thereof, the following poragraph:

“Unless otherwise specified, any references In this Policy to Insurance here
under, Ufe Insurence hereunder, of Insurence for Deoth or Dismemberment by Ac=
eldento} Means hereunder shell Include, respectively, optional Insurance, optionas
Ufe Insurance, and optional Insurance for Death or Dismemberment by Accidental
Meons.”

B. By Inserting as the first sentence of the fint paragroph of Section 2 thereof, the
following:

"The word ‘Insurance’ cs wed In this Section 2 means Insurance exclusive
of optional Insurance hereunder.*

C. By adding to sald Section 2, the following porogreph:

*IF an Employee Is not or would not become insured hereunder at the time he
cctuclly enters on duty on his first doy In @ pay status on or after the First doy of the
flrst pay period which begins on or after February 14, 3968, by reason of hoving
given written notice to an employing office, prior to the first day of the fint poy
period which begins on or after February i4, 1968, thot he desires not to be insured
hereunder, then the insurance on such Employee shall nevertheless become effective
at thet time, Irrespective of the Employee's oge and Insurabillty and notwithstanding
the provisions of the Immediately preceding parogroph, provided thet prior thereto
he hes not ogain given written notice thet he desires not to be Insured hereunder."

D. By odding Immediately following sald Section 2, the following Section 2As

“Section 2A. EFFECTIVE DATES OF OPTIONAL INSURANCE .-An Empioyee
on the roll af his employing office on February 14, 1968 shall become eligible for
optional insurance on February 14, 1968. Any person who becomes on Employee as
defined In Section 1 hereof ofter Fabrvary 14, 1968 shall become eligible for optional
Insurance on the day he actually enters on duty on his first day In @ poy stotus.

Form G.1985-2!


. ‘ET=OLITAN LIFE INSURANCE COMPAN' =

GROUP POLICY NO. 17000-6 bearing date of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION
Wherein called the Policyneicer)

pursuant To chapter 87 of Title 5, United States Code, Is hereny amanced as tollows:

AMENDMENT 60

cor

Ettective Octover I, 1977, by substituting: tor the second paragraph of Section 1s
thereat, the following:

“1¢ trem (5) [8 a positive amount, such amount shall de held by The Insurance
Company as a Contingency Reserve To be used for cnarges uncer this Policy only.
Such Contingency Reserve snail bear interest at a rate To be of nee in advance
ct @acn policy year by The Insurance Company, which rate snall be approved by the
Policyhoider as being consistent with the rates generally used by the Insurance
Company for similar funds held uncer other group lite insurance policies. Such
intarest shall be computed as of tne end ot each policy year on the mean anount ot
the Contingency Reserve during that poticy year at te rate applicable to that
polley y: tt the actual net Investment Income generated by the tinancial trans-
‘actions uncer tne Group Policy for tne calendar year ending during tre policy year
is excess of the interest that Is credited on the Contingency Reserve st the
rates previously guaranteed by the Insurance Company, The interest on the Cantin=
gency Reserve shal! be Increased by the Insurance Company to retiect such actual
net investment income. If such actual net Investment income is fess than such
Interest at the rates previously guaranteed by te Insurance Company, The deticit
will be carried forward to offset the actual net Investment income generated in
the totlowing calendar year or years. The total amount of Interest so calculated
shall de added to the amount of the Contingency Reserve as of the end of such policy
year or upon the request of the Polleyhoider shalt be paid To the Poltcyholder within
ninety days after tne end of such policy year tor deposit in the Treasury of the
United States for credit To tne fund created by subsection (c) of Section 5 of the
Feseral Employees’ Group Lite Insurance Act of 1954."

The foregoing amendment is to be attached To and made part of said Group Policy.

Signed at Washington, D.C.this oh day of November. 19_77
‘ UNITED STATES. CIVIL SERVICE COMMISSION
(Poticyholcer)

By__ Alen X. Campbel)
(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)

Signed at Rev. Zork. N.Y. this tventy-second day of Joveske> 19_T77
: METROPOLITAN LIFE INSURANCE COMPANY,

Richard D. Zinke
(Registrar) gq a4
bi nts yore, 2 ¥
‘Generat Counsel & Secremry

_ - COPY



METROPOLITAN LIFE INSTRAME COMPANT

GROUP POLICY NO. 17000-¢ dbearisg care of August 29, 2954 and issued to

OFFICE OF PERSONNEL MANACEENT
(Eeress cacaed the soiicynolicer)

pursuass to chapter 87 of title 5, United States Code, is hereby amended as
sollows:

SUMENT_ $6

esive Decenbes $9, 1980, dy substituting for the first senzence

i.
2 F238 in the fs paragraph of subsection (3) encitied “Applicable after
b+ Esployee's Retiresenc or Entitlesest to Benefits Under Subchapter 1 of
Ce.

ter 81 of Title $, United Staces Code” of Secsicn 4 thereof, as avecded,
the following: .

12980 . : .

= to Decesde:

The azount of Lita Insurance hereunder on any Exployee after retirement or
entitlesest to besefits uncer subchapter 1 of.chapcar @1 of title 3,
Daized States Code shall be che basic soount of Life Insurance reduced by .

ce thereof each month begiacing with the effective reduction date, subject
to a siztsus amouns of Life Insurance afte= retirenest or entitlement to

benefits under subchapter 1 of chapter 81 of ticle 5, United States Code
of 28% of the basic azovas of Lite Insurance.

On or afzer Decesder 9, 1980

The apoust of Life Insurance hereunder oo any Eaployee after retirepest or
entitlement tc benafits under subchaptezr 1 of chapter 81 of ticle 5,
Daited States Code shall be d saised is eccordasce with Election i
Election 2, or Election 3 as eleczed by the Inploye: .

Election 2

The Explovee may elect to have his/her basic azount of Life Insurance .
ed by 2% therecf each conch beginning with the effeccive reduction

avdject to a minim amount of Life Insurance after retirement ot

entitlement to benefirs under subchapter 1 of chapter 81 of title 5,-
Usited: States Code of 25% of che basic amount of Life Insurance.

‘Election 2

The Explovee say elect so have his/her basic amount of, life Insurance
reduced by 12 thereof each month deginning with the ective reduction
date, subject to @ ninimu avount of Life Insurance after retizesent oF
‘ entitlesent to benefits under subchapter 1 of chapter 81 of title 5,
United States Code ef SOX of che basic amount of Life Insurance.

ve COPY

ee



f

4
=
FeLED
JUL 15 2002
IN THE UNITED STATES DISTRICT COURT
MICHAEL W. DOBBINS FOR THE NORTHERN DISTRICT OF ILLINOIS
CLERK, U.S. DISTRICT COURT EASTERN DIVISION
METROPOLITAN LIFE INSURANCE )
COMPANY, )
Oz
Plaintiff, ) al ae Hy fy
49399
v. ) No.
) EPA TTORt a
MAXINE JONES and OSKER K. JONES, ) JUDGE GOTTSes
)
Defendants. )

MAGISTRATE JUDGE BOBRICK
COMPLAINT OF INTERPLEADER

Plaintiff, Metropolitan Life Insurance Company (“MetLife”), by its attorneys, hereby

complains of Defendants Maxine Jones and Osker K. Jones, as follows:
NATURE OF THE ACTION

1. This action for interpleader concerns a dispute as to the payment of benefits under
a Federal Employer’s Group Life Insurance Policy (the “FEGLI Policy”), which was created and
is governed by the Federal Employer’s Group Life Insurance Act (“FEGLIA”), 5 U.S.C. §§
8701-8716, and 5 C.F.R. Part 870. Although it is ready, willing, and able to pay the proceeds of

the FEGLI Policy, MetLife cannot determine which of two claimants is entitled to payment N

account of insured Osker Jones (the “Insured”). a te
THE PARTIES * ay
2. MetLife is a life insurance company registered with the Illinois Department of

Insurance and licensed to do business in the State of Illinois. MetLife issued the FEGLI Policy,
Group Policy No. 17000-G, to the United States Postal Service pursuant to the FEGLIA Statute.

(A copy of the FEGLI Policy is attached hereto as Exhibit A.)

/


i TO_914852725221 P.88/7es
MAY @3 202@ 14:15 FR METLIFE LAW DEPT.

. co

“4-

(3) pose~jodgment interest a2 the statutory rate alleved on
dJudgmenes in the applicable stete.”

F. By addtog tmmediaraly following Section 11 of said Supplementary Agreanent
Form G.1985-a the following Saccion 12:

“Section 12. EXTRA-CONTRACT DAMAGES. = In any action at lav or in equity
the Exployee or ‘claiment, as specified in Section $ haracf, shall be
limited ¢n the amount, of recovery to the benefit clained, plus reasonable
pitorner's fees as set by the court. The tare “besefic claimed” ig
imited tot

(2) the amount of Yamtly Life Insurance in force hereunder em account of
auch Vauily Meader in accordance with Secrion 4 hereof, at the date
of death of such Yamtly Member; and

(2) duterest, as specified in subsaceion C of Section 4 hereof; and

(3) post~Judgmant interest at the statutory rate allowed on judgments in
the applicable state.”

The foregoing smendasnt is to be attached to end usde parc of said Group
Policy. .

Signed at Washington, D.C.  chig 2k th day of My 19 483

OFFICE OF PERSONNEL MANAGIONY
olicyholdar,

sy. Carlos ¥. Leparsa

(Space 3elow for Use of Metropolitan Lite Insurance Company Oaly)

Signed et _ Mew Yors. wy this 20h day of __deroher 19 88

METROFOLITan LIFE INSURANCE COMPANY
. ; . Peakond 18 BkeaahurtEis
Sharron Williassen Hci po a
(Regiatrer) “

@OPVY

ML 0130


18/26/2881 18:42 17736261522 DELORES WILLIAMS PAGE 08

“Osi NES 61-90 . 1038 .
@ ers nin hs Lele PF son toe
ee OSS1EO TPZ. -_

OOO0% 37h

@ OSKER JONES 01-90
1927 S. Hamlin Ave.

Chicago, 11 60623 Lé-£- 9 FZ nk,
oot tiles, NATE Liki LMS,

1$ Hs; BO

~ Dollars
LE LOS SOF4G219O1

2

TENET stersmntion!TM,
“Ooc00d4 sabe
OSKER JONES 01-90 Cg & r 43
® sre FT poo anes
bore aw TMA Mew tablshile\% /O. 0°
TEN AND 766 Doers

be.
Panett OO Oe RTT

0430000002000."

we


12. The Insured died on July 5, 2001. A copy of the Death Certificate is attached
hereto as Exhibit D. As a result of the Insured’s death the Proceeds became payable, in
accordance with the terms of the Policy and FEGLIA.

13. MetLife has received three letters from Osker K. Jones challenging the validity of
the Second Form (Ex C). Osker K. Jones’ letter of September 16, 2001 is attached hereto as
Exhibit E. Osker K. Jones’ letter of October 7, 2001 is attached hereto as Exhibit F. Osker K.
Jones’ letter of October 25, 2001 (faxed on October 26, 2000) is attached hereto as Exhibit G.
Osker K. Jones claims that his father was out of town on September 5, 2000 and could not have
signed the Second Form on that day; that the Signature is a forgery; and that the Insured was
incoherent due to illness and did not understand what he was signing.

14, MetLife has received a claim for the Proceeds from Maxine. A copy of the Claim
for Death Benefits form from Maxine, dated July 25, 2001, is attached hereto as Exhibit H.

15. MetLife has received a claim for the Proceeds from Osker K. Jones. A copy of
the Claim for Death Benefits form from Osker K, Jones, dated July 26, 2001, is attached hereto
as Exhibit 1. MetLife has also received a Claim for Death Benefits form from Osker K. Jones
dated August 9, 2001. A copy of the August 9, 2001 form is attached hereto as Exhibit J.

16. By reason of the actual or potential conflicting claims of Defendants, MetLife is,
or may be, exposed to multiple liability.

17. On or about July 11, 2001, both Defendants signed and submitted a funeral home
assignment in the amount of $4,946.42 to the A.A. Rayner and Sons Modern Funeral Service. A
true and correct copy of that funeral home assignment is attached hereto as Exhibit K. Because

both claimants agreed, and at their joint direction, MetLife paid the funeral home bill from the


. P9989
MAY @3 2008 14:15 FR TEXLIFE LAW DEPT. TO 914852725221

. METROPOLISAN LIFE INSURANCE COMPANY

GROUP POLICY NO. 17000-G baaring date of. Auguss 29, 2956 and issued to

OFFICE OF PERSONNEL MANAGEYENT
“Clarets called the Policyhoider)

‘pursuant to, chapter 87 of title 5, United Steres Coda, se hereby anendad as follows:

AMENDMENT, 71

Effective on the date of execution of this amendsers,

A. By redestgnating subsections (C) and (D) of Section 5 therec! an subsections
(D) and (Z), and dy inserting the following subsection (C):

“cep Payment of Ineurence, ‘Benefits With Respect to Scace Tax Lawas—Paynent of
the suount. of Utfe Tosurance or Insurance for-Degth by Accidental Meany to
any ‘percon entitled thereco under subsections (A) and (3B) of chts Section
or the order of precedence set forth in Section 11 shall ba eade vithors
fegard co any State law relating to the collection of caxes by any Stata,
except thet the Office aay couply with any State law requiring that the
payor of the amount of Life Inscranca or.Insurancea for Death by Aceidental
Means give notice of such paysent ro any State tax sutlority. Payment of
the amguat of Life Insurance or Ingurance for Beath by decidental Meana to
any person entitled thereto under this Section or the order of precedence
set forth in Section 12 shell in no evesc subject the Office to aay
liability under any tax law of any $ Notwichscending the «ebnve,
nothing herein shall be construed to reli any person vho racatves che
payment of the amoust of Life Insurance or Insurance for Death by
Accidental Means uoder this Section or tha order of pracadence set forth
im Section 11 from compliance with any tex law of acy Scate.”

B. By adding iumedsately following che second paragraph of Section ll chereof, the
following paragraphs:

“acy Eaployes insured hereucdar may desigrate as Beneficiary, his/her eetate or
an executor or sdmioistrator of his/har astata by ffling written norice with
the appropriate office es specified in the first seatence of the first
paragraph of. thie Section, However, in co evant will payment under Section 5
, hereof be made to such designated Beneficiary, unless the Office raceives
either: .

(a) 8 | corttfied copy of an order cf a court of competent jurisdiction
appointing che executor or adminiatrator of che eetata, oF

‘(b) proof that the requirements for psrasnt under = Small Zatate statute of

the state of the Euployee's dowicitle at date of his/her death hsve been
met.

-~  GOPY

ML 0131


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G_ dearing date of August 29, 1954, and issued to
UNITED STATES CIVIL SERVICE COMMISSION
( MEReIN CaLieD THE POLICY OLDER)
pursuant to the Federal Employees’ Group J.iie Insurence Act of 1984, ia-hereby amended as follows:
AMENDMENT 14
Effective for the policy year commencing July 1, 1962, by substituting for Section 21 thereof, as amended. the follawing:
“Section 21, SCHEDULES OF BASIC PREMIUM RATES.
Scuxowre or Bt-Werxry Basic Lire Ixstaance Parscicx Rates Pee $1,000 or Live [xstaaxet

Atuuned Ape Anginad Age Arcuned Age | Atasaed Age
Sioasy Premium Sinnaay Premiget ieay Premivet | Bircntay Premium

3 $0.07 33 $0.12 7 0.61 a $3.16
16 a7 6 Ad 6 6 7% 341
7 08 v7 as 37 73 7 369
18 08 3B 4 8 Ped 78 4.08
19 8 39 AS 9 36 ” 43
2 Ee 40 Eta Cy 33 8 474
2 Oo at AB 61 1.00 gt 3.14
2 OF Bod 2 62 109 a 5.56 .
23 OF a 2 6 Lis 3 6.00
2s 09 bed 23 ad lz bad 6.46
35 Ed 45 2 65 1.40 as 6.94
26 oo « 4 6 1.82 % 744
7 10 7 30 67 165 87 7.98
2 AO a 3 ed 181 8 8.54
2 10 9 EJ o 197 89 9.15
#0 10 50 39 70 215 {90 9.83
By 10 st 33 a 23 9 10.59
32 10 52 a7 74 2 92 W146
33 Wn 3 a 73 272 93 12.46
34 a bad 6

In computing the average basic bi-weekly
there shall be added to the average basic bi:
the prenuums shown above an amount equal to. $2.95 divided by the toral amount of Life Insurance in force
uncer this Peticy on the date of such contputation expressed in thousands snd iractions thercoi.
‘The bieweekiy hasic premium rate for Insurance fer Death or Dismemisernent hy \ecinlental Mexns
shall be 50.0231 per $1.000 of the full amount ef such Insurance.”
The inregoing Schedules of Basic Premium Rates shall remain in she for policy years sulseqrrent t9 the policy yoar commencing
July 1, 1962 subject to further readjustment as provided in subsection (A) of Secon 14 of said Group Policy.

In accordance with the second paragraph of Amendment 15 See iat Gren Policy a4 a part thereof. it is acreed that
the forecoing reduction in Basic Life Insurance Premium Rates shall not of itself opersue to the ngure used for the Maxirium
Risk Charge in che “Schedule of Maximum and Risk Charges” in Section 1§ of said Group Policy. and that otherwise the
second paragraph of asid Amendment 13 shall remain fully wperative with respect to any future reduction wt reiuctions aa hasic
Premium rate of rentative average premium rate,

‘The foregoing amendment is to be attached to and made part of said Group Policy. .
Signed at Washington, D.C. this__Lkth_. day of Ts.) a Ce) a
UNITED STATES CIVIL SERVICE COMDISSION.
Maxy_¥._Wenzel. _ ~~

{Weemesed
By. Ce a ne
(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY!
Signed at_.___.New. Yorke MY, this... LR, day of DY. 19.62...
METROPOLITAN 1 INSURANCE COMPANY,

Maw. Heth becke

re rnery,

mimtvnare OM PY.



AMENDMENT 64 (Continued)

If the Folicyholde: receives wrizseax acsice Zzct the Eaployee that Opies a =
Standard Life Insurance and/or Option 3 - See csal Lite issurasce os his/her
accovst fs set to be consinued af t oF entitlesent to benefics
under subchapter 1 cf chaps ¢ States Code, the zrovisiers
of 8 paragraph shall be null aad veid asd no effect and? ne Optics A =
Standard Life Ineurance and/or Option 3 = additional Lite Insurance shall de
providad for che Exployee after retizenest cr ensitierent to sucn benefizs.”

the actached Group Lite
evest Form 6.198S-4.

E. 3p adding to said Group Policy as a parc sherect
Iasurance = Option C - Fanily Benefits Suppleseszasy Ags

etive on the first day of the first pay period beginning on or after
ber l, 1981, . 7

RE

A. Sy addizg to che fizst paragzaph of subsection (4) of Section 4 thereof, as
anended, che Solloving: ue

“any decrease ic the amount of such insurasce due to atcaiament of a specified
age shall become effective upoa the E=ployee's sainment, of such specified
age.”

3. By substitucing “PART ILA ~ SCHEDULE OF BASIC = INSURANCE, EXCLUSIVE OF OPTION a
= STANDARD INSURANCE AND OPTION 3B = ADDITIONAL LITE INSURANCE, OM AND AFTER FIRST
DAT OF FIRST PAY PERIOD WHICH BEGINS ON OR AFTER APRIL 1, 198] BOT PRIOR TO Finsz
Day OF FIRST PAY PERIOD WEICH SEGINS ON OR AFTER OCTOBER 1, 1981" far the caption
iz Part ILA of the Schedule of tssusance is said subsection (A) of said Section 4.

Cc. By adding demediataly after Pass ILA of che Schedule of Insurance ga said,

sudseesion (A) of said Section 4, the folloving:

Fors G.1985-39


AENDIENT 64 (Continued)

3. Sy subsetturing “Part II = SCHEDULE cr:
CZ, ON AND AFTER FIRST DaY OF FIRST PAY
ART 14, 1968 3US PRIOR FO FIRST DAY OF FIR PAY PERIOD WEICH SECINS ON
OR AFTER APRIL 1, 1981" fcr che capsicz is TI of che Schedule of
Insurasce {2 subsection (A) of Sectice 4 therect, as anended. ~ .

SURANCZ, EXCLUSIVE OF cPTIONAL
RIOD WEICH 3ECINS ON OR AFTER

C. By adding tznediately afcer Part II of.the Schedule of Insurance in said
subsection (a) of said Seccion 4, the following:

“PARS Ila - SCHEDULE OF 3asiC INSURANCE, =X EXCLUSIVE OF OFTION A = STANDARD
INSURANCE AND OPTION 3 = ADDITIONAL LITE INSURANCE, ON AND AFTER FIRST DAY OF
FIRST PAY PERIOD WZICR BEGINS ON O% AFTER aPRIL 2, isa

Basic Inserasce for Death
oz Diszesberment by
Accidestal Mears

Tne amount of she E=zployee's Basic The anoust of the E=xployee's Zasic
Life Insuzaace shall be az sncun: Insurance for Death cz Dissemder=
equal to che sum of (a) $2,000, and ment by Accidental Means shall be:
(>) the Esployee’s asnusl Compessation an azourt equzl to the azcunt of
(as fixed by law or regulation). his/her Basic Life Insurance.”

Such acount of Basic Life Insurance
shall de subject to (4) a minisus azount
of 3Sasic Life Insurance of $10,000 and
(i1) a vaxisus amounts of Basic Life
Insurance equal to the Annual Com
pensation rate for positions st Level
Il of che Executive Schedule under
seczion $313 of title S$, United

tates Code, as tn effect from tine

to tine, plus $2,000. If the anmusl
Compensation referred to is not a
multiple of $1,000 tc shall be taken
to the next higher aultiple of $1,000
for she purpose of this provision.

D. Sy substituting “PART III ~ SCHEDULE CF OPTIONAL INSURANCE ON AND AFIER-
FIRST DAY OF FIRST PAY PERIOD WEICE BEGINS ON OR AFTER FEBRUARY 14, 1968 BCT
FRIOR TO FIAST Day OF FIRST PAY PERIOD WEiCE BEGINS OK OR AFTER APRIL 1, 1981"
for the caption in Part III of the Schedule cf Insurance in said subsection
(a) of said Section 4.

Fora 6.1985-39


6, 34, 82

SEE AMEND.

SER AWENN, 6, 49

PREM Ree

ap Reh SCHR S-OF-B ASH
Uxetra, Senmoucs ov Bi-W

Veexty Basic Live Ixsuaance

Pagatum Rates Pre $1,000 or Lire Ixsumanct

wet “a
reves Ne Pree
ie caret
ss 276 73 O75
% 6 a 1% 4.06
7 10 7 2 4 r 7 4.40
18 410 3 2B 8 6 78 476
19 10 2s 9 1.04 vn 5.16
E 0 SCO 25 0 Lis 30 558
2 a 4 2B 61 12 8 6.03
2 a 2 30 a 132 & 652
2B a2 a 68 LS a 7.08
£) Az # >) o 133 a 761
3 2 ry 6 S 18 ry [er]
2 a3 «6 39 6 12 8 886
z a3 v7 a2 197 9 985
2 a 8 AS 216 & 10.28
] as 9 48 ry) 232 a9 11,06
aS 0 2 70 251 * 11.89
3 a6 st 6 n 1 1277
2 a7 $2 ey n 29} v2 13.69
3B 18 53 6 B 319 93 14.67
B 18 rm n 78 346 1570
In computing the averare asic bisweelly Life Insurance premium rare pursuant 1 14 hereof
there hall be added to the average basic bi-weekly Life Insurance premium the basis of

the premiums shown above the smaller of (i) $8.

19 divided by the total amount of Life’

force under this Policy oc the date of such computation expressed in thousands and fractions

(ii) $0.07,

‘The initial bi-weekly Lasic premium raze for Insurance i tor Death ur Dismemberment by Accident

tem POS per SOOO viet

Sestion 22, REINSURANCE.—The Insurance Company shall
reinsure portions of the toral amount of insurance under this Policy
under conditions determined by the Policyholder in accordance with
Sesion 7 of the Federal Employers’ Group Life Insurance Act
of 1954,

SEZ AMEND. 7, 10, 25, 27, 37, 49

we

ion-10.

s ameinaatenetl

SEE AMEND. 32, 39, 48 ,52

(9)

spproprians umendsoers te this Pole sigeea be nee

date of issue hereot, to be contained in this Policy are
ained herein, then such Goer shall be

Form G.198S
Aug. 1954


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 27, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyholder)

purauent to chopter &7 of title 5, United Stotes Code, is hereby mended as follows:
AMENDMENT 51

Effective March 1, 1970 ,
A. by substituting for Sections 2 ond 2A thereof, the following section:

"Section 2, EFFECTIVE DATES OF INSURANCE .-Ellgibllity of Employees
for Insurence hereunder and the effective dates of such insurance shall be dererm'ned
In oecordonce with regulations of the Polleyholder made pursuant to chapter &7 of
tt'e §, United Stotes Code.

In no event shall or Employes be Insured for optional insuronce prior to
the effective date of his insurance exclusive of optional Insurance.”

B. By substituting for the second parograph of Section 3 thereof, the following poro~
graphs

“However, If the insurance on any Employes Insured hereunder would cease
becouse of the happening of the event specified In either of items (J) or (2) of the
preceding porogroph ond the Employee meets the conditions for continuation of insur=
once after retizement or while receiving benefits under subchepter | of chapter 81 of
title $, United Stetes Code, os such conditions ore specified in the regulations of
the Policyhoider mode purivant to chagter 87 of title $, United States Cade, his Life
Insurance only shell be continued or reinstated for the emount af insurance ond period
of time specified in said regulations."

Cy By substituting “as specified In the second porograph of Section 3 hereof" for
as specified In item (A) of the second poragroph of Section 3 hereof® in the third porograph of
Section 6 thereof,

~ Dy By subatituting for Items (4) and (5) In the second parograph of Section 13 thereof,
the following: ; Pn ‘

"(4) The conditions ond specifications refarred to in the second porograph of
* Section 3 hereof, os relating te continustion of Insurance ofter retirement
or while the Employee is receiving benefits under subchapter | of chopter 83
of title 5, United States Cade.

Fone G 1983-24


-5-

Section 6. PRIVILEGE OF OBTAINING AN INDIVIDUAL POLICY OF LIFE INSURANCE.-—any
Fazily Member on vhose account the fanily Life Insurance hereunder shall cease in
accordance with any one of items (1), (2), (3), (4), (5) oF (9) of -the first
paragraph of Section 3 hereof, shall be entitled co have issuec to hin/ber, wichous
evidence of iasurabilisy, an tadividual policy of Life Insurance, wirhour
Disadilicy or Accidental Means Death Benefics, by directiy applying for such
individual policy, 14. the Employee. does sot apply for such indivigual policy on
behalf of such Family Member, sudject to the following conditions and provisions:

acaba Cart Wan Aaa abe Bee Oak Om And le AD NOs cere
thereon shall be made by che E=sployee, if living, or the Family sel withio
2. days after such cessacica (oz -withis such longer pertof as che Office aiy
allow) to the Insurance Cospany, o> _at—suchpersos's option to any other
insurance company which bas theo-bets accepted by the Policybolder as eligible
to issue individual-portcies in accordance vith the provisions of this Section
_§ in_the-Jurisdiction in which the Family Member will reside acd which has

1 —Sepreed-vieh-the-Policybeider-to—do—s #7—end-

2
a

xhat.cnstonarily issued
»-except—Term—Josurance;—and—— ~

f>-such—-individual- policy

(C) the premium for such tadividual policy shall be the premium; as determined by
the insurance company issuing such policy, applicable to the class of risk to
which the Family Member belongs and to che foras and smount of the individual
policy at the Family Member's accained age (nearest_birthday) at the dace of
issue of such individual policy, and

(D) the asount of such individual policy shall de equal co (or ac the option of the
Family Mawber less than) the anounc of the Family Life Insurance in force on
account of the Family Member at the date of cessation of such insurance,
subject to s ainimum azount of $1,000, and

(E).1£ che age of any Family Mamber is such as to preclude direct application for
such individual policy by ths Family Member, then application for such
individual policy on the life of such Fanily Menber way be.msde by the
Employee, 12 living, otherwise by che person vho in che judgment of the
iasurance company issuing such policy is responsible for the support of such

. person. The issuance of an individual policy on the life of any person shall
de subject to the provisions aod limitarions of any applicable law relating to
life insurance on che lives of minors.

Is the Family Member dies during the 31 days next following the date of cessation
of the Family Life Insurance in force hereunder on his/her account, upen receipt of
proof of such death and entitlenent co paysent as specified in Section 5 hereof the
Office shall pay to the Employee, whecher or not written application for such
individual policy or payment of the first premium therefor shall have been made, a0
amount equal to the amcunt of che Family Life Insurance in force on account of such
Family Member at the dace of cessation of such insurance. In the event of the

Form G-1985-A


2-26

(5) The contrector will notify cach labor union or reprasontative
of workers with which ho has a collective bargaining egreement or other -
contract understanding, that tne contractor ts bound by the terms of
Section 503(a) of Title ¥ of Public Low 93-112, as amended by Public
Law 93-516, of tne Renadliitation Act of 1973, and is committed to take
atfirmstive action to employ and acvance in employment physically and
mentally handicappod indivicuals.

(6) The contractor will Include -the provisions of the foregoing
paragraphs (1) through (5) In every subcontract or purchase order ct
$2,500 or more unless exempted by rules, reguiations,.or orcers of the
Secretary of .ador in 20 CFR Ch YI, Part 741, so that such provisions
wlil be Dinding upon each subcontractor or vendor. The contractor
will take such action with respect to any subcontract or purchase order
as tne Director of the Office of Federal Contract Compliance Programs
may direct to enforce such provisions, including action for noncompliance.”

The foregoing amendment Is to be attached to and cade part of said Group

Policy. _
Signed at _Weshington, 0, €, this 19th day cf _Sstober 19_ 36
UNITED STATES CIVIL soyict COUMISSION
(Policyholder)
By. Sohert FE, Hast:
(Space Below For Use of Metropolitan Life Insurance Company Only)
Signed at __New York, N.Y. this Ist day of November 1976
. METROPOLITAN LIFE INSURANCE COMPANY,
Vue A329.
Richard 0. Zinke : Donat Cesidant and Sacreany

- (Registrar)

Form G.1985-36 . '

GORY -



METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY Neo. 17000-G bearing dote of August 29, 1954 end Issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyhoider)

pursuant to the Federal Employees’ Group Life Insurance Act of 1954, Is hereby anended os follows:
AMENOMENT 42

Effective Jonvary 3, 1965, by substituting for items (4) ond (5) In the first porograph
of subsection (8) of Section $ thereof, the following Items (4), (5), ond (6):

"(4) coused directly or indirectly by war (decicred or undeclared),
ony oct of wer, of any oggression by armed forces, ogainst the
United Stotes, in which nucleor weapons cre actuaily being
used, or .

(5) cowed directly or indirectly by war (declared or undeciored),
‘ony act of war, ormed eggression, or insurrection, in which
the Employee is, at the time the bodily Injuries ore sustained,
in octual combat, or

(6) coused by or the result of Intentional self-destruction or in
tentionaily self-inflicted injury, while sone or insone.*

AMENDMENT 43
Effective Jonuary 1, 1965, by substituting for Section 20 thereof, the followings

"Section 20. OPTIONAL MODES OF SETTLEMENT.--Upon written
election after the death of the Employee by the Benefielory or other person
entitled to receive payment of amounts due at the death of the Employee,
made to ond eccepted by the Office, the whole or any part of the amount
of insurance payable upon the death of ony Employes insured hereunder
will be ratoined by the Insurance Compony and paid to such person in
the following manner insteod of in one sum:

By payment of monthly of ennval instalments over such specified
number of yeors (shown in the following table) os may be elected, the
first instalment being poyoble immediately upon the decth of the Employee.
The amount of ecch such instalment shall be determined from time to time
In occardance with the insurance Company's declarations with respect
to such instalments, but In no event shel! such amount be less than the
minimum omeunt specified in the following Schedule.

Form G.1985-18


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing dete of August 27, 1954 and Issued to

UNITED STATES CIVIL SERVICE COMMISSION
{Herein called the Policyhoider)

puruant to the Federal Employees! Group Life Insurance Act of 1954, Is hereby omended ax follows:

AMENDMENT 47

Effective December 16, 1967, by odding to Section 15 thereof, the following parogrophi
“The stotement required to be fumished by the Insurance Company fo the

Polleyhelder efter the end of each policy year as specified in the preceding pro=

visions of this Section, will olso specify thet part of eoch of the Items of the
statement which Is attributable te optional insurance hereunder."

The foregoing amandnent fs to be cttoched to and made port of sald Group Policy.

Signed ct Washington, 0.C. this ath” day of June 9 68
UNITED STATES CIVIL SERVICE COMMISSION
olicyholder)
by John W. Macy, Jr.

{Spoce Below For Use of Metropolitan Life Insurance Compony Only)

Signed at New York, New York this second doy of sury 1968
METROPOLITAN LIFE INSURANCE COMPANY,
Mat. Hrtoaheck

Wm. HN. Mayer, Jr.

Registrar CO PY

Form G .1985-22 “ .


important - the filing of this form, if valid, will completely cancol eny Designation of Bareficicry you may have pre i>urly filod under the Federal Employe
Group Life Insurance Program. Be sure to name in this form a'l psrsone you riish to eesignare as beneficiaries of any uf insurance payable under the

Program.

Examples of Designations

1, How to designate one beneficiary Do not write names as M.E. Brown or as Mrs. John H. Brown. \f you want to designate your estate as beneficiary
enter "My estate” in the beneficiary column.

Type or print first name, middle initial, and
last name of each beneficiary

Type or print address (Including ZIP code)
of each beneficiary

Relationship

Percent or fraction to be pai
each beneficiary

Mary E. Brown

214 Central Avenue
Muncie, IN 47303

Niece

1008

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.

‘Type or print first name, middle initial, and

Type or print address (Including ZIP code)

Relationship

Percent or fraction to be pak

last name of each beneficiary of each beneficiary each beneficiary
509 Canal Street Aunt 25%
Alice M. Long Red Bank, NJ 07701
360 Williams street Nephew 25%
Joseph P. Brady Red Bank, NJ_07701
792 Broadway Mother 50%
Catherine L. Rowe Whiting, IN 46394
ee Se es
3. How to designate a contingent beneficlary .
Type or print first name, middle initial, and © |- Type or print address (Including ZIP code) Relationshi Percent or fraction to be pai
last name of each beneficiary . _ of each beneficiary at id each beneficiary
810 West 180th Street Father 1008
John M, Parrish, if living mew York, WY 10035
Otherwise to: Susan A, Parrish 810 West 180th Street Sister 100%
New York, NY . 10033
Eee oe Le ee

4. How to designate different beneficiaries for

‘basic life and optional coverages*

‘Type or print first name, middle initial, and

Type or print address (Including ZIP code)

Percent or fraction to be paic

last name of each beneficiary of each beneficiary Relationship each beneficiary
Joha D. Jones heen Sereee o son 1008 Basic Lite
Jane M. Smith portland Me odz0a Niece 1008 Opt. A-Standard
Elizabeth J. Allen | ee ton ten 28 Daughter 50% Opt. B-Additional
Ann J. Borden 678 Ninth Street Daughter 508 opt. B-Additional

Philadelphia, PA 19123

eee

5. How to cancel a designation of beneficlary and effect payment under the order of precedenc:

e (See back of Part 2)

Type or print first name, middle initial, and
last name of each beneficiary

‘Type or print address (Including ZIP code)
of each beneficiary

Relationship

Percent or fraction to be paid
each beneficiary

Cancel prior designations

J

* If a beneficiary for Basic Life, Option A-Standard, or Option B-Additional predeceases the insured, and there is no surviving beneficiary or contingent
beneficiary for thet type of insurance, payment for that type of insurance will be made under the order of precedence or, it the insurance has been
’ assigned, to the assignee(s}:(See. back of Part


AMENOMENT_ 50 (Continued)

. _E. By substituting “Part Il of the Schedule of Insurance in subsection (A) of this
Section os to any such Employee whose retirement occurs prior to February 15, 1969, of Part IIA
of the Schedule of Insurance in subsection (A) of this Section 3 to ony such Employee whose re=
tirement eceurs on or after February 15, 1969, In either cose” for “Port I] of the Schedule of In-
surance In subsection (A) of this Section” appearing In the first sentence of the second porograph
of subsection (8) of sald Section 4,

F, By substituting “Port II] of the Schedule of Insurance in subsection (A) of this
Section as to ony such Employee whose retirement occurs prior to February 15, 1969, of Pert INA
of the Schedule of Insurance in subsection (A) of this Section os to ony such Employes: whose re-
tirament occun on or ofter February 15, 1769, which, in sither case, * for “Part Ill of the Sched=
ule of Insurance in subsection (A) of this Section, which” eppearing In the third paragraph of sub=
section (8) of sald Section 4,

The foregoing amendment Is to be attached to ond mode port of sald Group Policy.

Signed ot ___ Woshington, D.C. this 20 doy of _ Yovenbar 19 69.

UNITED STATES CIVIL SERVICE COMMISSION
(Policyholcer)

by Robert _, Hampton

(Spece Below For Use of Metropolitan Life Insurance Company Only)

Signed ot _ New York, New York this tvanty-first day of _ November 1969

. METROPOLITAN LIFE INSURANCE COMPANY,

Hate. Hellubecke
Bowesary,

Sa T Yarae Jo,

Qagistrer)

srowes : e O P Y



IMPORTANT INFORMATION ABOUT

AONEY REARBHNT ANOOINTS
AVENE T LYSATE 2 ALU

AUTOMATIC _
* If we are paying you $7,500 or more, we will automatically open a money market agcount in your name and -
mail you the checkbook. os

SAFE
* The account earns interest starting the first day we open it.
+ Metropolitan Life Insurance Company guarantees the full amount in the account, including all interest.

FREE
* You pay nothing for this account. There are no monthly service charges or charges for checks.

* You can write checks from $250 up to the full balance at any time.

FLEXIBLE
* You can withdraw all or part of your money at any time, with no penalty.
* You can name a beneficiary for your funds, in case something happens to you.

We will send you detailed information about the account when we open one in your name.

SPECIAL NOTE

Please complete, in ink, the information below and sign your name in the first box. We need this
information to open a money market account. Even though you may be giving the same information elsewhere
on this form, you must also give it here. We cannot process your claim without this information.

Your signature (Do not print) EL. Lone

Your name (Please print)

Osker Keviw Tones

Address (Number, stret, apt, no.) Ltr fa wttr . Lapa Ly CA GO Li “4
BLA Cheng Part A Yooees 407 Jo Wr 60623

City, state, ZIP code
OAKfneK £e £8302
‘Your Social | Security Nuraber 3 5 7 = é b ~ S 3 7 Y

Estate/Trust Identification Number

Date (mm/dd/yyyy) Daytime telephone no. Evening telephone no.

‘Area Code Area Code



METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY Ne. 17000-G becring date of August 27, 1954 ond Issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein cclled the Policyheider)

punuont to chepter 67 of title 5, United States Coda, Is hereby amended a3 follows:
AMENOMENT 49

Effective August 1, 1968,

A. By substituting “chopter 87 of title 5, United States Code” for

(1) “the Federo! Employees’ Group Ufe Insurence Act of 1954"
‘on the face poge thereof ond In item (d) of the second pare=
greph of Section 16 thereof,

(2) “the Federal Employees’ Group Life Insurance Act of 1954
(other then the provisions of Section 10 thereof), os anended
to and Including December 16, 1967" In the first sentence of
Section 23 thereof, and

(3) “sold Act enacted after December 16, 1967° In the second
santence of sald Section 23.

8. By substituting for the first three porogrophs of Section 1} thereof, the following
perographs

“The term 'Employee' means a person who Is considered, under cppliceble
lows and regulations, to be on employee for the purposes of chapter &7 of title 5,
United States Code.*

C.. By substituting “the appiiccble provisions of chopter 87 of title 5, United Stetes
Code" for

(1) “subsection (d) of Section 2 of the Federal Employees’ Group
Ufe Insuronce Act of 1954, os cnended” in the first porogroph
of Section 2 thereof ond in item (5) of the second porogroph of
Section 33 thereof,

(2) “subsection (c) of Section 5 of the Federal Employees’ Group
Ufe Insurance Act of 1954" In the fourth porograph of Sec~
ton 11 thereof and in the second porograph of Section 15
thereof, ond

(3) “Section 7 of the Federal Employees’ Group Ufe Insurance
Act of 1954, as amended August 11, 1955" In Section 22
thereof.

Form G.lveS 24 .


: — . i
. e2-
“" putnosent_€3 (Continued):

be separately determined, as hereinafter specified, in respect of (1)
Life Insurance exclusive of optional Life Insurance and (2) optional
Life Insurance, if eny. In the case of an Employ2e whose retirement
occurs cn or after December 18, 1967 but prior to Koverber 2, 1976, the
azount of Life Insurance af any time after retirement shal) te
separately determined, as hereinafter specifies, $n respect of (1) Life
Insurance exclusive of optional Life Insurance, end (2) optional Life
. Insurance, {7 any.

With respect to an Exployse whose retirement cccurs on or after Gecember
1S, 1957, of an Employee whose entitlement to benefits under subchapter
1 of chapter El of title 5, United Stetes Coce occurs on or efter
Noverder 2, 1978, ‘effective reduction cate’ means the first day of the
second calendar month after (1) the date his insurance would otherwise
have ceased because of the happening of the event specified in either of

items (1) or (2) of the first peragrapis cf Section 3 hereof, or (2) his
€Sth birthday, whichever is later.

With respect to an Employee whose retirement or entitlenent to benefits
under subchapter 1 of chapter 81 of title 5, United States Code occurs
on or after November 2, 1978, ‘basic enount of Life Insurance’ means, as
to Life Insurance, so such of the enount of Life Insurance in force on
his account on the date his insurance would otherwise have ceased Se-
cause of the heppening cf the event specified in either of items {1} or
{2) of the first paragraph cf Saction 3 hereof, in accordance with Parts
Il or III, whichever is epplicable to the Employee, of the Schedule of

Insurance in subsection (A) of: this Section which had been in force for
not less than

(a) the full perfod or periods of service during which such insur-
ance was available to his or . .

(b) the five years of service ixmedtately preceding such date and
guring which such insurance was available to hia,

whichever is shorter. If the Polleyholder recefves written notice from
the Employee that optional Life Insurance on his account is not to be
continued after retirement or entitlement to benefits under subchapter 2
of chapter 81 of title 5, United States Code, the provisions of thts
partsraph shall be null and void and of no effect end no optional Life

Insurance shall be provided fur the Employee aftar retirement or en-
titlement te such benefits.

With respect to an Employee chose retirement occurs on or after December
16, 1957 but prior to Noverdar 2, 1978, ‘basic amount of Life Insurance’
means, as to Life Insurance exclusive cf optional Life Insurance, the ~
amount of Life Insurance in accordance with Part II of the Schedule of
Insurance in subsection (A) of this Section based on the amount of his

Form G.1985-33«

; COPY - |


AMENDMENT 64 (Continued)

(a) she full period oF pe
available to hiz/hes,

(>)

ceding the date of the Ezployee's
ze ot of che txployee’s entitlement <6 benefits under
subchapter 2 of chapter 81 of title 5, Uniced States Code and during vhich
such insurance* vas available to his/hez,

whichever is shorter.

Option 3 - Additional Life Insusance seans so much of the amcunt of Option 3 -
Adéiziosal Lige insurance in force on his/her account, subject to the provisions
of the sext following sentence, os che dace his/her Additional iife Lasurance
vould otherwise have ceased decause of che happening of the event specified in
either of irens (1) or (2) of the first paragraph of Section 3 hereof, in
aceerdance with Part V of the Schedule of Insuratce in subsection (A)' of this
Section hich had been in fozce for not less thas

(a) the {ull period or periods of service during which such insurance vas
available to hin/her, o>

(b) she five years of service imediately p: edingTM che date of she Esployee's
retirement oz the date of che E=ployee’s entitlement to benefits under
subchapter 1 of chapser @1 of title 5, Usited States Code and during which
such insurance vas available to hiz/her,

whichever is shortez. Tha amount of Oprion 3 - Additional Life Insusance s5all

be based on she ast ciple of such insurance, which the Z=ple: had
- elected 4a accordance with the options specified in said Part V of the Schedule

of Iosurance, that vas ia effect for .

(a) the ‘five years of service imneciately preceding the date of his/her
retirevest ot entitlement to benefits under subchaptar 1 of chapter 81 of
title $, United States Code, or

(ob) the full period or periods of service during which such ircsurance: vas
available to hin/her, if he/she was insured for less chan five years.

‘The Esployee's Option-A - Standard Life Insurance and/or Option 3 ~ Additional
Lige Insurasce hereunder vill be continued after retirement or entitlement =o
benefits under subchapter 1 of chapters &1 of title 5, United States Code, as
specified above, only if she Esployee's 2asic Life Insurance, exclusive of
Optden A — Standard Life Insurance and Option 3 - Additional Life Insurance, is
continued after retirenent or entitlement to such benefits in accordance vith
the provisions bereof.

* {ncludes insurance set forth in Part III and/or Part IV.

"COPY


-2-
AMENOMENT “4% (Continued)

An Employee may become Insured for options! Insurance only by moking
written election thereof to his employing office on a form furnished by the Polley
holder. For the purposes of election of optional Insurance, on Employee's limiting
date is the later of (i) April 14, 1968, ond (Il) the thirty-first dey following the
date he becomes eligible for optional Insurance, or, If his employing office deter=
mines, within six months after on Employee becomes eligible for optional insurance,
that he was uneble, for couse beyond his contro!, to elect or deciine options! insure
once within thirty-one days following the dote he became eligibie for optional in=
suronce, the thirty-first day following the date the Employes Is odvited of such
daternination.

The optional Insurance hereunder on ony Employee whose election is re-
calved by his employing office on or prior to the date he becomes eligible for ap~
tlonai Insurance shell become effective on the dete he becomes eligible for such
Insurence, provided he is then Insured hereunder for Insurance exclusive of optional
Insurance.

The oftional insuronce hereunder on ony Employee whose election is re~
celved by his employing office ofter the date he becomes eligible for optional
insurence end on or prior to the limiting data specified obove, shal! become ef=
fective on the date such election Is recalved by his employing office, provided
he Is then insured for insurance exclusive of optional insurance.

If weltten election of optional Insuronee on behalf of any Employee is
not received by his employing office on or prior to the limiting dete specified
above, of if the Employee has declined optional Insurance, such Employee may
become insured for optional Insurance hereunder only If he makes written request
therefor to his employing offlee prior to his 50th birthday ond not less than one
yeor after the effective date of his declination of optioned! Insurence, end
furnishes of his own expense evidence of insurobillty satisfactory to the Office.
The optional insurance on any such Employee sholl become effective at the
time he actually enters on duty on his first day In o poy stotus following the
loter of (i) the dote his request for optional insurance Is approved, ond (ti) the
ction of optional Insurence on his beholf Is received by his em=
+ provided he ocquires such o duty ond pay status effective within
thirty-one doys following the date of such cpprovel and provided he 11 then
Insured for insuronce exclusive of optional Insurance. Any Employee who must
meet the requirements of thls perograph os a condition to becoming insured for
optional insurance hereunder and who ceases to be an Employee as defined in
Section 1 hereof without such requirements having been met shall continue to

. be subject to the some requirements If at any time he subsequently becomes on
Employee os defined in scid Sectlon 1. In the cose of on Employee who has
moda nelther written election nor written declination of optional Insurance,
the ‘effective date of his declination of optional Insurance’ shall be the limiting
date specified chove.

Form G.1985-21




"METROPOLITAN LIFE INSURANCE C COMPANY :

: GROUP POLICY NO. $7000. G beating the date of Au ust 29, 1954 and issued to

OFFICE OF PERSONNEL MANAGEMENT.

Pursuant to chapter: 87 of title 5, United States Code, is ‘amended as follows:
AMENDMENT 74

Effective November 1, 2000,

” By adding the following exclusion for payment to paragraph ), Insurance for Death or
Dismemberment by Accidental Means, in Section 5, INSURING CLAUSES:

(8) caused by the Employee driving a Vehicle while ititoxicated as defined by the.
laws of the jurisdiction in which the Employee was operating the vehicle,

Signed at Washington, D.C. this we day of Ocloloe— 2000

OFFICE OF PERSONNEL MANAGEMENT (Policyholder)

2

By AN = De VT
Frank D. Titus AY
* Assistant Director for Insurance Programs
Contracting Officer

Signed at New York, NY this act day of Ochoten , 2000

~ METROPOLITAN LIFE-INSURANCE- COMPANY——————

By

Margéry AZBrittain

Vice President
Group National Accounts

x


‘C oe ce - \
' -” OSKER JONES 01-90 7 eee i
® 1927 S. Hamlin Ave. ere , 1035
E Chicago, Il 60623 ; [Le 5-33 fF a0
RANCH S009

oberon Sar ae Cleo 1830: BY.



DELORES WILLIAMS PAGE 94

: 17736261522
10/26/7001 385 fo: 55 PM LPHILLIPS 1 773 Tee S226 P.es
" — oo rN oUF
" Geocae = ; . enc
Bape a laa on of Beneficiary . OMB No, 3200-0198
rex) , ty . . Werning
wt at roup Life Insurance Program Read inatuctions on back of
‘ before Sing In this form

erry NONDTST OEM ganl SEAUOSE ROMINIETRATR

Kame ol ineured GARE IAT middie) sae
Rossy

lhe : ou 4
Sa aa ee

applica tor nities oF an ‘Employs os’ Compenaavon, ghw “CSa’,

a

Tho Insured is:

Place an Xin the rothement appiicant for OWCP. "OS", of OWCP clam number,
appropriate box bandits .
“ig BEe CSA A S22 Ee ees

pavement or agency In which thd Tnosrad % presowly amployed i relied, lommer dyparinant w ag ong):

Dagavtment or a f

eave ROY DYE s1 tal og |B i, Olvision Location (City, state and ZIP code)
Ae Dh Lusbur ant Cheb STREAM,

: UBIA tL Ge#, gg

Priester ny a4 al! previous Ceaignotens of Deneticiary under me Faseres tundorsiand that his Oextgnaton of Deneliciary, d valid, w2t romain ia ull force and
be vetted ‘oop Ute insurance Program and am now cetignating tre henatciary lock, Unless oF ur veneetod by ma in werikng, of with Such tne ae dtle sutomadenty
Devefcarine namic Below i receta shy ariaun! af Lit trav ard Acol¢ental snnealed ok of Part 2), IF hi dealg mation form fs Geverm ad invalid fox ary

9 inauranes ove and payablo ot te Innurad's doa, reason, tie next por vaxld deaigneven form wil 9x ghee fll orca und ofect ne

tuck pllorfoem one; ho provecds wl be aetAbytcd under me Medel practtence, ”
0%, Fhe Insv-ance has bach dtelonad. 10 0 Karignee(s). ”

WI hove provioualy wolidly esslgnad my Insuranan, any
Md. and hay no lores ani

"Type of print fina name, middle intial, and
lest name of each binoficary

‘Type oF print addrasa (including BP code)
of nen beneficiary

elec 1 Litick Totes tel, Gitte 2| saat |e00 te

L

Racor iS Ey Ee Oe
Filnt or typo your name and adarbos Ploma chuck |Ghaak only ong: {Pleasd
tuatueng DP cova! ham .
- a {have not assigned my insurance,
have Ihe Ircured | have signed this form In the presence of tho two winosses who
: : & | have biked below,
have ner Jan Aselgnee Nekher wiinoas [9 named as a beneficiary,
‘aected Li Itt dosignated shares to be pad o more than one bendficiwy,
te Senet tie enarea add pte TON, (ook amour woncaccepabie)
J radhbeA at Lim, Option A-Standusd, and Option Be 2}  unorsland thel # none of the deunated Bon ofctaiey la Ivhhg at tho tno 0!
“TINAT HaiRaE cued ova, bal more Be mavied’s death, Biv preaoed wil be dluirbuted under tap érder of
inelictary 1s namod, the sharo of any benetciavy wo moy precedence, er, Bthe lnaurence has been axcignod, \s the assignos(s).
prodatara ms or become dequaiMed fot any lesson fem recahtig 4 shaio of ia dedi
tha denetls chall bo divebuted oguaty among the Uirviving benaticlules, oF thoraby specifically reserve the right lo cancel or change this designatien of
arTiewty bo tha punvor, 7 benoticiny at any ume witout Krowledge of cancani of the bon Mictaty ea).
Signature of lasored/Assignue (Only the Insured /Asilgace ma Signotures by guardions, conservators or Gate of exacdion (Month, day. you)

‘Useugh a power of atiomey are not occeplable,)
Gf Se? Tem

aS ¢
Number and strect

S357 yl,
4 Nummbaer wa Soot

Oks Sard,
Ageateng “A ff ‘of receipt
. wl

Signerviy ot sutnoriced agency Ofcel [
Ene back of Part2 for lustructiony on where ta file thin form. De riot Mtv with the Orites of Federal Employees Group hfe Inaurance,

: ate gong
: Ay PART 1-Crigipat oar, soe

US Orbe of Penonnd Management NSN 790123 148 Qe 9 . rr) Bends form 1288

Tha FOGLI Hosen uct har Paroormat and Pyretl OW ave renters ‘aun-102 Previous wcifors 123 usalce Bon. sity 1008

SEP @4 ‘OL 12:42 7247961332 PAGE .OD


First, to the beneficiary or beneficiaries designated by the employee in
a signed and witnessed writing received before death in the employing
office or, if insured because of receipt of annuity or of benefits under
subchapter I of Chapter 81 of this title, in the Office of Personnel
Management. For this purpose, a designation, change, or cancellation
of beneficiary in a will or other document not so executed and filed
has no force or effect.
5 U.S.C. § 8705(a). See also Ex. A, § 11.

9. The face amount of the FEGLI Policy is $48,000 (the “Proceeds”).

10. A signed and witnessed beneficiary designation form dated November 2, 1989
(the “First Form”) names Vera Jones as the primary beneficiary for 100% of the proceeds, if
living, or otherwise to Osker K. Jones for 100%. On information and belief, Vera predeceased
the Insured, leaving Osker K. Jones as the beneficiary under the First Form. A true and correct
copy of the Designation of Beneficiary form dated November 2, 1989 (the First Form) is
attached hereto as Exhibit B.

11. A second, more recent designation of beneficiary form (the “Second Form”)
contained in the Insured’s life insurance records is dated September 5, 2000. The Second Form
also appeared to be dated and witnessed. The Second Form names Maxine as the primary
beneficiary for 100% of the proceeds, if living, otherwise to Osker K. Jones, decedent’s son. A
true and correct copy of the Change of Beneficiary form dated September 5, 2000 (the Second

Form) is attached hereto as Exhibit C.


ASSIGNMENT OF PROCEEDS OF INSURANCE

OPM/FEGLI
(NAME OF INSURANCE COMPANY)

TO:

BOYERS, PA ,

1, MAXINE JONES + OSKER JONES IR being entitled to receive benefits under policy

(BENEFICIARY)

number(s) 43788243 with a face valuc of
. , Dollars (8, )

issued by -- FEGLI a y :

(NAME OF INSURANCE COMPANY)
on the life of ___OSKER JONES SR

Now deceased, and having
contracted with and being indebted to A. A. RAYNER & SONS, 5911 WEST MADISON STREET,

chicaGo, ILLINOIS 60644, for funeral services and merchandise for the deceased in the amount of
FORTY NINE NINETY SEX AND 42/100---------~--~-----~----~ Doltars cs fT FC ct ty

do hereby sct over, assign and transfer unto said Funeral Director, the sum of
FORTY NINE NINETY SIX AND 42/100----~----=----ereccsenen

out of the procecds of ' said Insurance Poligy(ios)s and I hereby authorize ad direot said Insurance Company
to make its check payable to said Funcral Director for the assigned amount and to pay the remainder of the
proceeds, if ‘any, to me, _

1 (we) hereby appoint A. A. Rayner & Sons as our attorney in fact to act for us with full power to make
collection of, compromise, scttle, and to endorse or receipt in our names or otherwise, any check, draft,
receipt or release for the proceeds of said policy of insurance or certificate, as fully to ali intents and purposes.

as we ourselves could do, hereby ratifying and confirming all that our said attommey may do or cause fo be

done by virtuc hereof.

WIFE
RELATIONSHIP

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cs] : r , RELATIONSHIP

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STATE OF ILLINOIS . .

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Th 914e52725221 P.66/89

MAY @3 2002 14:14 FR METLIFE LAW DEPT.

. fo
-2-

B. By substituting for the second paragraph of Section 3 theracf, as amended
she fallowing paragraph: ,

“Howaver, if che insurances co any Eupleoyae insured hereunder would
caasa because of the happening of the event specitied in any of the
items (1), (2) ov (3) of the preceding paragraph end the Employee
neets the conditions for continuation of insurance gfter retirement
ot while receiving benefice under subchsptar f° of chapter 81 of ,
title 5, Untted Seates Coda, a8 such conditions are specified in che
regulations of the Policyholder wade pursusst to chapter 87 of ritle
5, United States Code, his/her Life Issursnce only shall be
continued oy reinstated for che ‘amount of insurance and period ‘of
tine specified in said regulations.”

C. By substituting for item (3) eppesring in the first paragraph of Section 3
of said Supplementary Agreeasst Fors G.1985-4, the following:

"(3) The dste of expiration of a period of twalys sonths frou the date
the Employae enters on active duty or active duty for training as «
menber of a uniformed service.”

D. By substitueiag for the second paragraph of Section 3 of Group Life
Tasurance - Option C = Family Benefits Supplementary Agreement Fors
G.1985S~A, attached to the Group Policy as a part thereof, the fellowing
paragraph:

“Bowevar, if the Zeployee’s Yautly Life Insurance on sccount of his/her
Yanily Manders would cease because cf the happening of the event specified
tn any of the items (1), (2) or (3) of the preceding paragraph and the
Ewployee usets the conditions for continuance of his/her Fanily Lite
losucance after rectrepent or while receiving benefite under subchapter 1
of chaptar 61 of title 5, United States Code, a9 such conditioss sre
specified {n the regulation of che Palicyholder promulgated pursuant to
chapter 87 of title 5, United Scateg Coda, his/her Family Life Insurance
shall be continued or reinstated for the amoust of insurance and period of
time spectfied in said regulation.”

AMEXDMENT_70

Effective October 1, 1987;

A. By substituting “chapter 87 of title 5, United States Coda, S CFR Part
870° for “chapter 87 of citle 5, United States Coda” vheravar it sppears
in seid Group Policy.

Be. By substituting “chapter 87. of title 5, United Stacas Code, 5 CFR Part
873" for “chapter 6? of ritle 5, United States Code* wharaver ic appears
in Supplementary Agraesent Fore 6.198S~a.

cum @ 0 PY .

ML 0128


_ METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY NO. 17000-G bearing cate of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called The Policyhoiger)

pursuant to chapter 67 of titie 5, United States Code, is hereby amended as follows:

AMENOMENT $8

Ettective October 1, 1975, by supstituting tor Section 4 thereot, 83 amended, the
following:

"Section 4, AMOUNT OF INSURANCE.<(A) Appticatie Prior to the Employee's
Retlrement:--The amount of Insurance hereuncer on any Employee shaii de in
accordance with the Schedule set forth below. Any increase or decresse in
the amount of such insurance cue to change in annual compensation, in accorc=
with said Schedule, shal! become effective (1) on the stated ettective
of change in the Employee's annus! compen: tion “or The cate such change
in annual compensation Is approved, whichever date is later, or (2) on the
effective date of the change when a retroactive adjustment Is actually the
correction of an error, uniess otherwise stipulated in a law providing for
the change.

Part |! - SCHEOULE OF INSURANCE, EXCLUSIVE OF OPTIONAL
INSURANCE, PRIOR TO FIRST OAY OF FIRST PAY PERIOO WHICH
BEGINS ON OR AFTER FEBRUARY 14, 1968

insurance tor

Annual Comoensation ° Death or Oise
But No? Lite meaperment by
Greater Than Greater Than Insurance Accidenta! Means

C) 51,000 $1,000
31,000 2,000 2,000
2,000 3,000 3,000
3,000 4,000 4,000
4,000 3,000 3,000
5,000 6,000 6,000
6,000 7,000 7,000
7,000 8,000 8,000
8,000. 9,000 . 9,000
9,000 10,000 10,000
40,000 31,000 11,000
$1,000 12,000 12,000
12,000 13,000 13,000
13,000 14,000 14,000
14,000 15,000 15,000
15,000 16,000 16,000
16,000 17,000 17,000
17,000 18,000 18,000
18,000 19,000 19,000
19,000 20,000 20,000

Form G.1985-33


-2-

AMENDMENT $0 (Continued)

i for Death

Annual Compemetion | Inauronce
Greater ‘But Not Ufe or Dlumemberment by

Then Gréoter Than clnsuronce” Accidental Means
24,000 $25,000 $27,000 $27,000
5,008 26,000 28,000 28,000
26,000 77,00 27,000 27,000
27,000 28,000 30,000 30,000
28,000 29,000 31,000 31,000
27,000 30,000 32,000 32,000
30,000 31,000 33,000 3,000
31,000 32,000 34,000 34,000
32,000 33,000 35,000 35,000
33,000 34,000 36,000 . 36,000
34,000 35,000 37,000 37,000
35,000 36,000 38,000 38,000
36,000 37,000 37,000 39,000
37,000 38,000 48,000 4,000
38,000 39,000 41,000 41,000
39,000 40,000 42,000 42,000
40,000 41,000 43,000 43,000
41,006 42,000 44,000 44,000
42,000 _ 45,000 45,000°

C. By substituting "PART Ill - SCHEDULE OF OPTIONAL INSURANCE ON AND
AFTER FEBRUARY 14, 1968 BUT PRIOR TO FIRST DAY OF FIRST PAY PERIOD WHICH BEGINS ON
OR AFTER FEBRUARY 15, 1969° for the caption in Part III of the Schedule of Insurenes In subsec~
__tlon (A) of sald Section 4,

D. By cdding Immediately after Part [Il of the Schedule of Insurence in subsection (A)
of said Section 4, the following:

“PART IIlA~SCHEDULE OF OPTIONAL INSURANCE ON AND AFTER
FIRST DAY OF FIRST PAY PERIOD WHICH BEGINS ON OR AFTER
FEBRUARY 15, 1969

The amount of options! Life Insurance and the amount of optional Insurance for Death
or Dismemberment by Accidental Means Is the greater of (a) $10,000, or (b) the
excess, If ony, of the amount of the Employee's annual compensation (if not « muitl=
ple of $1,000, such ennual compensation to be taken te the next lower multiple of
$1,000) ever the amount of Life Insurence or the amount of Insurance for Death er
Olsmembermant by Accidental Means, respectively, In occordance with Port IIA
cbave." .

Form G.1985- 25°


Set CS COPEL

OPULITAS Lz!

Eifacsive J.

Ce

Form G.198S<41

(Herein called the Policynolae?)

at ce chapter 87 of title S, Uniced States Coca, is hereby czanced as
33

66

ary 1, 1983,

3y substicucing for item (A) appearing io the first paragraph of Section 6
thereer, the following:

“(A) written application fsr such individusl policy and paynent of the
Zirst premium thereon shall be made within 32 days after such
cessation (or within such longer period as the Policyholder may allow)
to che Insurance Company, or at the imployee's option to any other
Insurance Company which has chen bees accepted by the Insurance
Campany as eligible to issue individual policies in accordance with
the provisions of this Section 6 in the jurisdiction in which the
Employee will reside and which has agreed with the Insurance Company
to do so, and

By substituting for item (3) appearing in che first paragraph of said
Section 6, che following:

"(B) such individual policy shall be upon one of the forzs chen
sustesarily issued by the insurance company selected by che
Employee, except Tera Insurance, Universal Life Insurance and any
other form of Life Insurance with an indeterminate premiua, and”

By substicucing for trem (A) appearing in the:first paragraph of Section 6
of Group Life Insurance = Option C - Family Benefits Supplenentary
Agreement Form G.1985-a, attached to the Group Policy as a part thereof,
the following:

“(A) written applicarton fer such individual policy and paytent of the
first premium thereon shall be nade by the Euployee, if living, or the
Family Hember within 31 days after such cessation (or vithin such
longer period as the Policyholder usy allow) to the Insurance Company,
er act such person's option to any other insurance Cotpany which has
then been accepted by the Insurance Company as eligible cto issue
individual polictes in accordance with the provisions of this Section
6 in the jurisdiction tn which the Family Member will reside and which
has agreed with che Insurance Company to do so, and

«GORY.


METROPOLITAN LIFE INSURANCE COMPANY

ee

GROUP POLICY No. 17000-G bearing date of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein calied the Policyhol der)

pursuant to the Federal Employees’ Group Life insurance Act of 1954, is hereby amended as follows:

AMENDMENT _30

os of the date of issue of sald Group Policy, by substituting for the text In
der the heading “Maximum Charge” in the “Schedule of Maximum Expense
and Risk Charges” in Section 15 thereof, the following: .

“The actual acerved amount of such expense including expense for the
reinsurance required by Section 22 hereof, as determined by the Insur=
once Company, but not in excess of 0.6% of Premiums.*

The foregoing amendment Is to be attached to ond mode pert of sald Group Policy.

Signed ot _Vashington, D. ¢, this Sixth doy of _Decgsber 19 gm
Mary J. Angluin UNITED STATES CIVIL SERVICE COMMISSION
Wimess) TPollcyholder)
By Roger V. Jones

(Space Below For Use Of Metropolitan Life insurence Company Only)

Signed at Hew York, M. Y. thls twenty-ninth day of _ Decexber 19 60
METROPOLITAN LIFE INSURANCE COMPANY,

Mlac€. He lbubecke
Sowmery

C. G. arlinghsus
Registrar)

Form G.1985-8 : G (0) PP Y


METROPOLITAN LIFE INSURANCE COMPANY

—

GROUP POLICY No. 17000-G deanng dare of August 29. 198+ and issued to

UNITED STATES CIVIL SERVICE COMMISSION

(4exgiN CALLED THE POLICYROLDER)

pursuant to the Federal Employees’ Group Life Insurance Act of 1954, is hereby amended as follows:

AMENDMENT 17

Effective as of the date of issue of said Group Policy. by substi
tuting for the second sentence of the frst paragraph of Section 4

thereof, the following :

“Any increase or decrease in the amount of such insur
ance due to change in annual compensation, in accordance
with said Schedule, shall become effective (1) on the stated
edeenve date of change in the Employee's annual compen-
sation or the date such ehange in annual compensation is
approved, whichever date is later, or (2) on the erfective
date of the change when a retroactive adjustment is actually
the correction of an error, unless otherwise stipulated in a
law providing for the change.”

AMENDMENT 18

Effective August 2, 1957, by adding immediately aiter the first
paragraph of Section 1 thereof, as amended, the following para-

graph:

under the provisions of Si
“Muime Energy Agency Pa

AMENDMENT 19

Effective March 15, 1988, by substituting for the last sentence

of the rst paragraph of Section 1 thereof, as amended,

following:
“Any designation of beneficiary shall automatically cease
to be effective on (i) the date thiry-one days aiter the dace
of cessation of the Employee's insurance hereunder unless
the Employee's Life Insurance is reinstated in accordance
with the provisions of the second paragraph of Section 3
hereoi, or (ii) the date the Employee is transierred to an-
other agency, whichever first occurs.”

AMENDMENT 20

the

Effective January 31. 1959, by substituting for item (13) uf

Schedule A attached to said Group Policy as a part thereof, the
“The term ‘Employee’ shall also include any Presidential following:
appointee of elected officer during such time as provision (13) Retired employees reemployed under conditions
for coverage of such person under the Federal Employees’ not terminating their ttle to annutties, except such
Group Life Insurance Act uf 1984, a amended. is made reemployed retired employees serving frum August
ion 6(b) of the International 2. 1984 to January 31, 1959, without a break in
pation Act of 1957." service of more than 3 days.”
The ioreguing amendments are to Le attached to and made part of said Group Policy.
Washi c ; :
ashingron. D.C: this day of. Yar. nent 9.9,

Signed a.

UNITED STATES CIVIL SERVICE COMMISSIO

Yary..J0, ADELNAR.........
Wines

arcu

By. Roger W. Jones

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)

‘Signed at

COPY

hp Banner

Scerctary


P.@5/89
MAY @3 2082 14:14 FR METLIFE LAW DEPT. TO giaasevaszet
fTM

.

METROPOLITAN LIVE INSURANCE COMPANY

ry

CRCUP POLICY NO. 17000-G bearing date of August 29, 1954 and issued ta

OFFICE OF PERSONNEL MANACEMENT
(Berais called the -Policyholder)

Futsuane to chapter 87 of title 5, United States Code, iz hersby anended es
followa: .

AMENDMENT 68
Effecetve Nowesber 17, 1986,

A. By subscituting for the lest sectance of the fires paragtaph of Section 12
therect, as azended, the following:

“Avy desigcation of beneficiary shall automstically ceaea to be affective
on the date thirty-one daya after tha date of cessation of the Eaployes's
issurance bereucder unlese the Zaployse's Life Insurance is reinstated is
fccordanca with the provisions of the second paragraph of Section 3
erect.

3. By substituting for ites (8) appesring in Section 3 cf Group Life
Inaurance = Option C ~- Family SBenafits Supplementary Agreesent Form
G.1985-a, attached to tha Group Policy as a part thereof, the folloving:

"(8) The lest day of the pay period during which the employing office of
tha Employea xeceives written notice frow the Employee chat he/she
desires noc to da insured hereunder, except thst at the request of
the Employee and upom proof satisfactory to the employing office
that there wag no Veutly Member eligihic for Fautly Life Iuourance,
tha Employee's Famtly Life Insurance will cease on the last day of
the pay period in which there wes so eligible Femily Meaber.”

AMENDMENT 69

Effective Jemary 2, 1987, .

4s By substituting for item (3) in che first paragraph of Seetion 3 thereof,
as angoded, the following:

‘"C3) The deta of expiration of a period of twelve sonche from the date
che Euployes enters on active duty or acrive duty for training as a
aeaber of a cniforved service.”

ML 0127


METROPOLITAN LIFE INSURANCE COMPANY

ee
GROUP POLICY No. 17000-G bearing date of Auguse 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION

(WEREIN CALLED THE POLICYHOLDER)

pursuant to the Federal Employees’ Group Life Insurance Act of 1984, is hereby amended as follows:

AMENDMENT 39

Effective on the date of execution of this amendmen, by substi-
tuting ior the provisions added to said Group Policy by Form
G.198S-10 ( Amendure::t 321, the following:

“Dunng the periormance of this contract. the contractor agrees
as follows:

(11 The concrsctor will not discriminate against any em-
ployee of applicant ior emplovmeent because of race, creed. color.
of national origin. The contractor will take affirmative action
to ensure that applicants are employed. and that employees are
treated during employment. without regard to their race. creed.
color, of national origin, Such action shall include. hut noc be
limited to the following: employment, upgrading. demotion of
transier: recruiment of reeruntment advertising: layoff or ter-
mination: rates of pay of other forms of compensation: and
selection for training. including apprenticeship. The contractor
agrees to post in conspicuous places. available to employees and
applicants for employment. notices to he provided by the con-
tracing officer setting forth the provisions af this won-discrimina-
tion clause,

(2) The contractor will, in all solicitations or advertisements
for eniployees placed hy of on behalf of the contractor. state
that all qualified applicants will receive consideration for em-
ployment without regard to race. creed. color, or national origin.

(3) The contractor will send tn each lahor union of repre
ventstive of workers with which he has a collective bargaining
agreement ar other contract or understanding, a notice. to he
provided by the agency contracting officer. advising the said
labor union oF workers’ representative of the contractor's cont-
miitments under this seeriott, and shall post copres of the notice
in conspeevous places available to entployees and applicants for
employment,

(3) The contractor will comply with alt provisions of Ex-
ecutive Order No. 10925 of March 6, 1961, as amended, and of

SEE AWEND. 48

the rules, regulanons, and relevant orders of the President
Comnutree on Equal Employment Oppornunity created there

(5) The contractor will furnish all information and repor
required by Executive Order No. 10925 of March 6, 1961, :
amended. and by the rules. regulations, and orders of the sai
Conimittee. of pursuant thereto, and will permit access to h
books, records. and accounts by the contracting agency and th
Comminee for purposes of investigation 0 ascertain complians
with such rules, reguistions, and orders.

(6) In the event of the contractor's noncompliance with t
non-discriminanon clases of this contract or with any of th
said rules, regulations, or orders, this contract may be canceile
terminated, Or suspended in whole or in part and the contracts
may be declared ineligible for further Government contracts i
accordance with procedures authorized in Executive Order Ni
10925 of March 6, 1961. a2 amended, and such other sanctics
may be imposed and remedies invoked as provided in the sai
Execunve Order of by rule. regulation. or order of the Pres
dent's Conmmimee on Equal Employment Opportunity, or
otherwise provided by law.

(7) The contractor will include the provisions of paragrapl
(11 through (7) in every subcontract or purchase order unie
exempted by rules. regulations, or orders of the President's Con
mine on Equal Employment Opportunity issued pursuant |
section 303 of Executive Order No. 10925 of March 6, 1961, 1
amended, sn that such provisions will be binding upoa exc
subcontractor or vendor. The contractor will take auch sctio
with respect to any subcontract or purchase order as the contrac
ing agency may direct 2s 2 mesna of enforcing such provision
including sanctions ior noncompliance: Provided. however, th
in the event the contractor becomes involved in, or is threarenc
with, litigation with a subcontractor or vendor as a result «
such direction by the contracting agency, the contractor ma
fequest the United States to enter into such litigation to prote
the interests of the United Stares.”

‘The foregoing amendment is to be srtached to and made pert of said Group Policy.

Signed at.......Washinerom, DC ig oth _d8y Of TAL 19.3
vary ¥. Wenzel UNITED STATES CIVIL SERVICE COMMISSION
‘Weones ‘ruven?
3: 2 SEs _

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURA!

Signed at..Nev. York, Mew York this oben

Sts,

Form G. 1983-16

COPY -

COMPANY ONLY)

day Ot.2nF A
METROPOLITAN LIFE INSURANCE COMPANY,

Mat. Héliabece

Secretary



ion of Beneficiary and Effect Pay!

pe of. Print. Address (including
3:2atuieae, Of Bach, Beneficiary:



Skip Parts D and E if you are a designated beneficiary or the deceased’s widow or widower.
Part D. Information About the Deceased’s Next of Kin

I1. List below the name age. relationship. and address of: ~]
(a) Widow or widower; » 29: S@) If there are no children, list the parents; if one or both
(b) If there is no surviving widow or widower, list the énild* parents are deceased, so state and give the date of death;
or children of all the deceased’s marfiages (include (d) If there are no survivors in (a) through (c), list the next of
adopted children and children born out-of-wedlock) and kin who may be capable of inheriting from the deceased
the descendants of any deceased child or children (brothers, sisters, descendants of deceased brothers, sisters,
(use additional sheets if necessary); etc.). (Use additional sheets if necessary).

Relationship to
Iw Name Age the deceased NN Full address

\
N N

Fill in items 2 and 3 only if any of the persons listed above are under age 18.

2. If the court appointed a guardian for the estate of | Name 3, If the court did not
any minor children above, give the name and appoint a guardian for
address of the guardian and attach a copy of the [Address (Wumbeg, street, api. no,) the estate of any minor
court appointment papers. Natural parentage or children, will it appoint
custody as a result of a divorce do not City, state, ZIP code one later?
constitute guardianship. Yes No

Part E. Information About the Deceased’s Estate

1, Ifthe court appointed an executor | Name 2. If the court did not
or administrator to settle the appoint an executor or
deceased’s estate, give his/her Address (Number, stre 0.) administrator, wilt it
name and address and attach a appoint one later?
copy of the court appointment City, state, ZIP code :
papers, Yes No

Part F. Your Certification (Everyone must complete this part.)

1. Are you claiming accidental death benefits (did the deceased die solely through violent, external, and accidental means)?
If “Yes”, submit coroner’s and police reports, news clippings, and any other available reports concerning the accident.
OFEGLI cannot consider a claim for such benefits if the deceased separated or retired before

the accident. Yes | No
2. Backup Withholding _ Has the IRS notified you that you are subject to income tax backup
withholding as a result of a failure to report all interest or dividends? Yes | V] No
If the amount payable to you is less than $7,500, OFEGLI will send you Please be sure you complete the Date (mm/dd/yy)
a check, information on page 2
under “Special Note” OF >|
t

If the amount payable to you is $7,500 or more, OFEGLI will open a money
market account in your name, giving you complete control of and
immediate access to all of your funds. You may write cheeks for all or part
of the money in your account when you receive your checkbook. See page 2 YX
for more information.

Your signature (Do not print)

name (Please al —
axine Clark - Sones
I certify under the penalties of perjury that all statements made in this claim| Address (Number, street, apto.)

are true, correct and complete to the best of my knowledge, information, S atk W . Van ‘8 Uren Dred F(
and belief, and that I did not suppress or withhold evidence necessary to *

settle this claim. . aa buigo cd -r c bo 600%

Your Social Senurity Number Z A ||: 5/0}. b 4 5|Z| Daytime telephone hd. Evening telephone no.
Estate/Trust Identificati (TB) _ (173)
state/Trut Identification : 12? 261 3204 (V8 Z26I- IgRS

Warning—If you knowingly and willfully make any materially false, fictitious or fraudulent statement or representation on this form, or conceal a
material fact related to the requests for information on this form, you may be subject to a monetary fine or imprisonment for not more than five
years, or both, under {8 U.S.C. 1001. Form FE-6

Revised Apeil 2001
Do not use previous editions Page 4 OFEGLI Form in Adobe Acrobat POF (04/01)


METROPOLITAN LIFE INSURANCE COMPANY

—$——_—

GROUP POLICY No. 17000-6 bearing cate of August 29, 1954 and Issvee to

UNITED STATES CIVIL SERVICE COMMISSION
(Heretn called the Policyno:cer)

pursuant to chapter 87 of title 5, Unitad States Code, Is hereby amenced as follows:

AMENOMENT_ 33.

Sse

Eftective July |, 1972, by substituting for Section 20 thereot, as amended,
the following:

"$action 20. OPTIONAL MOOES OF SETTLEMENT. <= After the
an Employee, arrangements cay bo ade
due af The ceath of the Esployon will ba paid In a manner other than
in one tum to the Beneficiary or other persona entitied To recalve
payment. Information concerning such mes of sottienant will be
turnished by the Offica upca written request.”

The foregoing amendment |3 to be attschad to and mace part of said Group Policy.

Signed at Wasningten, DO. C. tals t3th day of October 1972.

UNITED STATES CIVIL SERVICE COMMISSICN
TPottcynolder?

by Rebert £. Eaxptcr

(Space Below For Use of Metropolitan Lite Insurance Company Oniy)

Signed ef New York, N.Y. thig sixteenth day of __Noveaber 19_72

METROPOLITAN LIFE INSURANCE COMPANY,

oe Bud O=3200

Donald A. Cuell ~*~
Thagiatrar) Vioe-Preeidant sod Searatacy

Form G.1995-28 G 0) [P Y -



METROPOLITAN LIFE INSURANCE COMPANY
GROUP POLICY NO. _17000-G bearing the date of August 29, 1954 and issued to
OFFICE OF PERSONNEL MANAGEMENT
Pursuant to chapter 87 of title 5, United States Code, is amended as follows:
AMENDMENT 73

Effective October 1, 2000, .

- A. By adding the phrase “or an equivalent loss as determined by the Insurance Company” after
each phrase “severance at or above wrist- and ankle-joints respectively” in Section 5 and any and
all other places this phrase appears in the contract.

B. By adding the phrase “or an equivalent loss as determined by the Insurance Company” after
each phrase “severance at or above wrist-joint” in Section 5 and any and all other places this
phrase appears in the contract.

C. By adding the phrase “or an equivalent loss as determined by the Insurance Company” after
each phrase “severance at or above ankle-joint” in Section 5 and any and-all other places this
phrase appears in the contract. |

CE
Signed at Washington, D.C. this “27 ‘day of Seuet H~ ,2000
ae

OFFICE OF PERSONNEL MANAGEMENT (Policyholder)

by Denk <0 zo
Frank D. Titus

Assistant Director for Insurance Programs
Contracting Officer

Ewa -
Signed at New York, NY this Ad day of hohe. fer , 2000
METROPOLITAN LIFE INSURANCE COMPANY

By 2 Drei, » Oe
Margery/A. Bétfain
Vice President
Group National Accounts



METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLicy No. 17000-G bearing date of August 29, 1954 and issued-to

UNITED STATES CIVIL SERVICE COMMISSION
{Herein cailed the Policynoider)

pursuant to chapter 87 of title 5, United States Code, Is hereby amended es follows:

AMENCMENT 62

Eftective January |, 1977, dy substituting for the lest sentence of
Section 17 thereot, 63 amondod, the following:

“The term ‘renewal cate’ as used in this Policy shall moan
the last premium due date in the month of November in each
of the calendar years 1955 through 1960, both Inclusive,

July ist for the calendar years i96! through 1976, both in=
elusive, and October ist in the calendar year 1977 and each

sudsequent calendar year."

The foregoing amendment Is to be attached to and made part of sald Group
Policy.

Signed at Washington, D.C. this fourth day of _April 1977.

UNITED STATES CIVIL SERVICE COMMISSION

+ (Pelleyhoider)
{Space Below For Use of Metropol! tan Life Insurance Company Only)

Signed at Nev York, N.Y. this — Telfth day of April 19_T

METROPOLITAN LIFE INSURANCE COMPANY,

RAW en iS . Orla fa Lynne, ue,

a CRagistrary” AN .  Goneral Counsel & Secretary

Form 6.1985-37 .



SE AND. 1D

METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION

(HEREIN CALLED THE POLICYHOLDER)

pursuant to the Federal Employees’ Group Lile Insurance Act of 1954, is hereby anrended as follows:

AMENDMENT 32
Effective on the date of execution of this amendment, by adding
to said Group Policy, the failowing:

“In connection with the periormance of work under this cnne
tractzhe contractor agrees as ioilows:

(11 The contractor will not discriminate against any em:
ployee of applicant for employment because of race. creed, color,
or nauunal omg. The contractor will take affirmative action
tw ensure that applicants are employed. and that employees are
treated during empinyment, without regard to their race. creed.
color. of national origin. Such action shail include. bur not be
limited to, the following: employment. upgrading, demotion or
trausier: reerutment of recruitment advertising; layoff or ter-
tuination: rates of pay of other forms of compensation: and
seiection tor training. including apprenticeship. The contractor
agrees to past m conspicuous places. avatlable to employees and
applicants for employment. notices to be provided by the con-
tracting ofiver setting forth the provisions of this nondisenmina-
tion clause.

(21 The contractor will. in all solicitations or advertisements
fur employees placed by or on behalf of the contractor, stare
that all qualified applicants will receive consideration for em-
pinyment without regard to race. creed, color. or national origin.

(34 The contractor will send to exch labor union of repre-
sentative of workers with which he has a collective bargaining
agreement of other contract or understanding, a nouce. to be
provided by the agency contracting officer. advising the said
labor umon of workers’ represemarive of the contractor's com-
mitments under this section, and shall post copies of the nonce
in conspicuous places avaiable to employees and applicants for
‘employment. .

(4) The contractor will comply with all provisions of Ex.
ccutive Order No. 10925 of March 6, 1961, and of the rules.

regulations, and relevant orders of the President's Cunimittee
on Equal Employment Opportunity created thereby.

(5) The contracsor will furnish all information and repor:s
required by Executive Order No. 10925 of March 6, 1¥6t. and
dr the niles, rezulations, and orders of the said Committee ur
pursuant thereto, and will permit access to his books, records.
and accounts hy the contracting agency and the Commitee ior
purposes of investigation in ascertain compliance with such
rules, regulations, and orders.

(61 In the event af the contractor's non-compliance with the
nondiscrimination clauses of this contract or with any of the
said rules. regulations. or orders. this contract may be cancelled
in whole of in part and the contractor may be declared ineligible
for further government contracts in accordance with procedures
authorized in Executive Order No. 10925 of March 6, 1961.
and such other sanctions may be imposed and remedies invoked
as provided in the said Executive order or by rule. regulation.
or order of the President's Committee on Equal Empluymenr
Opportunity, or as otherwise provided by law.

(7) The contractor will inctude the provisions of the fure~

| Boing paragraphs (11 through (6) in every subenntract or pur

chase urder unleas exempted by rules, regulauions. or orilers of
the President's Committee on Equal Employment Opportunity:
issued pursuant ro section 303 of Executive Order No. 10928
of March 6, 1961, s0 that such provisions will be binding upon
each subcontractor or vendor. The contractor will take sh
action with respect to any subcontract or purchase orier as the
contracting agency may direct as a means of eniorene such pro
vinions, including sanctions for non-vompliance: Provided. huw-
ever, that in the event the contractor becomes imvolved in. or is
threatened with, litigation with a subcontractor ar vendor as
a result of such direcuon by the contracting agency. the cnntrac-
tor may request the United States to enter into such litigauen to.
protect the interests of the United States”

‘The forezoing amendment is to be attached to and made part ef saig Group Policy.

day of. AY.

UNITED STATES CIV!

By.

> of

'SPACE BELOW POR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY!

Signed ar Nev_Yorks Nev. York.

this.

Sikeenth,

day of. JSRUASY.

. 19.62,

Son Sin APDIDEPRUE, nn

arm ds HOSE1Q

COPY ©

METROPOLITAN LIFE INSURANCE COMPANY,



tage
‘

Section 4. AMOUNT OF INSURANCE.-=(A) apslicable Prior to the E=plovee's Rettrerent

oz Eagitiesast to Benefits Under Subchaprer 1 of Chapter 81 of Title S. Uniced

States Code:--The amount of Fanily Life Insurance hereunder on sccount of any

Fazily Mesber on whose account the isployee is insured hereunder shall be in

accordance wich che Schedule set forth delow:

Schedule ef Family Life Insurance On and
after April 1, 1981

Family . .

Member . +Family Life Insurance
Spouse $5,000

Each Child _ $2,500

(3B) Applicable after the Enployee's Retirement or Entitlement to Benefits Under
Subchaprer 1 of Chapter 81 of Title 5, United Scaces Code:—The amount of Family
Life Insurance hereunder on account of any Family Member on vhose account the
Ezployee is insured hereunder after the Esployee's retirement or entitlement to
benefits under subchapter 1 of chapter &1 of citle 3, United States Code shall be
the basic amount of Family Life Insurance reduced by 22 thereof for each month
beginning with the effective reduction dste and continuing for 50 months. The
teras “basic amount of Family Life Insurance” and “effective reduction date” are
defined in the following paragraphs of this subsection (3).

The tem “basic amount of Family Life Insurance” neans the amount of Family Life
Insurance 1a force on account of each of the Employee's Fasily Members on the date
Family Life Insurance on account cf such Family Men! vould otherwise have cessed
because of the happening of the event specified in eithar of items (1) or (2) of
the firse paragraph of Section 3 hereof, in accordance with che Schedule of
Insurance in subsection (A) of this Section vhich had been in force for sot less
thas

(a) che full perfod or pertods of service dusting which the Family Life
Insurance hereucder vas available to the Employee, or
(>) tha five years of service immediately preceding the date cf the Employee's
retirement or the date of che Employee's enticlament to benefits under
subchapter 1 of chapter 81 of ticle $, United States Code and during which
. " the Family Life Insurance was available to the Exployee,

whichever 4s shorter.

The Employee's Family Life Insurance hereunder will be continued after retirement
ot entitlement to benefits under subchapter 1 of chapter 81 of title 5, United
States Code, .as specified above, only if the Exployea's Basic Life Insurance is
continued after retirement or entitlement to such benefits in accordance with the
provisions of the Group Policy.

Form 6.19854


Pa

SEE AMEND.

tion (B) of this Section, the amount of Iife Insurance in
furce om such due date un the lives of Enpluyees who are
making contributions during the payroll period in which
such due date falls, multiplied by the sum of such tentative
bi-weekly average Group Life Insurance premium rate antl
the bi-weekly premium rate fur Group Insurance for Death
of Dismemberment by Accidental Means, such premium
rates being those in effect on such clue date.

In liew of the exact calculation of the premium payable on either
of such bases, an approsinvite nicthod for determining the amount
ef the premium payable may he used by muttal agreement of the
Tisuranee Company antl the Holicyhohter,

‘Mi premiums falling due under this Policy, including adjust-
ments thereof, if any. are payable hy the Volicyhoidler. on or before
thei reapevave due dates, direct tu the Insurance Company, The
payment of y shall sx ain the Insurance unler
this Holi
chye elite, except an pruvitled in submection (1D) following.

(1D) Grace Perind—ed race periud-of thirty-one days or of
such longer periad as the Insurance Company may allow (with or
without interest charge after the first thirty-one days as the Insur-
awe Company may determine} shall he granted to the Poti
far the payment of any premium due provided the Policyholder
has neg previously given written autice te the Insurance Company
that this Policy is to be discontinued as of the due date of such
prenmim, and durityg any auch grace period this Policy shall cone
tinve in force.

If the Puticyhokler fails ws pay any premium within the grace
period, this Pulicy shall be discontinued at the end of the last day
of such gence period. but the Uolivyhokler shall, nevertheless, be

hie tu the Insurance Company far the payment of all ppremituns
pail, tegether with the preminms for the grace
periml, Hf, however, written notice ix given

y shall he cliscontinned as oi the date of receipt uf such written
notice ly the Insumince Company or the date spec

halder fur swh discontinuance, whichever date is Inter, and
the Kekler shall be Hable to the Insurance Connpearny
Tayment af all prensines then due and unpaid, together with the
prerata prowinm fur the period commencing with the lat due
date ani ending with sh date of dixcuntinuance.

Section 18. ANNUAL ACCOUNTING AND CONTIN:
GENCY RESERVF.—Not later than ninety days after the end of
cach policy year the Inatrance Company shall prepare and furnish
tw the Pulicyholder a statement, in form apprived hy the Polies-
hudder, setting furth the following: ‘
U1) (an The aggregate amuemes of prentivas actually accrued
under this Policy under the provixions of Section 14
here frum the date of insite to the exw of such policy
year, rethiced by
Ub) Any prenitens eettemnest a» the Policyhobler in actor
ance with the prorinions ul the secund fullewing paras
graph,
(2) The augereyate anmastita of interest for all policy years from

the date of issue to the ent! of auch policy year added to
the Contingency Reserve held for this i'olicy in accordance
with the provisions of the next following paragraph.

(3) The aggregate amounts of all mortality and other claim

charges incurred under this Policy frum the date of issue to

the end of such policy year.

‘The aggregate amounts of expense and risk charges in-

curred under this Policy fram the date of inaue w the emt

of such policy year.

(S) The algebraic sum of items (1) plus (2) minus (3)
minus (4).

(4H

the Insurance Company as a Contingency Reserve to be used for
charges under this Policy only. Such Coatingency Reserve shall hear
interest at a rate to be determine! in ailvance ul exch policy year
hy the Insurance Company, which rate shall be-Spproved by the
Policyholder as being consistent with the rrés generally used by

11 be contputed as of the.
amount of the Contingency
‘at the rate applicable to that policy
an calculated shail he aikied to the
amount of the Conti Reserve as of the endl of auch policy
year or upem the -fequest of the Policyhuller shall be paid to the
Policyhoker within ninety days after the end of such policy year
for depesi¢ in the Treasury of the United Seates for credit to the
func created hy sulmection (1 af Section 5 of the Federal m-
a 5 ave 4.

Reserve during that policy
year, and the amount of j

If and when the Poticyhukler shall determine that such Contin-
yency Reserve has aftaineil an anmnunt estimated by the Policy:
holder to make satisfactory prruvision fur adverse fluctuations in
future charges unser this Policy and shall s0 notify the Insurance
Company in writing, then the amount by which the Contingency
Reserve cumyntted as of the endl uf the pulicy yearin which the n=
surance Company receives auch notive shall exceed the amount af
the Contingency Reserve at the besinning of the policy year in
which the hunrance Company feceives such notice shall be paid
te the Policyhokler ax a rettim of premium, fur deposit ia the
Treasury uf the United States for credit to said fund. Similarly, the
amount by which the Contingency Reserve computed as of the end
of each sulwequent policy year shall exceer! the amount of the Cons
Tingency Reserve at the beginning of the policy yrar in which the
Insurance Company receives such notice shall also he 10 paid to
the Volieyholder. Any interest computed on the Contingency Re-
serve far the policy year in which the Insurance Company receives
such noice antl for all subsequent policy yrars shall abo be paid
to the Policyhulder for such deposit. If and when this Policy shall
he discontinued, and if after all changes accrued hereunder have
heen mare, there is any pamitive Iniance remaining in the Contin-
gency Reserve, such balance shall be pail te the Policyhokler as a
retam of prreminm, for deposit in the Treasury uf the United States
for credit to said fund aubject to the right of the Insurance Con
pany to make auch retim in equal nwnthly instalments over a
period of iat more than two years eetiiny of gore to he

&

H
8

g

SEE AMEND. 33,56


. t
weCoupoLiTaN LIFE INSURANCE L.../ANY>”

GRUP POLICY WO. 17000-6 bearing date of August 29, 1954 and Issued to

UNITED STATES CIVIL’ SERVICE CO:4ISSION
(Herein called the Policynolder)

" pursuant to chapter 87 of title 5, United States Code, is hereby amended as

folloxs:

a
1.
A.

ENT 63. :
Effective November 2, 1978,

By substituting for the first paragraph of Section 4 thereo’, as amended,

the foliowing:

* Section 4, AMOUNT OF INSURANCE.-

(A) Applicable Prior to the Employee's Retirement or entitlement to
benefits uncer suochapter 1 of chapter 81 of title 5, United States
Codes--Tne exount of insurance hereunder on any Employee shall be in
accordance with the Schedule set forth below. ~Any increase or decrease
in the amount of sucii insurance cue te change in annual compensation, in
accordance with said Schedule, shall become effective (1) cn the stated
effective date of change in the Employee's annual compensation or the
date such change in annual compensation is approved, whichever date is
later, or (2) on the effective date of the change when a retreactive
adjustment is actually the correction of an error, unless otherwise
Stipulated in a Jaw providing for the change.*

By substituting for subsection (8) of Section 4 thereof, as amended, the

following:

" (8) Applicable After the Exployee's Retirement or entitlement to bene-
fits under subchapter 1 of chapter 81 of title 5, United States
Code:--The amount of Life Insurance hereunder on any Employee after
retirement or entitlement to benefits under subchapter ‘1 of chapter 82
of title 5, United States Code shall be the basic emount of Life
Insurance reduced by 2% thereof each month beginning with the effective
Tecuction Gate, subject to a minimum amount of Life Insurance after
retirement or entitlenent to benefits under subchapter 1 of chapter 81
of title 5, United States Coce of 25% of the basic azount of Life
Insurances. The tarms ‘basic amount cf Life Insurance’ and ‘effective

date’ ace defined in the following paragraphs of this
subsection (3). )In the case of an Employee whose retiresent or

sentitlement to defefits under subchapter 1 of chapter 81 of title 5,
United States Code occurs on or after flevember 2, 1978, the acount of
Life Insurance at any tine after retirement. or entitlement to benefits
under subchapter 1 of chapter 81 of title S, United States Code shall

Form 6.198$-32

Gory ..


J2ENDYENT 64 (Continued)

Election 3

che lovee tay, elect to have his/her basic amount of Life Insurance
contizued in full afzer retiremest or entitlenent to benefits under
subchapter 1 of chapter &1 of ticle S, United Scares Code.

<= an Employee on che date of his/her cecizrecest oF entitlesent ‘to
dSesefizs under subchapter 1 cf chapter 81 of citle 5, United States Code,
elects to have his/ber Lise Insurance deterzined {3 accordance with either
Flection 2 or Election 3, such Exployee may, at 2 later date, cancel che
asoust of Lite Insurance provided by eisher Election 2 o: Fleccion 3 and
thereafzer his/her Life Insurance will continue in the amount he/she would
have had if he/she selected Zlection 1 on the date of his/ber retirement.”

Il. Effective Apeid 1, 1981,

A.  3y adding to the last paragraph of Section 1 thereof, as amended, che
following:

“On and after April 1, 1981, unless othervise specified any reference to
(a) dosurance hereunder shall include:

Basic Life Insurance

Option A ~ Standard Life Insurance

Option 3 - Additional Life Insurasce

2asic lesuzance for Death or Dismenbernent by Accidental Means
Option A - Standard Insurance for Death or Disnenbdernent by
Accidental Means .

(>) Life Insurance hereunder shall include:

Basic Life Insurance
Option A = Standard Life Insurance
Option 3 = additional Life Insurance

(¢) Insurance for Death oz Disnembernent by Accidental Means shall -
include Basic Insurance foz Desth or Dismembersent by Accidental
Means and Option 4 ~ Standard Insurance for Death or Discenberment
by accidental Means. . :

(4) Option & = Standard Insurance shall isclude Option 4 = Standard

Life Insurasce and Option A ~- Standard Insurance for Death or
_Disnambersent by accidental Means.~


a an he-seusiad-in-end-bave-marai
fea lor tetipement on immediate annuity under any ui the
& Reti stems listed in Schedule B attached ta this Policy as

(ii) the day preceding the first day the
under & subsequent appuintment of che reri
tion such that he ayain falls
ployee” in Section | here. ur (

SEE AMEND.

. shall become effective on the stated
the Employee's annual compensation oF

SB —_Annual Compensation
z Wut Nea
 Gereater Than Greater Than
g ) $1,000
R $1.00 2,000
® 2.000 3.000
3 3.000 4.000
= 4.000 3.000
“5.000 6,000
ew 6.000 7.000
= 7.000 ¥,000
g 3000 9,000
% 9.000 10,000
2 10,000 11,000
m= 11.000 12.000
wm 12.000 13,000
13,000 14.000.
15.000
16,000
17,000
1,000
1,000

caace Sussggvent ro tee Last Dav or tue Cacennaa
vm Next Fou.owinc raz Catenpan Monte in Waicn THe

umoen Arrea His 65H Birrnoay
the first day of the second calendar month next fol-
month in which the 65th birthday of the Em-

day, and shall be further reduced by 3
of each calendar month thereafter untit

shall be eyual to 24% of the amount
i before the first reduction.

the amount remaining in
of insurance in effect ii

ast Recowas om Acai
is GSte Biarnoay

Arrucasce To any Exrtovex Wxo
Becomas Insvego Hesgecxoea Arran

‘The amount of Lile Insurance and the
applicable to any
ured hereunder

had the Employee been insured under PART A of 1

on his 63th birthday hased on (1) the amount of his ann
pensation on the latest date he becomes insured hereunder,
the amount of his atinual compensation on his 3th birthday the
Employee was eligible to be insured hereunder un his oSth hirthi
vhichever ig the lesser,

nt of Insurance for”

(2)

Sertion 5. INSURING CLAUSES.<-(.41 Life Iasurance:—
‘Upon receipt by the Office of satisfactnry penol, in writing, that any
Employee shall have dint while maueed hereunder, the (Hfice shall
pay. sulsject to the terms hereof, the amount of [ile Insurance, if
any, in force hereunder on account of such Emuloyee in acewrdance
with Section 4 hereof, at the date of hin death. Uayment shall be
made to the Beneficiary of recurd uf the Employee or atherwise as
provided in Section 11 hereof immediately after reveyw of such prov
and of proof that the claimant is entitled tu such payment,

(B) Jasurance fur Death or Dismembrrmwar dy Ievidentat
Meuns:—UC pon receipe by the Office of mawe and watisiactury praot,
as required herein, that any i"...loyee, while insured herrunder ive
Tasurance [ue Death et Dismemberment liy Accidental Mews shall
have sustained bodily injuries solely through violent, external anu!
accidental means, and within ninety days thereafter shall hive sul
fered any of the losses specified in the Schedule of Lamres of this sub-
section (B) as a direct result of such bealily injuries indepemently
of all other causes, the Office shall pay. subject ts the torus and
limitations hereof, the smnount of insurance apevined Gor such bene
tn saidl Schevdule. prownled, however, that in ine case stall ane pase

Forts be
Mug, 1484

SAA,


PEC @L 2008 14:24 FR METLIFE - 50 2511636 . Pe4e4

The foregoing amendment is to be ~— toand made part of said Group Policy.

Signed at Washington, D.C. this wah, of Lecewte ,1998

OFFICE OF PERSONNEL MANAGEMENT
(Potieyholder)

oy anaes

ore eet Be utenitams Frank D. Titus .

Assistant Director ~
for Insurance Programs

Contracting Officer

" gigned at New York. NY. this,’ ay of__Sebye, 1998

METROPOLITAN LIFE INSURANCE COMPANY

By TTT,
Margéty AdBrittain
Vice President ~
” National Accounts

Page 2 of 2

Po

ae TOTO! POC |


“eM

“ an —
ENOMENT 62 (4 inusa)”* .

1. no interest shall be payable on delayed payment of claims under the
Insurance for Death or ODisnemberment by Accicentel Heans for any joss
other than loss of life, and -

2. mo interest shall be payable for periods (a) in excess of two years
or {b) when payment has been prevented pursuant to orders, regula-
tions or edvice of the United States Government, and

3. no interest shall acerue for any period during which payment is
delayes cue-to the inability to locate the claimant; however payment
of interest will be considered when a proper claimant files proof of
claim under the terms of the Group Policy.® .

Il. Effective January 1, 1979,

A. By substituting “Office of Personnel Menagement” for “United States Civil
Service Cosmission® as the Policyholder under the Group Policy, it being
understood and agreed that the Group Policy shall continve in full force.

8. By substituting "Office of Personnel Managenent” for “United States Civid
Servica Cesmission® or “Civil Service Connissicn” wherever the latter eppear
in either the certificate or the certificate supplenents. ’

The foregoing amendment is to be attached to and made part of safd
Group Policy.

Signed at Washincton. D.C. this 27th day of, June 29.79

OFFICE OF PERSONNEL MANAGEMENT.
olicyholder

. . By__ Alan K. Camcbell
(SPACE BELOW FOR USE OF HETROPOLITAN LIFE INSURANCE COMPANY OMLY)
Signed_tev York, N.Y. _thisTuirty-Mirst_ day of___July 19.79
. METROPOLITAN LIFE INSURANCE COMPANY,

Richard Dh. ticks Lun og
(Registrar) Dsante a

Form 6.1$35-38

eorpy


To siaesev2s2d1 P.07/789
zN

‘ : FE L@W DEPT.
hay 03 2080 14t14 FR rETLI
: cn

“3°

c. By adding tnaediacely following ite® (6) tn the first paragraph of
subseceton (2) of Section 5 thaseof, the following teem (7):

“(7). caused by of rasulcs from cha self sdeinistrsriod of fitegal oz
tLlegally obtained drugs. . :

D. By adding ‘fnmediarely following the fourth paragraph of Section -1!
- ghareof, the following paragraph! : . Loe Ca

Hawaver, 1f the Seusficiary (either by designation cr under che
order of precedenca) is & minor ead the share of che escust of Lite
Tasurance er Insurance for Death b: , cidental Neans to vhich he/she
da entitled te receive under Sect 5 bereof bas @ cet value o!
$10,000 or less, exch ascunt vill be paid to the ainer's parent(s)
on behalf of such uinor rather than to & geardisn appoisted by che
court, provided the parent(s) agree in writing £0 seat all of the

following cooditious:
. (1) che psrent(#) will hold such amount for the sole use and benefit

of tha ainor unc} cha ainor reschas majority; and

(2) che parent(s) will account to the afer for such amount whet he
gainer reaches majority; 20d

(3) che psrent(s) will indeanity the Insurance Company in che even
the minor, wheo he/she reaches ssjority, brings any legal acciat
agaicat the Iosurance Company challenging ia snp way thi
Insurance Company's psyuent of such amount Co che perent(s).”

E. +4 addieg imeedtarely following Section 23 thereof, tha following Section:
24 and 2353 .

“Section 24. TOM LOMT OM STARTING Law SUITS WITE RESPECT To LIV
THSURANCE ONLY. ~ No action af law or in oquity wball be brought ©
recovar on the Policy unless brought withia six yeara from the dat
of receipe by the Offices of the weitten procf of claim require

usder tha Policy.

Seerten 25. XUPPA-CONTRACT DUMAGES. = In any ection at law or
a equity, the Sesefictary of racord or claisant, 48 epecified
. Seation Ll berecf, shall be linited.tn the amcunt of racovery to rt
beaafit claimed, plus reascomable aficrnsy‘s fees 8 set ry th

court. The term “benefit clained” 1s lintted coz

(1) the amounts of Life Tosuranca and Insurance for Death «
- , Dismemberment by Aceidencal Heava, 2f any, in force hereunder <
aceount cf the Laployes in sccordance with Seegion 4 hereof, |

cha data of tha Zuployea's death; and ve

(2) interest as specified in subsection C of Section 4 herecf; sod

ree eames COPY

ML


METROPOLITAN LIFE INSURANCE COMPANY
(Beraia‘ called che Insurance Company)

Group Life Insurance - Option C - Family Benefits

Suppiezentary Agreement actached to and cade part of Group Policy No. 17000-¢
issuec to . .

OFFICE OF PERSONNEL MANAGEMENT
(Hereto called the Pcolicynolder)

pursuant to chapter 87 cf title 5, United States Code, and in consideration of che
paynent dy the Policyholder of the premiums as hereinafter provided, the Insurance
Conpany hereby agrees, subject to the provisions of this Supplementary agreement,
30 pay che insurance benefics herein provided with respect to the Exployecs insured
hereunder. . .

Section 1. DEFINIZION OF CERTAIN TERNS USED IN THIS SUPPLEMENTARY ACRESMENT.—

The sersa “Zmployee” seans a person who is considered, under spplicable laws and

gulasions, to be as Esployee for the purposes of chapter 87 of title $, United
States code.

The tersm “Family Member” nears a person who is considered under applicable laws and

yegulacions, to be a Family Mezber for che purposes of chapter 87 of title 5,
Unired Scates Code.

The term “Office” means the Office of Federal Employees’ Group Life Insurance which
is che administrative office established by the Insurance Company with respect to
the Group Policy and this Supplementary Agreement. The post office address of the
Office is 4 East 24th Street, New York, New York 10010. The Insurance Company
shall have the right to change the address of the Office upon three months notice
in uriting to the Policyholder.

The tearm “Option C ~ Family Life Insurance” (hereinafter referzed to as Fanily Life
Tusurance) means insurance providing benefits payable to an Employee, subject to

the terms, conditions, and limitations hereof, in the event of the death of any of
his/her Fartly Members.

The terms “hereof”, “herein”, “herefor”, and “hereunder”, as used ia this
Supplementary Agreement, refer exclusively co chis Supplesentary Agreement and not
to the Group Policy.

Section 2. EFFECTIVE DATES OF INSURANCE.--Eligibilicy of Eaployees for Family Life
Insurance hereunder and che effective da of such insurance shall be determined

in accordance with regulations of the Policyholder made pursusnt to chapter 87 of
title 5, United States Code.

Fors C.1985-A



METROPOLITAN LIFE INSURANCE COMPANY

ET
GROUP POLICY No. 1 7000-3 dearing date of August 29, 1954 end issued To

UNITED STATES CIVIL SERVICE COMMISSION
(Herein calieo the Pol icynol cer)

pursuant to chapter 87 of title 5, United States Code, is heredy aranced as follows:

MENCHENT 35. :
Ettective __July 2, 2973__,

by adding to Section 13 thereof, tre following
paragraon: :

Records and flies which relate to the adainistration of me insur
ance uncer this Policy and are maintained by the Office, including claim
tiles, snail de subject To such general disposal program as say be agreed
wwoon by the Policyholder and the Oftics.” —

The foregoing amenarent is to be attached to and mace part of said Group Policy.

Signed at __Wasnineton, 0. C. this 2Sth dey of October 197:

. UNITED STATES CIVIL SERVICE COMMISSION
(Policynotcer)

By. Robert £. Hampton

(Space Below For Use of Metropoliten Life Insurence Company Only)

Signed at New York. New York _ this 20th day of November. 1973,

METROPOLITAN LIFE INSURANCE COMPANY,

win ava t Biol A3209

(Registrar) Donate A. Coed
Viga-Preneent ane Seeriary

Form G.1985-30 ( 0) P Y


METROPOLITAN LIFE INSURANCE COXPANY

GROUP POLICY No. 17000-G bearing cate of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION

(Herein called the Polleyholcer)

pursuant to chapter 87 of title 5, Unitee States Code, Is hereby amensed as follows:

AMENDMENT $2.

Effective for the policy year commencing July !, 1972, by substituting tor
Section 21 thereot, as amanced, the following:

SCHEDULES OF BASIC PREMIUM RATES.

"Section 21.

Schedule of Bi-weakiy Basic Lifo Insurance Premium Rates Per
$1,000 of Lite insurance - Mates

Attained Arraines Attained Attained
Age A

Nearest Nearest Nearest Nearest

Birtngay Premim Birthday Premium  Birthaay Premium Birthday  Premive
15 $2.06 33 $0.10 oS $0.30 3 $2.57
16 * 408 36 210 56 54 76 2.77
17 +08 x” an 37 239 n 3.00
18 207 38 oll 38 ’ 64 78 3.26
19 07 Bi) 12 39 070 9 3.54
20 07 a0 ary 60 +73 oO 3.85
21 207 al ofS 61 82 a 4.18
2 07 42 +16 62 89 82 4.52
23 +08 43 7 63 6 83 4.83
26 08 “a 39 64 1.04 4 3.25
23 208 45 +20 65 1.13 85 5.6¢
26 08 “6 222 6 1.23 86 6.05
27 08 a 24 67 1.34 67 6.48
2s "08 48 27 63 1.47 83 6.98
2 08 49 29 69 1.60 8 7.44
39 30 32 70 1.76 9 7.99
3 3 38 7 1.90 ” 6.60
33 32 38 72 2.03 92 9.31
33 33 41 13 2.2 3 0.13
34 09 $4 245. 2e 2.39 94 11.09

Form 6.198527


METROPOLITAN LIFE INSURANCE COMPANY

——$ $$$

GROUP POLICY No. 17000-G bearing date of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION

(CLERRIN CALLED THE POLICYIOLDER)

mmesuant to the Federal Employees’ Group Life Insurance Act of 1954, ix hereby aineniled as follows:

AMENDMENT %
Effective as uf the date of issue of sait Group Holicy,

AA. ly sudotituting for the seenud paragraph of Section 3 thereo',
‘as ameniterd, the fullnwineg:

“However, if the insurance on any Employee insured hereunder
ai the event specified in either
paragraph and the Employee
on ui insurance after retire:
ment or while rev ts amuter the Federal Employers’
Coampensateas et, 1 tents (.\3 andl (B) of this pure
api, avul dacs at exercise lus right to have an individual policy
wife Insur-
with the
dlate he lest arte siwh enliven, for the amaunt of instrance
and period ai time spevitied i said items:

tar

nd items (1) at 121 af the yoreves
mueets the seoeclinacs

comtmustinn of insurance after sctire-
lave muat be entitled to and have
All requirements (or renrement on immediate annuity
wi the Retirement Systema listed in Schelule
H attached te this Motivy asa part herenf, and (b) the
player mist euher be retired ior disabil
lvted 15 years
1 greilitable wervive, if the I
mnplerel at least five yenes
weable active servive in the Anny,

. Marine Cons, of Cuast Guard af the

he anwamnt af his File Insurance conunacd
ast as tieresaid shail be in the ammunts ier which
Flave len insured hereunder if he hat not ees
yayments had continued at the sme
Fate a ont the date of his retirement. Such Life Insurance
shall autumnatically cease on (i) the date of termination of
the aunuity of the retired Enphiyee, (ji) the day pres
the tirst day the Finployee is ina pay status under
wert apprintment of the retired Employee to a

he corwlitions fv

of the temt “Employee” in Section | hereof, of
late uf discontinuance of this Volicy, whichever first occurs,

(11), The coninions (or cuntinuativn of insurance while an Em-
ployee i eeveiving benetits under the Federal Employees’
Compensation act are: the Employee must be receiving
hentits umber said .\ct because af disease or injury to hime
self ard nist he held hy the United States Department of
Labur ta he unable to return to duty. The ainount of his

Form G. 1985-2
Sept. 1956

Life Insurance continued or reinstated as aforesaid shall be
in the amounts for which he would have been insured
hereunder had his salary payments continued at the same
rate as on the «late insurance would otherwise have ceased.
Suh Life Insurance shall automatically cease on (i) the date
af termination of the Employee's benerits under said Act.
(ii) on the date of a finding by the said Department of
Tabor that he is able to rerurn to duty, or (iii) the date of
diycontinuance of this Policy. whichever frst occurs. The
continuation of insurance provicled by this icem 113) shall
be available to any Employee otherwise meeting the condi-
tious of this paragraph and of this item (B) even though-he
‘exetcines heivre May 23, 1956 his right to have an indi-
vidual policy issued to him in accorilance with Section &
herent.”

B. By substituting for the first paragraph of Section 11 thereoi,
the following:

“Section 11. BENEFICIARIES.—Any Employee insured here-
under may designate 2 Benericiary and may, from time to time.
change his designation of beneficiary. only by filing written notice
thereof, signed and witnessed, with his employing office of. in the
ease of (1) 2 retired Envpioyee and (2) an Employee whose Liie
Insurance hereunder is continued while he is m receipt of benefits
under the Federal Employees’ Compensation Act, with the Policy
holler, whereupon an acknowilerlgment of such designation oF
chanye will be furnished the Employee. Consent of the Beneficiary
shall not be requisite to oh: of heneticiary. A witness to 3
designation or change of beneticiary shall be ineligible to receive
payment as a Beneficiary. A «designation or change of benesciary
ahall take effect only if it is received by the appropriate office prior
to the death of the Employee and shall be effective as of the date
of receipt of said written notice. Any designation of beneficiary
shall automativally cease to be effective on {i) the date the Em-
ployee is transferred to another agency, (ii) the date thirty-one
days after the date of cessation of the Employee's insurance here-
under, (iii) the date of retirement of the Employee, or (iv) the
date the Employee qualifies for continuation of Life Insurance
hereunder, a3 provided in item (B) of the second paragraph of
Section 3 hereof, because he is in receipt of benefits under the
Federal Employees’ Compensation Act, whichever first occurs.”

AMENDMENT 16

Effective August 2, 1956, by substituting the date “August 2,
1956” for the date “August 11, 1955S” in the two places in which
it appears in Section 23 thereof, as amended.


-6-
AMENDMENT 46 (Continued)

Life Insurenca on his eceount is not to be continued fter retirement, the
provisions of this poregraph shall be null and void ond of no effect and no
optional Life Insuronce shell be provided for the Employee after retirement.

With respect to on Employee whose retirement occurs on oF otter
December 16, 1967 but prior to Februory 14, 1968, ‘basic anount of Life
Insurance’ means, a 10 optional Life Insurance, on amount of optional Life
Insurance in cccordance with Part II} of the Schedule of Insuronce In sub~
section (A) of this Section besed on the cmount of his annual comperastion
on the date insurance would otherwise have cecsed becuse of the hop=
pening of the event specified in either of items (1) or (2) of the first pore~
groph of Section 3 hereof. The basic amount of Life Insurence for the pur=
poses of this parograph shail be determined os set forth above without regord
te the specificotions in Part. {11 of the Schedule of Insurance in subsection (A)
of this Section relating to the period for which such schedules effective.

‘The provisions of this paragraph shall be nuil and void and of no effect ond .
ne options! Life Insurance shell be provided for the Employee cfter retirement,
unless written election of optional Life insurance by the Employee is received

by the Policyholder on or prior to April 14, 1968."

M, By substituting “on or ofter September 23, 1957 but prior to December 16, 1967, ° for
"on or ofter September 23, 1959," in the next-to-lost porograph of subsection (8) of seid Section 4,

N. by substituting “Port | of the Schedule of Insurance in subsection (A)* for "the Schedule
of Insuronce in subsection (A)” in the last two poragrophs of subsection (8) of scid Section 4.

©. 8y odding to Section 5 thereof, the following subsection (0):

*(D) Spaciel Provisions in Event of Deoth During the Period Beginning
December 16, 1967 and Ending April 14, 1968:As to insurance exclusive of
ootionc! msurence. In the event that on Employee insured hereunder, other
than 6 retired Employes, dies during the period beginning December 16, 1967
ond ending immedictely prior to the first dey of the first pay period which be~
gins on or ofter Februory 14,1968, the amounts payoble pursuant to the pre=
ceding subsections (A) ond (8) on oceount of such decth, exclusive of amounts
of optionel insurance, shall be determined os if Port Il of the Schedule of in=
surance in subsection (A) of Section 4 hereof hod been in effect on the dote
of death of the Employes.

As to optional insurance. In the event thet an Employee insured hereunder,
other than o retired Employee, dies during the period beginning December 16,
1967 ond ending February 14, 1968, the anounts payable pursuant to the pre
eading subsections (A) and (B) on occount of such death sholl be determined

& if the Employee were also insured, at the date of his death, for optional
-insurance in occordonce with Part lil of the Schedule of Insurance in subsection
(A) of Section 4 hereof, irrespective of whether the Employee was 30 insured.

In the event that an Employee insured hereunder, other than a retired Employes,

dies during the period beginning February 15, 1968 and ending April 14, 1968,

Form G.1965-21


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000~G becring date of August 27, 1954 ond Issued to

UNITED STATES CIVIL SERVICE COMMISSION
{Herein called the Policyhoicer)

Pursvont to chopter 87 of title $, United States Code, Is hereby amended as follows:
AMENOMENT_ 50
Effective Febrvory 15, 1969,

A. By substituting "PART I} = SCHEDULE OF INSURANCE, EXCLUSIVE OF OP-
TIONAL INSURANCE, ON AND AFTER FIRST DAY OF FIRST PAY PERIOO WHICH BEGINS ON
OR AFTER FEBRUARY 14, 1968 BUT PRIOR TO FIRST DAY OF FIRST PAY PERIOD WHICH BEGINS
ON OR AFTER FEBRUARY 15, 1969% for the caption in Part II of the Schedule of Insurance In
subsection (A) of Section 4 thereo!.

8. By adding immedictely after Port I! of the Schedule of Insurance In subsection (A)
of said Section 4, the following:

“PART HA*SCHEDULE OF INSURANCE, EXCLUSIVE OF OPTIONAL INSURANCE,
ON ANO AFTER FIRST DAY OF FIRST PAY PERIOD WHICH BEGINS ON OR AFTER

FERUARY 15, 1969
Annvel_ Compensation Insurances for Death
Greater But Nor Ute . or Dismemberment by
Thon Grecter Than Insuronce
0 $ 8,000 $10,000 $10,000
$ 8,000 9,000 11,000 11,000
9,000 « 10,000 12,000 32,000
10,000 11,000 13,000 13,000
11,000 12,000 14,000 14,000
12,000 13,000 15,000 13,000
13,000 14,000 16,000 16,000
14,000 13,000 17,000 17,000
15,000 16,000 18,000 18,000
16,000 17,000 19,000 19,000
17,000 18,000 20,000 20,000
18,000 19,000 21,000 21,000
19,000 20,000 22,000 22,000
20,000 71,000 23,000 23,000
21,000 22,000 24,000 24,000
72,000 23,000 25,000 25,000
23,000 24,000 %,000 26,000

Form G .198S- 25


. tom

AMECMERT 63 (0 einved =

period for which such schedule is effective. The provisions of this
paregreph shal) de null ano void and of no effect and no optional Life
Insurance shall be providec for the Exployee after retirement, unless
written election of optional Life Insurance by the Exployee is received
by the Policyholcer on or prior to April. 14, 1553.

with respect to an Employes whose retirenent occurs on or after
Septender 23, 1959 but prior tc December 16, 1967, ‘baste snount of Life
Insurance’ means the amount of Life Insurance in accorcance with Part 1
of the Schedule of Insurance in suosection (A) of this Section based on
the amount of his annual compensation on the date his insurance would
otherwise have ceased because of the haopening of the event specified in
either of iteas (i) or (2) of the first paragraoh of Section 2 hereof;
and ‘effective reduction deta’ mesns the first cay of the second calen-
dar month after (1) sucn dete, or (2) his 55th birthday, whichever is
later.

With respect to an Employee whose retirenent occurs prior to Septenber
23, i953, ‘basic anount of Life Insurence> means the enount of Life
Insurance in accorcance with Part I cf the Schedule of Insurance in sub-
section (A) of this Section besed on the znount of his annual conpen-
sation on (a) the cate his insurance would otherwise have ceesed decause
of the happening of the event specified in either of itens (1) or {Z) cf
the first paragraph of Section 3 hereof, or (b) his 65th birthday,
whichever {s eartier (or in the case of any such Ecployee who first be-
came or again became insured hereunder efter his 65th birthday, dased on
(i) the amount of his annual comenseticn on the latest date ke becaose
fnsured hereuncer, or (if) the emount of his annual ccnpensation on his
65th birthday if the Emplcyee was eligible tc Se insured hereunder on
his 65th birthday, whichever is the lesser); and ‘effective reduction
date means the first day of the second calendar month after his 63th
rthday.

In addition to the anounts of Life Insurance and Insurance for Death or
Dismemberment by Accidental Means, if any, in accordance with the pro-
visions of the preceding subsections (A) or (8), whichever is appli-
cable, the Office shall pay interest, es determined Sy the Insurance
Company to the Beneficiary af record or claimant, as specified in
Section 21 hereof, on
(4) any dalayed payment of claims paid in one sum from the date of
death of the Enployee to the cate of the payment of such claims,

(41) any delayed payment of optional modes of settlement, as specified
4a Section 20 hereof, fras the date cf death of the Employee to
the effective date of the supplenentary contract issued in cone
nection with sucn optional ances of settlement,

provided, in either case, the Employse's death occurs on or after
, January 1, 1976, and provided further, that:

Form G.1985-38

_GOPY -


IMPORTANT INFORMATION ABOUT
MONEY MARKPFT OPTION ACCOUNTS

Designed to put you in complete control of your life insurance proceeds.
Money Market Option Accounts provide . . .

SAFETY
* The account earns interest from the first day it is established.
¢ The full amount, including all interest earned, is guaranteed.

COST-FREE CHECKING
* You pay nothing for this Account. There are no monthly service charges. No charge for checks.
* You can write checks from $250 up to the full amount of your proceeds at any time.

FLEXIBILITY
* You can withdraw all or part of your money at any time, with no penalty or loss of interest.
+ You can name a beneficiary for your funds, in case something happens to you.

YOUR MONEY MARKET OPTION ACCOUNT GIVES YOU:

Safety * Security + Privacy ¢ Flexibility * Free Checking

SPECIAL NOTE

PLEASE BE SURE TO COMPLETE, IN INK, THE
INFORMATION REQUESTED BELOW AND SIGN YOUR
NAME IN THE APPROPRIATE BOX.

Your signature (Do not print) KEVA Fal
Your name (Please print)
ORE CAL ~l OWES

Address (Number, street, apt. no.)

3 io- CHlicago Ave Af. Aff

City, state, ZIP code

OARFIRK Ell, G36?
Your Soci Security Number 3 |s [7 |-[¢ |g |[-|*s lz |7 J

Employer identification number

Date (mm/dd/yyyy) Daytime telephone no. Evening telephone no.

8/9/e/ (773) SHA- BO) | (7B) SEE -5338

‘Area Code

Form FE-6
Revised January 1999
Page 2 OFEGLI Form in Adobe Acrobat PDF (1/99)


Otfice of Federal Employees’
Group Life Insurance
P.O. Box 2627
Jersey City, NJ 07303-2627

Claim for Death Benefits

———
FEGLI Federal Employees’ Group Life Insurance Program

Read the instructions carefully
before filling out this form.

» Part A. Information About the Deceased (Everyone must complete this part.)

1. Deceased’s full name

(First) (Middle)
VENES

(Last)

2. Date of birth (mm/dd/yyyy) 3. Date of death (mm/dd/yy)

Tle] 39 HOS/ol

; Ken
IBF_-29 -F22O

5. Legal residence at time of death—(City and a)

S34 W\VGnPB wenrZ! dread ye

6. Department or agency in whieh last employed

Oe Lae

7. Logation of last employment (City, state, ZIP code)

sores Steel (fund Sleson, Meroe

8. At the time of death was the decegefi WA

(a) Retired and receiving monthly annuity under any Federal

civilian retirement system 2
Yes a No Q

(b) Receiving Federal Workers” Compensation benefits?
ves O) noQ Unknown

Unknown C)

(©) Claim number (CSA, CSE CSD

A 37%3243

If “Yes” to either 8(a) or 8(b), please

complete boxes 8(¢) and 8(¢) to the
right.

(@ Effective date of Federal Workers"

lanka benefits (mm/dd/yy)

Part B. Information About the Deceased’s Family (Skip this part if you are a designated beneficiary.)

1. How many times was the
deceased married?

a

2. Give the name of each spouse 3. How did the marriage end? | 4. When did the marriage end?
(include ALL marriages) (Check one in each case) (mmiddiyyyy)
Vera ones vent proce 109-5 -F 4
Moax\ne-Clack anes i [ome [9 F-05-O]
Death Divorce

5. Did the eased have any living children on the datg of his/her death?
Yes No If Yes, how many? if

6, Did the deceased tne chee who died before the date of his/her death?
Yes No" If Yes, how many? :

yl
dota}

Part C. Information About You

1, Yourname (Last)

Janes Maxine Claclk.

(First) (Middle)

2. Your relationship to the deceased

W1Fe

3. Your date of birth (mm/dd/yyyy)

(0-23-45

Complete Items 4 through 13 only if you are the deceased’s widow or widower.

4. Date of marriage (mm/dd/yy)

[0-23 -A't

5. Place of marriage (City and state)

Los \eeas Nevada,

6. Me
val

‘was performed by:
Clergy or Justice of the Peace
Other (specify)

7. Were you living with the

8. Were you divorced from te-deceased

9. If you were divorced from the deceased, give the date (mm/dd/yy)

deceased at the time of death? at the time of death? and place of the divorce.
V/ ves No Yes No n ( fA
10. How many times were 1]. Give the name of each spouse 12. How did the marriage end? 13, When did the marriage end?
you married? (include ALL marriages) (Check one in each case) (mmi/dd/yyyy)
Osker Sones Aoen [oie | OF (OS IO)
t T
] Death Divorce
Death Divorce

Do aut use previous editions

(continued on the other side)

Page 3

Form FE-6
Revised April 2001
OFEGLI Form in Adobe Acrobat PDF (04/01)


SCHEDULE

(Referred tu in Section 1)
Offers and employees in the following groups are excluded from the definition of
the terin,“Eniployee” in Section | hereof.

(1) Rhuplayves in any corporatiun under the supervisiun af the Farm Credit
(Administration of which corporation any member of the Bosrd of Directors
is clected or appointed by private interests,

(2) Noncitizen employees whose permanent duty station ix lucated outside a
State of the United States or the Wistrict of Columbia.

SEE . 14 (3).Commissioned.of Lwislistanly anal. stim slaatenk ish-the
AMEND kee Seepaie c Mavi Leeper Grant she hens
SEE AMEND. 12 + - te 1H.

SEZ AMEND. 38

(6) Parttine, when-actually-employed. of intéruittent employees having no
regular tour of duty. -
(7) Eanployees whore salary, pay or compensation ware anal haxix ix $12

3 year uF leas. .

(8) Member or patient employees in Government hospitals Nemes
(9) Employees paid oa a contract of fee basis,

except those whee _——

sng ere a t wh
te

(40) Employees pais ona piewework hasi
provides far regular or full-time servic

SEE AMEND. §

112) Employers whose duties involve the security of the United States and
preclude their identification as employees of the Federal Government.

deve mn

SEZ AMEND. 20

SEE AMEND. 41

aay



ey
FEGLI

Claim for Death Benefits
Federal Employees’ Group Life Insurance Program

FEGL

(Do not use this form to claim Option C-Family Benefits. Please use form FE-6 DEP to claim those benefits.)
Instructions

General

The, Office of Federal Employees’ Group Life Insurance (OFEGLI)
pays claims under the Federal Employees’ Group Life Insurance
Program. “We” and “our” on this form refer to OFEGLI.

FEGLI death benefits are not subject to Federal income tax, but the
interest that we pay on those benefits is subject to such tax. We will
report all interest payments to the Internal Revenue Service.

Who receives the death benefits?
We will pay benefits in the following order of payment:
If the deceased assigned ownership of his/her life insurance to
someone else (generally by filing an RI 76-10, Assignment form),
then we will pay:
First, to the beneficiary(ies) the assignee(s) validly designated;
Second, if none, to the assignee(s).
If the deceased did not assign ownership and there is a valid court
order on file with the agency or OPM, as appropriate, we will pay
benefits according to the court order.
If the deceased did not assign ownership and there is no valid court order
on file with the agency or OPM, as appropriate, then we will pay:
First, to the beneficiary(ies) the deceased validly designated;
Second, if none, to the deceased’s widow or widower;

Third, if none of the above, to the deceased’s child or children
and 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 deceased’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 deceased’s estate;

Sixth, if none of the above, to the deceased’s other next of kin,
entitled under the laws of the state where the deceased lived.

How will 1 receive benefits?
If you’re entitled to less than $7,500, we will mail you a check.

If you’re entitled to $7,500 or more, we will open a.money market
account in your name and mail you a checkbook. You may write
checks for some or all of the money in your account as soon as you
receive the checkbook. See page 2 for details.

How do I complete this form?

Please type or print legibly in ink.

If you need help completing this form, call our service
representatives, toll-free, at 1-800-OFE-GLIA (1-800-633-4542).

Here is a summary of what parts of the form you must complete:

Then Complete These Parts of the Form:
If you are A |B [c c DIE F | Page
a 13. | 4-13 2
Designated | #7 v viv
Beneficiary
Widow or vjv|lvuliyv viv
Widower
AU Others vivlie vilv|vjiy

Don’t skip any questions you’re supposed to answer. That will delay
our action on your claim. If a question doesn’t apply, write “N/A” o
“not applicable”. If the answer is “No” or “Unknown”, write that.
If you are completing this claim on behalf of someone else (such as ;
minor), complete items 1-3 of Part C with that person’s information,
not yours. In Part F and page 2, sign your own name “on behalf of”
the other person. Fill in your name, address and phone numbers.
However, the Social Security Number should be the other person’s, n
yours.

What else do I have to submit?

In addition to this claim form, you must submit a certified copy of t
deceased’s death certificate that contains the cause and manner of
death. (However, if you know for sure that another claimant is
submitting the deceased's death certificate, you don’t have to). You
can get the certificate from your city or state’s Bureau of Vital
Statistics or equivalent agency. We cannot process your claim until )
receive the certified death certificate.

Please submit an English translation of any foreign language death
certificate.

In addition, send us all Designation of Beneficiary Form(s) (SF 282
and/or SF 54) that you may have which show the agency receipt dat
on the bottom.

If you are an executor or administrator filing this claim on behalf of
the deceased’s estate, send us a copy of the court appointment pape:
‘We will let you know if we need anything else.

Where do I send this form and other documents?

If the deceased was employed at the time of death .

Send everything to the deceased’s employing office. We will proces
your claim after we receive certification from the agency. However,
you are the deceased’s widow(er) and the agency told you to send
your claim form and other documents directly to us, you should do
that. Please include copies of any letters you received from the agen
that mention death benefits.

If the deceased was retired or receiving Federal Workers’
Compensation benefits at the time of death

Send everything to OFEGLI, P.O. Box 2627, Jersey City, NJ
07303-2627.

Instructions to the employing agency
Forward the completed claim, death certificate and court appointme
papers, if any, to OFEGLI, PO, Box 2627, Jersey City, NJ 07303-
2627, together with:
1. The original Agency Certification of Insurance Status (SF 2821)
2. The original Designation of Beneficiary form(s) (SF 2823 or
SF 54), if any;
3, All court orders on file, if any; and
4. All other FEGLI forms (for example, SF 2817 or RI. 76-27 electi
forms, RI 76-10 assignment form, etc.) EXHIBIT

=


-2-
AMENOMENT SI (Continued)

' (5) The effective dates of Employees’ insurance in occardence with
Section 2 hereof." :

E. By deleting the second sentence in Section 23 thereof.

The foregoing amendment is to be attached to and made part of said Group Polley.

Signed ot Washington, 0.C. this gird doy of aren 197
UNITED STATES CIVIL SERVICE COMMISSION
Colicyholder)
by Robert 2. Kasptan

(Spoce Below For Use of Metropolitan Life insurance Company Only)
Signed ct __ New York, New Yor _ this ninth day of sprit) Vm
METROPOLITAN LIFE INSURANCE COMPANY,

Nata. Heleabecke
seme

eee

Form G 1985 = 26 G (0) [P Y.. .


Cc. Requiring that Defendants Maxine Jones and Osker K. Jones settle and adjust
among themselves or, upon their failure to do so, the entry of an order of this
Court declaring to whom the Remaining Proceeds should be paid;

D. Permitting MetLife to deposit the amount of said Remaining Proceeds,
$43,053.58, plus applicable interest, into the Registry of this Court, or as this
Court otherwise directs, subject to further order of this Court;

E. Discharging MetLife from any further liability upon deposit of the
aforementioned Remaining Proceeds into the Registry of this Court, or as
otherwise directed by this Court;

F, Awarding MetLife its costs and attorneys” fees associated with this litigation; and

G. Awarding MetLife any other and further relief that this Court deems just and
proper.

METROPOLITAN LIFE INSURANCE COMPANY

By:

One of Its Attorneys

Steven P. Mandell #6183729

Catherine Van Horn #6204707

Leon E. Farbman #6269718

MANDELL MENKES & SURDYK, LLC
333 West Wacker Drive

Suite 300

Chicago, Illinois 60606

Telephone: (312) 251-1000

84747.2


ANENGHENT 39 (Continued) _
-2-

B. By substituting tor the first sentence of subsection (A) of Section 5 thereot,
the following:

“Upon recelpt by the Office of satisfactory proof, in writing, that any
Employee shall have died while Insured hereunder, the Office snail pay,
subject to the terms hereof, the amount of Lite Insurance, If any (plus
interest, If any, as determined by the Insurance Company) in force here-
under on account of such Employee In accordance with Section 4 hereot,
at the cate of his death.”

C. By substituting for the first santence of the second paragraph of subsection (B)
of said Section 5, the following:

“Benetits (plus interest, if any, a8 determined by the Insurance Company) for
loss of lite as soecitied in this subsection (B) are payable to the Beneficiary
of record of the Employee or otherwise as provided in Section ft! hereof.

0. Sy substituting for item (3) of Section 15 thereof, the tollowing:

“C3) The aggregate amounts of ai! mortality and other claim charges,

except interest charges, if any, tor the delayed payment of
death claims and accidental death claims, incurred under this
Policy from the date of Issue to the end of such policy year."

The foregoing amendment is to be attached to and made part of said Group Policy.

Signed at Washington, D.C. this thirtieth day of April 1976

WITED STATES CIVIL SESVICE COMMISSION
(Pol icynoi der)

ay Robert E. Hampton
Chairnan

(Space Below For Use of Metropolitan Lite Insurance Company Only)

Signed at Nev York, N.Y. this___ seventeenth  __ day of May. 976.

METROPOLITAN LIFE INSUPANCE COMPANY,

bul A=320Q

Denne A Coed

Sander Vice-Presicent ang Seeretary
Richard D. Zinke
(Registrar)
Form G. 1985-34 ,

GOPY .


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G becring date of August 297, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyholder)

pursuont to the Federal Employees’ Group Life Insurance Act of 1954, Is heraby omended as follows:

AMENDMENT _31

Effective February 14, 1961, by substituting for the second sentenceof the last paragraph
of Section 2 thereof, os cmended, the following:

“The insurence on any such Employee shell become effective ot the time he
eetually enters on duty on his first day ine pay status following the doze his
request for insurance is cpproved provided he acquires such @ duty ond poy
stotus effective within 31 days following the date of such approval.”

The foregoing amendment is to be attached to ond mode port of said Group Policy.

Signed at Jeshington, D.C. this Tenth day of April 19 62
sary V. Zenzel UNITED STATES CIVIL SERVICE COMMISSIO!
Witness) (Pelicyhoider) ”

wy. John 3, Macy, Jr.

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)

Signed ct _New York, New York this Trenty-etehth day of April «1962

METROPOLITAN LIFE INSURANCE COMPANY,

West. Hetbabecke

C, G. Arlingheus
Registrar)

Form G.198S-9

COPY .-


AMENOMENT 58 (Continued)

With respect to an Empicyee whose retirement occurs prior to
September 23, 1959, "basic amount of Life Insurance” means The amount
of Lite Insurance in accorcance with Part | of the Schedule of Insur-
"ance in subsection (A) of this Section based on the amount of his annual
compensation on (a) the cate nis Insurance would otnerwise have ceased
because of The happening of the event specified in eitner of Items (1)
.or (2) of the first paragraph of Section 3 hereof, or (b) his 65in birth=
day, whichever Is earlier (or in the case of any such Employee who tlest
became or again became insured hereunder efter his 65th-birtnasy, dased
on (1) the amount of his annua! compensation on the latest date he became
. Insured hereuncer, or (11) the amount of his annual compensation on his
65th birthday If the Employee was eligible to be insured hereunder on
hls 65th birthcay, whichever is the lesser); and “effective reduction
date" means the first day of the second calendar month atter his 65th

birtneay.”

The foregoing amendment is to be attached fo and made part of said
Group Policy.

Signed at _ Washingtes, D.C. this __ tvelfth day of May. 1976.

UNITED STATES CIVIL SERVICE COMMISSION
(Pot icynoicer)

By Robert_£. Bampton

Chairman
(Space Below For Use of Metropolitan Life insurance Company Only)

Signed at _ yey yore, wy. this _ syenty-rirth day of May 19.76,
METROPOLITAN LIFE INSURANCE COMPANY,

Richard D. Zinke
(Registrar)

Form G.1985-33



Civil Cover Sheet Page 1 of 2

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS

Civil Cover Sheet

This automated JS-44 conforms generally to the manual JS-44 approved by the Judicial Conference of the United States in
September 1974. The data is required for the use of the Clerk of Court for the purpose of initiating the civil docket sheet. The
information contained herein neither replaces nor supplements the filing and service of pleadings or other papers as required
by law. This form is authorized for use only in the Northern District of Illinois.

Plaintiff(s): Metropolitan Life Insurance Defendant(s):Maxine Jones, Osker K. Jones

Company
County of Residence: New York (NY) County of Residence:
Plaintiff's Atty: Steven P. Mandell Defendant's Atty:
Mandell Menkes & Surdyk
ue Y2C 499
333 W. Wacker, Suite 300,
Chicago IL 60606 :
312-251-1000 JUDGE GOTTSCHALL
IL. Basis of Jurisdiction: 3. Federal Question (U.S. not a PUY OTRATE JUDGE BOBKICK

IIL. Citizenship of Principal
Parties (Diversity Cases Only)
Plaintiff:-N/A
Defendant:-N/A

DOCKETEN

IV. Origin : 1. Original Proceeding

WL 16 2092
V. Nature of Suit: 890 Other Statutory Actions
VI.Cause of Action: Interpleader proceeding to determine proper recipient of proceeds

on life insurance policy under Federal Employer's Group Life
Insurance Act, 5 USC 8701-8716.

VII. Requested in Complaint
Class Action: No
Dollar Demand:
Jury Demand: No

VIIL. This case IS NOT a refiling of a previously dismissed case.

Signature:

Date: Sl psldx — J

httn:/Avww.ilnd uscourts.cov/PUBLIC/Forms/auto is44.cfm 7119/9002


~
~~

PE IKUPULIIAN LIFE INSURY  * LUMPANT

GROUP POLICY HO. 17000-G bearing date of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyhotder)

pursuant to chapter 87 of title 5, United States Code, Is hereby amended as follows:

AMENOMENT_57 .
Eftective January !, 1975, by adding to said Group Policy, the following:

"During the performance of this contract, the contractor agrees as follows:

(1) The contractor will not discriminate against any employee or
applicant tor employment because of physical or menta! handicap in regard
to any position for which the employee or appiicant for employment Is
qualified. The contractor agrees to take affirmstive action to employ,
advance in employment and otherwise treat qualified handicapped Individuals
without discrimination based upon their physical or mental handicap In all
employment practices such as the following: employment, upgrading,
demotion or transter; recruitment or recrultment advertising; layoff or
termination; rates of pay or other forms of compensation; and selection
tor training, including apprenticeship.

(2) The contractor agrees that If a handicapped Individual files a
complaint with the contractor that he Is not complying with the requirements
ot Section 503(a) of Titte V¥, Public Law 93-112, the Rehabilitation Act of 1973,
ewill

(a) Investigate the comptaint and take appropriate action
consistent with the rules and regulations of the
Secretary of Labor in 20 CFR Ch VI, Part 741.29
and

(b) maintain on file for three years, the record regarding
the complaint and the actions taken.

(3) The contractor agrees that If a handicapped individual tiles a
complaint with the Department of Labor that he has not complied with the re-
quirements of Section 503(a) of Title ¥, Public Law 93-112, the Rehabl I itation
Act of 1973, he will

(a) cooperate with the Oepartment in Its Investigation of
the compiaint, and

(bd) provide all pertinent Information regarding his
employment practices with respect to the handicapped,

Form 6, 1985-32 CG 0) [Pp Y -


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 29, 1954, and isved to
UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyhalder)
pursvent to the Federai Employees’ Group Life Insurance Act of 1954, is hereby omendedas follows:

AMENDMENT _15

Effective for the policy year commencing November 30, 1958, by substituting for the figure
0.4%" in item (b) of the “Schedule of Maximum Expense ond Risk Charges" In Section 15 thereof
"0.5%". This substitution shall remain In effect for subsequent policy yeors subject to
ermination as provided in said Section 15, ond subject to the following poragroph.

If a besic premium rate or tentative average premium rate shall be reduced for any policy
yeor in accordance with Section I4 thereof, the said figure shall cutomaticaily revert to “0.6%"
for that policy yecr, unless the Policyholder ond the Insurence Compeny ogree to the use of the
figure “0.5%" or of tome intermediate figure for that policy year, or unless the Policyholder shell
hove given written notice to the Insurance Company in cecordence with said Section |5 at least
one yeor in edvance of the beginning of such policy year of « different Maximum Risk Charge to
be applicable to that policy year.

The foregoing amendment is to be ottached to ond made part of scid Group Policy.

Signed at Washington, D.C. this 2ktn day of | June 19 58
z. uin UNITED STATES CIVIL SERVICE COMMISSION
(Witness) (Poltcyholder)

By Barris Ellsvorth

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)

Signed ct Mev York, New York this lots dey of July 19 58

METROPOLITAN LIFE INSURANCE COMPANY,

Form G 1985-3


“22
AMENDMENT 43° (Continued)

SCHEDULE OF MINIMUM INSTALMENT PAYMENTS
PER $1,000 OF INSURANC3

Minimum Amount of Minimum Amount of
Number of Yeer: Each Annus! instalment Eoch Monthly Instalmen?
Specified {Per $1,000 of insurance) (Per 31,000 of Insyronca)
’ o- $84.19
2 $905.61 42.56
3 340.84 28.69
4 258.39 21.735
Ss 208.97 17.59
” 110.37 9.29
15 77.38 6.53
yr.) 61.30 . 5.16

The Insurance Company shall have the right to change, os of eny
renewal of this Polley or whenever the terms of this Polley are changed,
the Schedule of Minimum instalment Poyments, but ony such change shell
not be opplicatie to Instalments payable on occount of deaths occurring
prior to the effective dote of such change.

If the payes of ony optional! mode of settlement to elected dies
before ail instolments for the period selected have been paid, the
uapald instalments shall, unless otherwise specified In the election
of such instalment payments, be commuted and pold In one sum to the
estate of such poyee. Such commuted sum shall be calculated on the
besls of the amount of the instalment payable on or immediately price
to the date of death of the payee ond the Interest rate auumed In
determining such amount.

A mode. of settlement other than one of those specified above mey
be arranged if the Beneficiary or other person entitled to receive poyment
of amounts due at the death of the Employee, after the death of the Em=-
ployee, ond the Office mutvally ogree thereon. information conceming
auch other possible modes of settiement will be furnished by the Office

upon written request,

No Irstalment election shall be allowed under which the fint
Inatelment peyment Is less than $20.00. :

Form G.1935-18


AMENCMENT $32. (Continued)

‘The Dl-weekly basic Life Insurance prenium rate for a temele lite Is 60%
of the Dieweekiy basic Lite Insurance presiia rate specified above tor s mle
tite. ~ .

In computing the everage basic bi-weekly Life Insurance preniua rate
purrusnt to Sectien 14 herect there stall be added to the average basic
bieweekly Life Insurance oremium cetermined en the basis of the premiums
Shown above an acount equsl te $2.40 diviced sy the total amount of Lite
Insurance In force uncer this Pelley cn the cate of such commutation exe
pressed In thousands and fracticns theroot.

‘The bi-weekly basic premium rate for Insurance for Death or Olsmenderment
by Accidental Means shell be 50.0231 per $1,090 of the full amount of such
Insurance."

The foregoing Schedules of Basic Premium Rates shal} remain tn eftect for
policy yeers subsaquent to the colicy vear cesnencing July ty 1972 subject to further
Peadiustront as previiad in subsection (4) of Section 14 of said Group Policy.

The foregoing amendment Is to be attached to and mace pert of said Group Policy.

Stgnad at Washington, 0. ©. this Lith day of October 19 72,

. UNITED STATES Orie SERVICE COMSISSICN
(Policynoicer)

By ___ Robert £. Faxpton

{Space Bolow For Use of Metropolitan Lite Insurance Cezgany Caly)

Slgned at __Nev York, N.Y. — gig _3txteenth day of Noveaber 19 72

METROPOLITAN LITE INSURANCE CCMPANT,

heed Ox

Donald A. Udull
Myton Scehhetcor Vice-Prosidunt aad Secretary

(Registrar >

Fore Colunsea7 G 0) [P Y *



METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 29, 1954 and issued to

UNITED STATES CIVIL SERVICE COMMISSION

(wungin CALLED THE POLICY motDEE)

pursuant to the Federal Employees’ Group Life Insurance Act of 1954, is hereby amended as follows:

AMENDMENT 21

Effective May 18, 1959, by substituting “25 East 24th Street,
New York 10, N.Y." for “330 Fourth Avenue, New York 10,
N. ¥." as the post office address of the Office of Federal Em-
ployees’ Group Life Insurance appearing in the third paragraph of
Section | thereof, as amended.

AMENDMENT 22

Effective September 23. 1959, by substituting “1S years of
creditable service in the case of an Employee whose retirement
occurs prior to September 23, 1959, or 12 years of creditable
service in the case of an Employee whose retirement occurs on or
ater September 23. 199,” for “15 years of creditable service,” in
the first sentence in item (A) of the second paragraph of Section 3
thereof, as amended, and in item (4) of the second paragraph of
Seetion 13 thereof, as amended.

AMENDMENT 3
Effective September 23, 1989, by substiruting for the second
sentence in item (A) of the second paragraph of Section 3 thereof,
as amended, the following:
“The amount of his Life Insurance continued or reinstated as
aioresaid shall be in accordance with Section + hereol.”

AMENDMENT 26

Effective September 23, 1999, by substituting for Section +
thereof, as amended, the following:

“Section 4. AMOUNT OF INSURANCE.—(A) appliceble
Prior to the Employee's Retirement:-—The amount of insurance
hereunder oa any Employes shall be in accordance with the
Schedule set forth below. Any increase or decrease in the amount
of such insurance due to change in annual compensation, in
accordance with said Schedule, shail become effective (1) on the
stated effective date of change in the Employee's anmual com
pensation or the date such change in anaual compensation is
approved, whichever date is later, or (2) on the effective date
of the change when a retroactive adjustment is actually the
correction of an error, uniess otherwise stipulated in a law
providing for the change.

Form 6.

Sea.

SCHEDULE OF INSURANCE

Serva Compre ee
Lile

Inserance tor
Death or Die

C] $1,000 $1.0 $1,000 .
$2,000 2.000 2,000 2.
2,000 3,000 3.000 3.000
3.000 4,000 4.000 4.00)
4,000 $000 5.000 §
5.000 6,000 6,00) 6.000
6,000 7,000 7,000 7
7,000 8.000 8,000
8,000 9.000 9.009 9.000
9,000 10,000 10,902 10,000
10.000 11.000 11.000
11,000 12,000 2.000 12,000
12,000 13,000 13,000 13.000
13.000 14.000 14,000 14.000
18,000 15.000 1$,000 15,000
15,000 16,000 16.000 16.00)
16,000 17,000 17,000 17,000
17,000 18,000 18.000 18.000
18.000 19,000 19.000 19.000
19,000 — 20,000 2,000

(B) Applicable after the Emplosee's Retirement: —The
amount of Life Insurance hereunder on any Employee after
Tetirement shall be the basic amount of Lile Insurance reduced
by 2% thereof each month beginning with the effective reduction
date, subject to a minimum amount of Life Insurance after
retirement of 23% of the basic amount of Life Insurance, The
terms ‘basic amount of Life Insurance’ and ‘effective reduction
dese’ are defined im che folowing paragraph of this ruberction
(B).

With respect to an Employee whose retirement occurd on or
after Sepcember 23, 1959, ‘basic amount of Life Insurance’ means
the amount of Life Insurance in sccordance with the Schedule of
Insurance in subsection (A) of this Section based on the ainsunt
of his annual compensation on the date his insurance would
otherwise have ceased because of the happening of the event
specified in either of items (1) of (2) of the first paragraph
of Section 3 hereof; and ‘effective reduction date’ means the
fire: day of the second calendar month after (1) such date, or
(2) his 65th birthday, whichever is later.


Fill in Parts D and E only if you are not the designated beneficiary or the widow or widower of the deceased.

Part D. Information C

(a) Widow or widower,

(b) If there is no surviving widow or widower, list the child
or children of all the deceased’s marriages (include
adopted or illegitimate children, stating relationship)

‘oncerning Next of Kin of.the Deceased
7 FU

(c) If there are no children, list the parents; if one or both
parents are deceased, so state and give the date of death;

(d) If there are no survivors as indicated in (a) through (c), list
the next of kin who may be capable of inheriting from the
deceased (brothers, sisters, descendants of deceased

and the descendants of any deceased child or children;

brothers, sisters, etc.),

Relationship to

Name the deceased

Age

Full address

(ER KWoves 133 | Sap

alo CHican AYE gpl 2H

oak Park Thea b7302-

Bemanin’ ADD

)4a0_& Mal v2

ehw AL LIC

Fill in items 2 and 3 only if any of the persons listed above are under age 18.

uv

2. Ifa guardian has been appointed by the court for | Name

the estate of any minor children above, give the

3. If a guardian for the
estate of any minor

name and address of the guardian and attach a
copy of the appointment papers issued by the

children has not been

court. Natural parentage or custody as a result
of a divorce does not constitute guardianship.

di . nO.
Address (Number, street, apt. no.) appointed, will one be
appointed?
City, state, ZIP code
Yes No

Part E. Information Concerning the Estate of the Deceased

1, Ifan executor or administrator has | Name

been appointed by the court to

Nove

Nv

If an executor or
administrator has not

settle the estate of the deceased,
give his/her name and address and

Address (Number, street, apt. no.)

been appointed, will one

attach a copy of the court
appointment papers.

City, state, ZIP code

be one (Aro)
1 No

‘ Yes

Part F. Certification by the Claimant

Aye you claiming accidental means death benefits (injuries sustained solely through violent, external, and accidental means)? If
“Yes”, submit coroner’s and police reports, news clippings, and any other available reports concerning the accident.
OFEGLI cannot consider a claim for such benefits if the date of the deceased’s separation or retirement is

prior to the date injuries were sustained which caused the death of the deceased. Yes yr No
Backup Withholding _Has the IRS notified you that you are subject to backup withholding of
as a result of a failure to report all interest or dividends? Yes No
If the amount payable to you is less than $7,500, OFEGLI will issue Please be sure to also complete the Date (mm/dd/yyyy)
payment by a single check. information requested on page 2 OY.
under “Special Note” ~O G-of

If the amount payable to you is $7,500 or more, OFEGLI will open a
Money Market Option Account—as described on page 2—in your name,
giving you complete control of and immediate access to all of your funds.
You may write checks for all or part of the money in your Account when
you receive your checkbook.

wok.
,

Your name re tat)

OS&e eC

Thereby certify under the penalties of perjury that all statements made in
this claim are true, correct and complete to the best of my knowledge,
information, and belief, and that no evidence necessary to settle this claim

Address (Ni r, street, apt, no,
Bie Chee Me Apt 24

City, state, ZIP codé

is suppressed or withheld.
3i5 | n} e2//5|3|a1Y

Your Social Security Number
OR

§|3

CRPARK AD 603 0

Daytime telephone no. Evening telephone no.

Employer identification number - -

473) 6U9- $0} | (7B) SER S33Y

Area Code Area Code

Warning—Any materially false, fictitious or fraudulent statement or representation which is knowingly and willfully made or any concealment of

a material fact which is related to the requests for information required herein is
imprisonment for not more than five years, or both.

Page 4

punishable under 18 U.S.C. Statute 1001 by a monetary fine or

Form FE-6
Revised January (999
OFEGLI Form in Adobe Acrobat PDF (1/99)


SMENSYENT 64 (Continued)

“PART 223 - SCHEDULE CF BASIC INSURANCE, EXCLUSIVE OF OPTION A = STSMDARD LNSURANCE
AND OPT:

X 3B = ADDITIONAL LIFZ INSURANCE, ON AND ATTER FIRST DaY OF FURST PAY
CZ 3EGINS ON OR AFTER OCTOBER 1, 1981 :

Basic Insurance for Death or

Basic tile Issurasce Dissembersent by Accidental Meass
@ azouss of the Esployee's Basic Lite The amount of the Explovee's Jasic
sce shall Se detercised as follows: lasurance for Death or Disnez-
(2) lovees age 45 and berwent by Accidental Meass
AS amous: equal to the sum of (a) $2,000 shall be an amount equal co
ané (3) e Esployee's acsual Compensa~ the sus of (2) $2,000, and. ©
tion® (as fixed dy law cz regulation). (b) the Exployee's annual -

Such anount of Sasic Life Insurasce shall Compensation® (as fixed by

de subject to (4) a minimum amounts of Life lav or regulation). Such

Issurance of $10,000, and (41) a Bax~ azount of Basic Insurance for Death
imum amount of Basic Life Insurance equal oz Dismemberment by Accidental

te the Annual Compensatios* rate for posi- Means shall be subject to

tious at Level II of the Executive (4) a miniaum amoust of Basic In
Schedule under section 5313 of title 5, surance for Death or Disuembernest
United $ Code, a8 in effect from by Accidental Means of $10,000,
tipe to time, plus $2,000. and (24) a maximum azount of Basic
Insurance for Beach or Diszer-

{2) Exolovees age 44 and Under (See Note) bermess by Accidestal Means
. tbe amouns of the E=ployee's Sasic Lite equal to the Annusl Conpensa-
Tssurance shall be an amous: desersined tion* rate for positions at
ic accordance wirh (1) above, culsiplied Level IZ of the Execucive

de

by she spplisable facz
from the following Table:

ined Schedule under section ‘5323 of
title 5, United States Code, as
dn affect from tise to tine,

Table plus $2,000.

age of age of
E=sloyee Factor Encloyee Factor
35 and under 2.0 40 1.5
. 36 1.9 4l 1.4

37 2.8 42 1.3

38 1.7 43 1.2

39 1.6 oe 1.2

Fora ¢.1985-39


o3-

AMENDMENT 46 (Continued)

If an Employee, on the date his optional Insurence would otherwise
become effective, ls nat insured for insurance exclusive of optional Insurance,
then such Employee shall not be Insured for optional Imsyronce yatll such time
as he becomes Insured for Insurence exclusive of optional insurones.*

E. By deleting the word “continuous” from Stem (2) In the frst parogroph of Section 3
thereof.

F. By odding the words “other thon os specified In the third porograph of said Section $
with respect to optional Life Insurance, ” Immediately after the words “does not exercise his right to
have on individual policy issued to him In oceordence with Section 6 hereof," appearing In the first
sentence of the second paragraph of sald Section 3.

4
G.. By substituting “work Injury” for "disecse or Injury to himself” In the fint sentence
in Item (8) of the second perograph of sald Section 3. -

H. By substituting for the second sentence In Item (8) of the second parogroph of said
Section 3, the following:

“The amount of his Life Insurance continued or reinstated as oforescld
shall be the amount of Life insurance, exclusive of optional Life n=
surance, for which he would heve been insured hereunder hed his
sclary peyments continued at the same rate a: on the dete Insurance
would otherwhe hove ceased, and, In eddition, so much of the amount
of optional Life Insurance In force on his account on such date which
hed been In force for not less than

{s} the full pertod or perlods of service during which
optional Insurance was avaliable to him, of

(b) the twelve year of service immediately preceding
such date ond during which the eptional insuronce was
evalichle.to him,

whichever Is shorter.”

1. By edding fo said Section 3, the following paragraph

"The optional Insurance hereunder on any Employee shell gutomatlcally
cease, In ony event, on the lest day of the pay period during which elther (0)
his employing office receives written notice from him that his optional insurence
is to be conceled, or (b) his employing office determines that his periodic pey,
ennuity, or compensation for work injury Is Insuffictent to cover his required
contributions to the cost of such Insurance .* if

J. By substituting for the heading to the schedule In subsection {A) of Section 4 thereof,
the following:

Form G.1985-2)


SetENT 64 (Continued)

£. By addizg immediasely after Pare IIl of the Schedule cS Insurance in saic
subdsaction (A) of said Section 4, the following: +

“PART IV - SCHEDULE OF OPTION A ~ STANDARD INSTRANCE ON AND AFTER FIRST DaY oF
FIRST PAY PERIOD WELCH YECINS ON OR AFTER APRIL i, 1981

e@ Exployee's Option A-- Stancard Lite Insuracce’ and the amoun:
e's Option A - Standard tnsurance for Death or Disme=bermest by
the greater of (a) $10,000, or (b) the excess, if any, of
slovyee's Acnual Cozpensasica (if not a mulsiple of $21,001!
Compensation shall be saken to che next lower sulsiple of $1,00
urance oz she asount of Basic Insurasce £
espectively, in accordance with

The anoust of
of the isp)
accidental
she asou:

Pars, IZA above.

PART Tv =

Day OF FR

SEQULE CF OPTICN 3 = ASDITICNAL LIFE INSURANCE CN AND AFTER FiRsT
T PAY PERIOD WEICE ZEGINS ON OR AFTER aPAIL 1, 198)

apoust of Option 2 = Additional Lite asurance shall de an’ anount
ed in aceordance with Opsion 1, Opeion 2, Option 3, Oprion 4 or Option
3, elected ty the fzployee. :

. . Azoust of Optter 3 ~ Additional
Option Lise Insurance

tines the Exployee's annual compensacion
tises the Esploy annual compensation
tises the Enployee's sasual compensations
tines the Esployee's annual compensatios
tines the Enployee's annual compensation

Grune
weune

‘The saximum Annual Conpensacion to be used is the Asaual Compensstion rate for
positions at Level IZ of the Zxecuzive Schedule under Section 5313 of ticle 5,
Uniced States Code, as in effect from tine to tine. If annual Cospensation is
not a sulsisie of $1,000 tc shall be taken to the next higher. cultiple of
£1,000 for she purpose of this provision.

conditions under which as Eaplovee tay acquire Cption B - Additional Lite
ance in addition to Opsion 4 = Standard Life Insurance or change che
on he/she has elected shall be deterzined is accordance with regulations of
Policyholder promulgated pursuant to chapter 87 of title 5, United States
Codes”

fF. .By substituting for the heading to ‘subsection (3) of said Section a, the
fcllowing:

“(2) Applicable afcer the faployee's Resirenent or Eacitlemenc to Senefizs
Under Subchapter 1 of Chapeer. 6] of Title 5, United States Code:

1. With Respect to aa F=vlovee whose resirement or entitlement to benefits
under Subchaptar 1 of Chapter §1 of Title §, United States Code occurs

pricr to Apri] 1, 1981- (nr
. WD a
Fors 6.2985-39 (C J) 2



AMENSMENT_ 56 {Coari ave)

For tne purposes hereot, in the case of The cessation of the tora!
amount of an Employee's Lite insurance hereuncer, te snount ot

lite insurance issued under any such individual policy which Is
artriputacie to an Emicyes's optional Lite insurance hereuncer Is
the excess, If any, of the amount of Iifte insurance under such
individual policy over tne amount of the Employee's Life insurance
exclusive of optional Life Insurance on The date of such cessation,”

The foregoing amancment is to be attached to and made part of said Group Policy.

Signed at washington, 0. C. this 2th day of June 1
UNITED STATES CrviL SERVICE COMMISSION
(Poti cynolcer)
ay ROBERT. RAMPTOW

(Space delow For Use of ‘etropolitan Life insurance Company Only)

Signed at New York, New York this 12th Gay of ne 1973

METROPOLITAN LIFE INSURANCE COMPANY ;

Bel Q=3200

Conag A Coen
Richard D. 2inks Serer Viea Presider ana Secreitry

Registrar)

Form G. 1985-3) G ® P Y


$4 (Continued)

By addizg to said subsecsion (3) of said Section 4, the followiag:

"2. Wish Resvecs to as
Sudcnapter 1 cf Cra
2. 238i

pleyee whose recirenen: or entiétiement co benefics
Coa ec Staszes Coce occurs ca or

The asount of (1) Basic Lite Insurance, exclusive of Option 4 - Scandasd Life
iasurance and Option 3 = adcicional Life insurance; (2) Option & = Stand,
lige Insurance; and (3) Opetos 3 ~ Additional Life Iasurance, if any,
at acy tine afte: & oF entizlenent to benefics under sudchapter 1 of
chap 5, ¢ States Code shall be sepazazely detercined, as
hereinafcer specified.

peans the first day of the second calendar conch
Lite Insurance vould otherwise bave ceased because
of the happenisg cf che event specified in either of items (1) or (2) of the
first paragzaph of Section 3 herec#, or (2) his/her 65cb bisthéay, whichever
occurs larer. .

The amount of Basic Life Insurance hereunder on any E=plovee after retirenent
or ensislenens to bene? uncer subchapter 1 of chapter @1 of title 5, United
States Code shall be decezcined ia accordance’ vith Fleerios i, Election 2, or
Elecsion 3 as elected by the Esplo; .

Election 1 .

The Exployee cay elecs to have such amount of Basic Life Insurance reduced by
25 thereof each month beginning with the effective reductios eate, subject to a
einisum amount of 3asic Lite Jasurance after retirement or entitlement to
benefits under subchapter 1 of chaprer 82 of title $, United States Code of 252

‘od she amount of Basic Life Insurance.

Flection 2 .

The E=ployee may elect to have such amount of Basic life Insurance reduced by
1s thereos each month beginring with the effective reduction dat bject to a
Rinimum amount of Basic Life Insurance after retirement or enzitlement to
dbenesits under subchapter 1 of chapter 81 of title 3, Unttead States Code of 502,
of the amount of Basic Life Insurance. .

Election 3

Toe Exployee nay elect to have such amount of asic Life Insurance continued io
full after retirement or extitlement to benefits under subchapter 1 of chapter
81 of title 5, Taited States Code.

Fora 6.1985=39


__ Bas & the a unde. bs gonad andl coarch

| 4 Lure cet oe Lamitelln...

laste ae

_ PE haa. chads Bhan eka:
| eet gee Lot

Praipine ties Lot dh. ACo/ 14324



18/26/2881 19:42 17736261522 DELORES WILLIAMS PAGE a1
DET Z5~8Ll O9F51 PM LPMILLIPS 3 773 76S 3226 P02

FAX COVER SHEET

DATE OF FAX: = October 26, 2001- PAXH: 201-395-7950
SENT TO: Mr. George Vieglemann, Case Management Specialist

ADDRESS: Office of Federal Employees Group Life Insurance
P. 0. Box 2627, Jersey City, New Jersey 07303-2627

TELEPHONE #: 1-800-633-4842 or 201-395-7990

RE: Deceased employee - Mr. Osker Jones
Case # 20010705945 CSA # A3788243

FROM: Mr. Osker K. Jones
312 Chicago Avenue, Unit 2-H
Oak Park, Ulinols 86832 GO302
TEL #: 708-763-0813

REMARKS:

NUMBER OP PAGES FAXED INCLUDING THIS COVER SHEGT:

EXHIBIT

I ¢


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 29, 1954 ond Issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein coiled the Policyhoider)

pursuant to the Federal Employees’ Group Life Insurance Act of 1954, Is hereby omended os follows:

AMENDMENT 35
Effective July 13, 1962,

A. By adding immediately after the words “Items (1), (2), G)e or (4) of the first poragraph of
Section 3 hereof," in the first parogroph of Section 6 thereof, the following:

“and who shall not, within three colendor days next following the date of such
cessation, return too pasition in which he is on Employee as defined in Sec~
tlon | hereof, ".

8. By substituting for the words “the maximum amount of Life Insurance for which on ine
dividual policy could have been Issued under this Section 6,” in the first sentence of the second pare=
graph of Section 6 thereof, the following:

“on amount equal to the amount of the Employee's Life Insurance hereunder on the
date of such cessation, ".

The foregoing amendment Is to be attached to ond made part of said Group Policy.

Signed at __Weshington, D.C. this 3x day of October 19 62
Mary V. venzel UNITED STATES CIVIL SERVICE COMMISSION
Wines) VWolicyholder)
By. Jobs W. Macy, Jr.

(Space Below For Use of Metropolitan Life Insurance Company Only)

Signed ot Nev York, N.Y. this Sth day of October 19 62

METROPOLITAN LIFE INSURANCE COMPANY,

' Mew €. Hstiabecke

©. G. Arlinghaus -

Form Gumsas G @ P Y “



a9

Sortion 7. NOTICE AND PROOF OF CLAIMS FOR
SURANCE FOR DEATH OR DISMEMBERMENT BY AC+
CIDENTAL MEANS.—(A) Written notice of lass on which
claim may be based must be given to the (fice within twenty days
‘aber the date of the accident causing such less, Pruuf uf such kn
must be furnished to the Office not later than ninety days after the
slate of such loss.

The Office. un receipt of the notice required by this Policy.
will furnish such forms as are usually furnished by it for fling
proofs of claim. If such forms are not recevved by the claimant
within fifteen days after the Office rectives such notice. the claim
ant shall be deemed ty have complied with the requirements of this
Poliey as to proof af claim upon submitting. within the time fixed!
in the Policy ior filing prools of claim. written proof covering the
uccurrence, character and extent of the loss for which claim is male,

Failure to furnish notice of proof within the time jwovided in
this Policy shall nox invalidate nor reriuce any claim if it shall be
shown not ty have been reasonably possible to furnish such notice
of proof and that such notice ut prow! was furnished as sion as was
reasonably possibile,

(B) The Office shall have the right and opporrunity to have
physician designated ly it examine the person of the Employee when
and 40 often as it may reasonably require during the pendency of
claim, hereunder, anil alsa the right and opportuniry to have an
autopry made in case uf death, where it is not forbidden by law,

(C) Neo action at law or in equity shall be brought to recover on
thin Policy prior to the expiration of sixry days after proof of claim
‘has been filed in accordance wth the requirements of this Policy,
wer shall such action be brought at all unless brought within two
years from the expiration of the nme within which proof of claim
is required hy the Policy,

Svetion 2, ENTIRE CONTRACT: INCONTESTABILITY.
—This Pulicy and the application of the Policyholder, a copy of
which is amachedl hereto, constitute the entire contract berween the
varie,

‘The validity of this Policy shall mot be contested, except for non-
payment of premiums, after it baa been in foree for two years from
its daze of issue, No seatement made by any Employee insured here-
under relatinr to his imsurability shall be used ia contesting the
Validity of the insurance with respect to which such statement was
made after such insurance has been in force prior to the contest for
a periul of two years during sock Employee's lifetime nor unless it
jx contained in a written instrument signed by him.

ment made by any insured Employer shall be wed in any coovest
‘unless a copy of the instrument containing the statement is or has
been furnished w such Employee or hia Beneficiary of to such other
person ty whum henetite may be payable as provided in Section I

(4)

Section 9. AGENTS : ALTERATIONS.—Nu Agent of the in-
surance Company is autborued to alter or amend this lolicy,
accept premiums in arrears or to extend the due dare uf any pre
mium. to waive any nutice or proof uf claim reyuired ly this Policy.
of to extend the date before which any such noice of proof must he
submninned, :

No change in this Policy shall be valid unless evidenced hy
amendment hereto signed by the Policyholder and by the Insurance
Company.

Section 10. CERTIFICATES.—The Office will provide the
Policyholder with certificates, for delivery to each Employee in
sured hereunder, secting forth the benefits to whch such Employee
in ensitied under this Policy, to wham such benefits are payable, us
whom notice snd proof of claim should be sulmnitted and sun
murizing the provisions of this Policy prinerpally atfecting the
Employee.

Hie BENSEICIARIES—>

y dexignaie a Beneficiary and may, {rom time to time.
igmation of beneficiary, only by filing written notice
witnessed, with his employing office or. in the

Somele- Sahone-

SEE AMEND. 9, ty, 49

of the Employve and shall be effective as of
said written notice, Any

If, at the death of any Employee insured hereunder. there shall
be more thaa one designated Beneficiary, then, unless such Em-
ployee shall have specified the respective interests of such Hene-
Seiaries, the interests of such Beneficiaries shall be several andi
sont Uf any devignaud Beneficiary shall predeease the Emplovee
the rights and interes of such Benedciary shall thereupon auto-
matically terminaze. If, at the death of the Employee, there be ov
designated Beneficiary a3 to all or any part of the insurance, thm
the amount of the insurance payable for which there is no devig-
nated BeneAciary shall be payable to the person or persons lined

Form G.198S
Aug. 1956


Office of Federal Employees’
Group Life Insurance
P.O. Box 2627

Claim for Death Benefits

—
FEGLI Federal Employees’ Group Life Insurance Program |

Read the instructions carefully
before filling out this form.

Part A. Information About the Deceased (Everyone must complete this part.)

I. Deceased’s full name

“love S$

(Last)

OSKE R.

(First) (Middle)

2. Date of birth (mm/dd/yyyy)

07 -/G-39

3.

Date of death (mm/dd/yyyy)

O1-5-o/

4. Social seouiy Number

334- 30-9996

5. Legal yesidence Wii jing of of depth —(City and state)

1927 5

its Poste! CHgd. TLL “40623

6. De r inwl " 7. Location of last employment (City, state,

inching oueau eration OAR9 J | SEAT CA ae of ast ejeenan * (City, state, ZIP code)
North Sobur Ban Paoc/ Dist Ls eS ice FIFE

8. At the time of death was the deceased:

(a) Retired and receiving monthly annuity under any Federal
civilian retirement system
Yes [ noQ

(b) Receiving Federal Workers’ Compensation benefits?

yes No () Unknown ()

Unknown

If “Yes” to either 8(a) or 8(b), please
complete boxes 8(c) and 8(d) to the
Tight.

©

379-8243

‘Claim number (CS4, CSE CSI)

(@) Effective date of Federal Workers"

Compensation benefits (mm/dd/yyyy)

Mandi

Part B. Information About the Deceased’s Family (Skip this part if you are a designated beneficiary.)

1, How many times was the | 2. Give the name of each spouse

deceased married?

3. How did the marriage end?

4, When did the marriage end?

(include ALL marriages) (Check one in each case) (mm/ddlyyyy)
Death Divorce
Death Divorce
Death Divorce

5. Did the deceased have any living children on the date of his/her death? |

6. Did the deceased have any children who died before the date of his/her death?

Yes No If'Yes, how many? yesQ) no If Yes, how many?
Part C. Information About You
1. Yourname (Last) (Firs) (Midale) 2, Your relationship to the deceased | 3. Your date of birth (mm/ddiyyyy)
Towes C&R Kev eo SOA Of-O/- EF

Complete Items 4 through 13 only if you are the deceased’s widow or widower.

4, Date of marriage (mm/dd/yy) 5. Place of marriage (City and state)

6. Marriage was performed by:

Clergy or Justice of the Peace
Other (specify)

7. Were you living with the 8. Were you divorced from the deceased

9. If you were divorced from the deceased, give the date (mm/dd/yyyy)

deceased at the time of death? at the time of death? and place of the divorce.
Yes No Yes No
10. How many times were It, Give the name of each spouse 12. How did the marriage end? 13. When did the marriage end?
you married? (include ALL marriages) (Check one in each case) (mmidd/yyyy)
|

Death Divoree
Death Divorce
Death Divorce

(continued on

Do not use previous editions

the other side)

Page 3

Form FE-6
Revised April 2001
OPEGLI Form in Adobe Acrobat PDF (04/01)


UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS

In the Matter of
METROPOLITAN LIFE INSURANCE COMPANY
v.

MAXINE JONES and OSKER JONES

ose 495 5

APPEARANCES ARE HEREBY FILED BY THE UNDERSIGNED AS ATTORNEY(S) FOR:

METROPOLITAN LIFE INSURANCE COMPANY

ATTORLIRT:

JUDGE

MAGISTRATE JUDGE BORN

@)

7 @)
ee Man~ LP Thanrdilh

=a «En

NAME Steven P. Mandell

Name Catherine A. Van Horn

"RM Mandell Menkes & Surdyk, LLC

"RM Mandell Menkes & Surdyk, LLC

STREET ADDRESS 333 W, Wacker, Suite 300

STREET ADDRESS 333 W, Wacker, Suite 300

orvstareraie Chicago, IL 60606

citystateziP Chicago, IL 60606

‘TELEPHONE NUMBER 312/251-1000 FAX NUMBER3 1 2/251-1010

TELEPHONE NUMBER 312/251-1000 FAXNUMBER3 1979511010

E-MAIL ADDRESS

E-MAIL ADDRESS

SDENTIFICATION NUMBER (SEE ITEM 4 ON REVERSE) 6 1 833729

IDENTIFICATION NUMBER (SEE ITEM 4 ON REVERSE) 6204707

MEMBER OF TRIAL BAR? ‘YES wf NO. o ‘MEMBER OF TRIAL BAR? YES oe xno
‘TRIAL ATTORNEY? yes [] NO ‘TRIAL ATTORNEY? YES i no [J
DESIGNATED AS LOCAL COUNSEL? ys wo

AN ©

@)

i oA ‘SIGNATURE
Name Leon E. Farbman MMe _ DOCKETFA
PM Mandell Menkes & Surdyk, LLC new JUL 1 6 2002
. STREET ADDRESS
STREET ADDRESS 333 W. Wacker, Suite 300
CITY/STATE/ZIP

crrvstatezi? Chicago, IL 60606

TELEPHONE NUMBER 312/251-1000 raxnumper3 12/251-1010

TELEPHONE NUMBER

E-MAIL ADDRESS:

E-MAIL ADDRESS

IDENTIFICATION NUMBER (SEE ITEM 4 ON REVERSE) 6969718

IDENTIFICATION NUMBER (SEE ITEM 4 ON REVERSE) y £)

MEMBER OF TRIAL BAR? vs Qo xo MEMBER OF TRIAL BAR? vs /Q wo /Q
\

‘TRIAL ATTORNEY? ves [] of ‘TRIAL ATTORNEY? \= o Wa a

DESIGNATED AS LOCAL COUNSEL? yes NO DESIGNATED AS LOCAL COUNSEL? \e Oo no 1



-5-
AMENDMENT 46 (Continued)

K By odding ot the end of the fint perograph of subsection (8) of said Section 4, the
following sentence:

"In the cose of on Employee whose retirement occurs on or after
December 16, 1967, the anount of Life Insurance at ony time
iter retirement shall be seporctely determined, os hereinofter
specified, in respect of (1) Life Insurance exclusive of optional
Life Insuronce, and (2) optional Life Insurance, if any.”

L, By odding ofter the first parograph of subsection (8) of said Section 4, the following
porographs:

“With respect to on Employee whose retirement occurs on or after
December 16, 1967, ‘basic amount of Life insurance’ means, os to Life
Insuronce exclusive of optional Life Insuronee, the amount of Life insur
ence in cecordence with Part {I of the Schedule of Insuronce in subsection
{A) of this Section based on the amount of his cnnvol compegsation on the
dote his insuronce would otherwise hove ceased becouse of the hoppening
of the uvent specified in either of items (1) of (2) of the first poragroph of
Section 3 hereof; and ‘effective reduction date’ means the first day of the
second cclendar month after (1) such date, or (2) his 65th birthday, which=
ever is later, The basic amount of Life Insurance for the purposes of this
perogroph shal! be determined @ set forth cbave without regard to the
specifications in Port I of the Schedule of Insurance in subsection (A) of
this Section relating to the period for which such schedule is effective.

With respect to on Employee whose retirement occurs on or citer
Februcry 14, 1968, ‘basic amount of Life Insurance’ means, a3 to optional
Life Insuronce, 10 much of the amount of optional Life Insurence in force
‘on his cecount on the date his insurance would otherwise hove ceaed be~
cause of the happening of the event specified in either of items (1) or (2)
of the first paragraph of 5ection 3 hereof, in occordance with Pert lil of
the Schedule of insuronce in subsection (A) of this Section, which hod
been in force for not less thon

(0) the full period or periods of service during which
optional insurance wos avoiloble to him, of

) the twelve yeors of service immedictely preceding
such date ond during which the optional insurance was
evailoble to him,

whichever is shorter. For the purposes of this perogroph, in the case of
an Employee who was on the roll of his emplaying office on February 14,
1968 ond whe wes insured for optional insurance on April 14, 1968 oF the
dote of his retirement, if earlier, such optional insurance shall be deemed
to heve been in force for the full period or pariods of service during which
optional insurance was available to him prier to such eorller dote. If the
Policyholder receives written notice from the Employee that optional Life

Form G .198S-21


~

SEE AMEND, 42, 44, 46, 49

ment he nade for death ut sity other lems which is:

ab

camel wholly or peartly. directly ar mclirect
Innlily of mental antiry
ment UF diggin theres

cattsed wholly oe part!

except unly septic iniection of and
thrnugh a vine woondl sustane viely thraugh violent.

external aml accidental aveans. of
hy hema, ne

including, lait not linuterd te, any war deviared oF
meiunived aggressions resisted by the armed
y COUNT) imedanonal veganization. af cone

tied int the s

the Ks

i the pproai,spevition in the provetling paragraph 4
CD and of ga is

fp as sjavified in this wlmevtwn (1) are
vor of otherwise
led in Sevtwan HE hereui, Benetite iur all nther lmsex apeci=
eelule si Lasees of this subsevtion (11) are payable 1
ev. These henttite will be paid inmediately alter receipt
> atibnection:
nt is cutie t0 such payment.

that the els

SEE AMEND. 3, 44

payable 33 provicted! in this sulecti

Larsa of One Land ly severanee at of

the full amuunt

The full anvamt of Insurance for Death »
dental Mea

Dixmembennent by
vec at the date
1 accordance with Section + hereuf, shall be pays
sored itt this silsectuns CR) if the Employee suiTers any

hy severance at ut aluive ankie-joi
anid oof Oe Fine hy severance at at aleve

ing losses:

ov shail suffer more than me Imnes set furrthe

iar More than

vidental Means shall be payable. »
Tany Exnployre has suffered priug to the date of is
or does thereaiter suffer, the huss wf one hand by seve
abuve the wristejuint, or af one fut hy severance at ar abot
aakle-joint, wr the taal amd irrecuveralde hms of sight ul nue cv

Insurance for Death ur Diamembernout hy Accidental Means he

ed)

‘ nS 7”

vided.

subsequent I
as provided in this subsection (B) shall be

¢ amount of such insurance payable for the
or the sicht of one eye
eh full

how?l
of one

Section 6, PRIVILEGE OF OBTAINING AN INDIVI-
DUAL POLICY OF LIFE INSURANCE.—Any Employee

whose
‘one of

Life Insurance hereunder shall cease in accordance with any
items (1), (2). (3). of (4) of the first paragraph of Section,

J hereuf, shal) be entitled to have issued co hum. without evidence
of insurability, an individual policy of Life Insurance unly, without
Disability or Accidental Means Death Benefits. subject to the fol-

bowing

conditions and provisions:

fe yniteolinsehas init

(B

c

1D:

tf the |
eat such cessanon af his Lie Insurance hereuuler,

seit

rt srtiveandpaennny,
of the firse premium thereun shall be marie within 3bvlay>
aiter such ceasation (or within such loner perind as the
(fice may allow) ws the Insurance Cinta at the
Employee's option to any other insurance cunpany which
has then been acceyxert hy thie Molicyhoiiler as elyble to
issue individual policed in accordance with the provisions
of this Section
will retide anid which has axreed with the Policyhoiler te

fn the jurisdiction in which the Fnnpluyee

46

SEE AMEND. 35,

the nor and,

)4ueh- individual policy -shall-le-sporroneobthe frrmismthen
customarily issued by the insurance company sclevtel by

_the-Eeipiovee-cxceyeFerm-tmurancesaul

Tthe premium for such intlividual policy shall Ie the premi=
tit, as tletermined hy the inwirance ct i h
policy, applicalde to the class of risk t which the Employee
helongs anil to the form ane amount af the individual policy
at the Employee's attained age t nearest lurthilays at the
date of insue of stich indivielual policy. and

) the amount of such individual policy shall be eye tu tor
at the option of the Employce lens than) the anwamt of the
Finployee’s Life Insurance hereunder on the dite ui such
cessation. :

apogee dies during the JT days went tulle

the

pruuf of such death and entitlement 0 pas

in subnection (A) of Section 3 herent the Office shall yay to hi
Beneficiary of record or otherwise as apecitiet! in Section 11 here.
whether oF not written application fot such individual policy of pay
ment of the fiest premium therefur shall have been muule, the same
oe ll have beet Nie ene

aS ‘
sentences. If the former Employee shall have again bevmne insured

subject tw the text tw

hereunder ia accoriance with the provisions uf Sectim 2 hereuf,
any payment made under the provisions of this paracraph shall In
reduced by the amount of Life Insurance payaile upon the death wi

such Employee under the other provisions of thir Volicy
individual policy has been issued in accuntance with the fo

It an
cng

provisions of this Section 6, any paynsent nuule under the previntnn

of this

shall be reduced hy the amumnt of insurane fur

which such individual policy was isned, unless such individual

twilicy is surrendered without claim therennler tv rie i
enenpany which iasuel such policy.

Kor ¢

Aa

SFE AAD.

SEE AMEND. 35, 48


METROPOLITAN LIFE INSURANCE COMPANY

* GROUP POLICY Ne. 17000-G bearing date of Augat 27, 1954 and lnved to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein colled the Polleyhulder)

pursuant to the Federal Employees’ Group Ufe insurance Act of 1954, ls hereby anended a follows:
AMENDMENT 45

Effective July 1, 1967, by substituting for the schedule foliowing the Mith paragraph
of Section 15 thereof, the followings

“Schedule of Madmum Expense ond Risk Cherges

Item Maximum Charge
(a): Expense Chorges
(i) Tees The cetue! occrued amount of toxes directly attributcbie

to the premiums, amounn of insurance in force, or reserves

under this Policy, a determined by the Insuronce Company.

(Il) Expense of maintenanes and The ectud occrved amount of such expense inciuding ex-
cparction of the Office pense for the reinsurence required by Section 22 hereof,
a3 datarmined by the Insurenca Compeny, but not In excess
of 0.6% of Premiums.

(111) Other expenses For ony policy year beginning prior to November 20, 1955 =
. 0.39% of Premiums;
- For ony policy yeor beginning on or subsequent ta November
20, 1955 but prior to July 1, 1967 = 0.30% of Premivenn; :

For ony policy yeor beginning on or subsequent to July 3,

1967 © 0.30% of thet pert of Premiurs for the pollcy yeor
which ls not In excess of $190 million, plus 0.06% of thet
port of Premiums for the polley yeor which Is In excass of

$190 million.

Fonn G.1985-20


—e ees sade ls Laser. Baca bales US
oh Zh ‘fa
from hae vem sad te dam

fe ther carao.. at of TBs. L002 a

( aria

(eS peal chc ign sah i gi i

owt dad
Bic ine il Th ony
thea vl tet oe wie Lf

EXHIBIT

ia



AMENDMENT 1

Effective on the first day of the first pay period which begins
aiter August 11, 1986, by inserting the words ‘including Gallaudet
Colleges” immediately aiter the words “United States Govern-
ment owned or contrelled corporanon” in the first paragraph of
Section 1 thereof.

AMENDMENT 12

Effective October 17. 1986. by substituting ior item (4) of
Schedule A attached to said Group Policy as a part thereoi, the
iollowing:

“(4) Employees serving under appoinuments limited to one year
of less, except. aiter November 3, 195+, acting posunasters,
and except. aiter October 16. 1986. employees 40 appamted
for iuil-time employment, without break in service or alter
3 sepsration of three days or less, following service in
which they were insured hereunder.”

AMENDMENT 13
Estective November 6, }!
\. By substituung for the third paragraph of Section 2 thereof,

the following:

~The insurance hereunder on each person who becomes an Em-
ployee as defined in Section 1 hereoi. aiter November 5, 1956
and on of after the effective date speciiied in the first paragraph
of this Section 2 for the group of Employees of which he isa
snember, shall become effective at the time he actually enters on
uty on his first day in a pay status unless on of beiore such first
day he has given written nouce to his employing office that
he desires not to be insured hereunder or had previously given
such 3 notice which remains uncancelled. .

The insurance hereunder on each Employee who transfers
aiter November §, 1936 from one employing office to another in
which he remains an Employee shall become effective at the be-
ginning of the effective date of his appointment by transfer, unless
‘on of before that day he has given written notice to his new em-
ploying oifice that he desires not to be insured hereunder or had
previously given such a notice to a former employing office which
remams uncanceiled.” .

J. By substituting for the fourth paragraph of Secon 2 thereof
the following:

“The insurance hereunder on each Employee who returns to”
duty and is in a pay status, after November 5, 1956 and on or
aiter the effective date specified in the first paragraph of this Sec-
tion 2 for the group of Employees of which he 1s a member, aiter
having been in a non-pay status which extended continuously for
more than 12 months, shall become effective at the time he actu
ally enters on duty on his first day in such pay status unless on
of before such first day he has given written nowce to his em-
ploying office that he desires not to be insured hereunder or had
previously given such a notice which remains uncancelled.”

AMENDMENT 14

Effective January 1, 1987, .

‘A. By deleting item (3) of Schedule A attached to said Group
Policy as a part

B. By inserting immediately after the word “hereof” at the end
‘of the first paragraph of Seccion | thereof, as amended. the fol-
lowing:

*, provided, however, that no person shall become an Employee

hereunder by virtue of his status as a ‘member of 3 uniformed

service’ as that term is defined in Section 102 of the Service-
men's and Veterans’ Survivor Benefits Act”

C. By substituting for item (3) of the first paragraph of Section

3 thereof, as amended, the following :

(3) The day immediately preceding the date the Employee
enters on active duty or active duty for training as a mem~
ber of a uniformed service, uniess the period of such duty
is covered by military leave with pay from his civilian posi-
tion, This provision for cessation of insurance shall not
apply with respect to any insurance effective hereunder
prior to Jamuary 1, 1957 on commissioned officers of the
Coast and Geodetic Survey or of the Regular or Reserve
Corps of the Public Health Service. The terms ‘active
dury’, ‘active duty for training’ and ‘member of a uniformed
service’ shall have the meanings assigned to them by Sec-
tion 102 of the Servicemen's and Veterans’ Survivor Bene-
fits Act.”

The foregoing amendments are to be artached to and made part of said Group Policy.

37

Signed at. Washington. D. C. thi Twentieth
__Mary J. Angluin

(Wiasened

UNITED STATES CIVIL SERVICE COMMISSION

Thaterhods

by.

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)
March

‘iumed at...

New York, HM. Y. .
or ora Me Le this nee

¢. oe Arlinghaus

Form G. 1985-2
Sept. 1936

Twenty-niath

bop: acest

Seeretary


SEE AMEND. 4, 26

SCHEDULE B

Last or Retinexent Systems Rererren to iN THE
Secono Paracaary or Section 3 Hexcor

nee

Atyen

(5) System for Civilian Teachers at the | Acadenty
(6) Foreign Service Retirement System
(7) System for Policemen arnt Firemen of the District of Col

Secticrree Rett
Sodicrary-Rerirement-Sysrenr

uf the Territories Retirement Syatem

(12) Old Age and Survivors Insurance Spsteqy ( Social Security)
(13) Coast and Geodetic Survey System

(14) System for Officers of the Public Health Service

The Policyholder may, upon written notice to the Insurance Company, add to

‘or eliminate from the foregoing list any System, provided that the elimination of
any System from said list shall net operate to discontinue any insurance then being
continued in force hereunder on any retired Employee in accordance with the pro-
visions of the second paragraph of Section 3 hereof uniess the Policyholder and the
Insurance Company otherwise mutually agree.

ate

Farm G19
Aug. 1


(MEREIN CALLED THE INSURANCE COMPANY)

GROUP POLICY Ne. 17000-G.
IN CONSIDERATION

of the application for this Policy made by

(WEAXIN CALLED THE POLICYHOLDER)

pursuant to the-Federal-nmployeesGroup-bife-insurence-whemetetb4, 3 copy of which
application is attached hereto and made a part hereof, and in consideration of the payment
by the Policyholder, during the continuance of this Policy, of all premiums when they fall
due as provided in this Policy,
HEREBY AGREES

subject to the provisions of this Policy to pay the insurance benefits herein provided with
respect to the several Employees insured hereunder. ; .

This Policy shall take effect as of the 29th day of August, 1954, which date is the date
of issue hereof.

The provisions hereinafter contained are part of this Group Policy as fully as if re-
cited over the signatures hereto affixed. :
3n Mitness Whereof, the Metropolitan Life Insurance Company has caused this

Policy to be executed heen thy of_tievamber. ist, to take
effect as of the date of issue hereof.

W. J. Barrett YF. W. Ecker
Secretary President

Fonn G.1985

Aug. 1954
PRINTED IN USA,

EXHIBIT

Pp


19/26/2891

18:42

17736261522

SENDEM conn.

Complete items 1,2, and 3. Also complete
tom 4 If Rastricted Detivory ta desired.
TM Print your name and address on the reverse.
80 that we can return the card to you,
TM Attach this card to the back of the mallploce,
or on the front It space permits.

SU AAR? He fa
Ne MUN

DELORES WILLIAMS

Q

1. Article Addressed to:

gibened Emp qerupt jon

ey 26a7

Agont
2 mt D Addressee
0. tu deitvery, ftom 17 0 Yan .

IWery address below: ~=— 1) No

Que?
op
Mm. R

sey City NJ 07803-2627

( Ceo gre Kexelma ww

3. Service Type
OD Contitiod Mai 0 Exproas Malt
O Registored © Retum Receipt for Merchandise

D inoured Mal O c.0.0.
4, Routicted Delivery? (Extra Foo)

2, Article Number (Copy from service lab

7001 O3k0 Oo02 7806 S047

O Yea

PS Form 3811, July 1800

Domestic Retum Receipt

PAGE


,DEC BL 2000 14723 FR METLIFE . TO 2511636

METROPOLITAN LIFE INSURANCE COMPANY

. GROUP POLICY NO, _17000-G_ bearing the date of 29,1954 and issued to. ©

OFFICE : L i
‘(Hcrein called the Policybolder)

pursuant to chapter 87 of title 5, United States Code, is hereby amended as follows:
AMENDMENT 72 ° ,
Effective October 1, 1998,

A By replacing “only from the thirty-first day following the date of death” in paragraph
(C)G) and (C)(ii) of Section 4 thereof, as amended, with “from the date of death”,

B. By replacing “on or after July 1, 1983" in paragraph (C) of Section 4 thereof, as amended,
with “on or after October 1, 1998". -

C. By adding “to be equal to the prevailing delayed settlement interest rate the Insurance
Company pays.on its other large group contracts. The Insurance Company shall consult
with the Contracting Officer before any change to the interest rate becomes effective.” .
after “as determined by the Insurance Company” in paragraph (C) of Section 4 thereof, as
amended, -

D By replacing “only from the thirty-first day following the date of death” in paragraph (C}
of Section 4 of Suppiementary Agreement Form G.1985-A, attached to said Group Policy
as a part thereof, as amended, with “from the date of death”. .

E, _ By replacing the period after “Agreement” in paragraph (C)2 of Section 4 of
Supplementary Agreement Form G.1985-A, attached to said Group Policy as a part
thereof, with “, and” and adding a new paragraph (C)3 as follows:

“3, the Family Member’s death occurs on or after October 1, 1998.”

F, _ By adding "to he equal to the prevailing delayed settlement interest rate the Insurance

. Company pays on its other large group contracts. The Insurance Company shal! consult
‘with the Contracting Officer before any change to the interest rate becomes effective.”
after ‘as determined by the Insurance Company” in paragraph (C) of Section 4 of
Supplementary Agreement Form G.1985-A, attached to said Group Policy as a part
thereof, as amended. :

Page 1 of 2


AMENOMENT 58 (Continued)

whichever Is shorter. For the purposes of this paragraph, in the case
of an Employee who was on tne rol! of Als employing office on February
14, 1968 and who nsured for optional insurance on April 14, 1968
or the date ot his retirement, if eariier, such optional insurance shall

. De deemed To have been in force tor the full period or periods of service
during which optional Insurance was available to him prior to such eariler
date. if the Policyhoider receives written notice from the Empioyee that
optional Life insurance on his account is not to be continued after retire=
ment, The provisions of this paragraph shall be nul! and void and of no
atfect end no optional Life Insurance shail be provided for the Emloyee
atter retirement.

With respect to an Employee whose retirement occurs on or after Oecember
16, 1967 but prior to February 14, 1968, “basic amount of Lite Insurance”
means, a% To optional Lite Insurance, an amount of optional Life Insurance
in accordance with Part 111 of the Schedule of Insurance im subsection (A)
of this Section based on the amount of his annual compensation on The date
his insurance would otherwise have ceased because of the happening of the
event specified In either of items'(1) or (2) of the first paregrapn of Sec-
tlon 3 hereot. The dasic amount of Life Insurance for the purposes of this
paragraph shail be determined as set forth above without regaré to the speci-
tications In Part Il! of the Schedule of Insurance in subsection (A) of this
Section relating to the period for which such schedule Is eftective. The
provisions of this paragraph snall be null and void and of no effect and no
optional Life Insurance snail be provided for tne Employee atter retirement,
unless written election of optional Life Insurance by the Employee is received
by the Policynolder on or prior to April 14, 1968.

With respect to an Employee whose retirement occurs on or after Septemer
23, 1989 but prior to December 16, 1967, "basic amount of Life insurance” means
the amount of Life Insurance in accorcance with Part | of the Schedule of in=
surance in subsection (A) of This Section besed on the amount of nis annual
compensation on the di his insurance would otherwise have ceased because of
the happening of the event specified in either of items (1) or (2) of tne first
paragrapn of Section 3 hereot; ang "eftective reduction date” means the first
gay of The second calendar month atter (1) such gate, or (2) his 65th birthday,
whichever is later.

Form G.1985-33

COPY


AMENDMENT 26 (Cooiinned)

With respect te aq Explayee whose retirement occurs peiot
to September 23, 1959, ‘basic amount of Life Insurance’ means
the amount of Life Insurance im accordance with the Schedule
of Insurance in mubsertion (A) of this Sertion based og the
amount of hit annual compensation on (&) the dave bis insur-
ance would otherwise have ceased because of the
che event specified in either of items (1) or (2) of the first
paragraph of Section 3 hereol, or (b) his 6Sth birthday, which-
ever is earlier (or in the case of any such Employer who Grst
became of again became insured hereunder after his 6Sth hirth-

day, Sassd on (i) the amcamt of bis sanual compensation ¢
larest dare he became insared hereunder, or (ii) the amo
his snmuaal compensation on his 65th birthday if the Exis
was Clipible to be insured hereunder on his 65th birt
whichever ia the fester); and ‘effecnve reduction date’ 1
the firs: day of the second calendar month siter his
birthday.”
AMENDMENT 33
Effective Septamber 25, 1959, by rubstituting the date “Sep
23, 19597 for the date “August 2. 1956” in the two places in
‘is appears im Section 23 thereof, a3 amended.

‘The foregoing amendments are to be artached so and made pert of said Croup Policy.

Signed atone.) ashingwon. D.C,

this. Sourkh.

CO en |.

UNITED STATES CIVIL SERVICE COMMISSIC
Talleyieiers”

By. fognt. 2. Jones. Soairman.

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANC® COMPANY ONLY)

Signed at.... Baw. York, New. York _..this,

Go.Gs Avlingnaus,

iReport

Form G. 1985-6

reve e eae,

“bgp anaes

Vice-President & See


Office of Federal Employees’
Group Life Insurance
* 200 Park Avenue
New York. NY 10166-0188

—)
FEGLI Fed

Claim for Death Benefits

eral Employees’ Group Life Insurance Program

Read the instructions carefully
before filling out this form.

Part A.

General Information About the Deceased

1. Full name of the deceased (Last) (First)

DWones OSH

(Middle) 2. Date of birth (mm/dd/yyyy)

7-16°37

3. Date of death (mm/dd/yyyy)

7-5-9

4, Social Security Number

5. Legal residence at time of death—(City and State)

EM 1c AG p> LL

6. Department or agency in a which jest song ed, oy l, 7. Location of last employment (City, state, ZIP code)
including bugeau or hoes 7 >
Service rE Sarda GO Cheol stecam LU. 60177

8. At the time of death was the deceased:

civilian retirement system ?

Yes Y No Q

(b) Receiving Workers’ Compensation benefits?
Yes No Q

(a) Retired and receiving annuity under any Federal

If “Yes” to either 8(a) of 8(b), please
complete the box(es) to the right.

Unknowa G }

Unknown

Claim number (CSA, CSF, CSI)

37 8Y JY3

Bifective date of Workers’ Compensation
benefits (mum/dd/yyyy)

If the deceased named you as beneficiary on a Designation of Beneficiary form under the Federal
Employees’ Group Life Insurance Program (Standard Form 2823 or Standard Form 54), attach a copy of
the form that has the agency or retirement system’s receipt date on the bottom. Please indicate your date of
birth and relationship in the boxes to the right, and complete Part F on the other side. If you do not attach
either Standard Form 2823 or Standard Form 54, you must complete all parts of this claim form.

‘Your date of birth (mmm/dd/yyyy)

o/- 01-69

Relationship to the deceased

bon

Part B. Personal Information Concerning the Deceased

1. How many times was the | 3.
deceased married? ace

Givg the name of each spouse (include all marriages)
Reh ro Geer

4, Hlow was marriage terminated?
(Check one in each case}

5 Date marriage was terminated
{mmldd/yyyy)

Vera M =a, Af Peat Divorce
2. Was the deceased survived] 9 4 ;
ryany cise? | MAive “Anves Dexth |__| Divorce
Y Yes No. Death Divorce
Part C. Information Concerning the Claimant
1. Your name (Last) (First) (Middle), 2. Your relationship to the deceased | 3. Your date of birth (mm/dd/yyyy)
doves OSeR Levin SON Ol- ol- 68

Items 4 through 13 must be filled in if you are the widow or widower of the deceased.

4. Date of marriage (mm/dd/yyyy)

5. Place of martiage (City and State)

6. Marriage was performed by:

Clergy or Justice of the Peace

Other (specify)

7. Were you living with the
deceased at the time of death?

Yes No

at the time

Yes

8. If you were not living with the deceased

of death, was there a divorce? and place of the divorce.

No

9. If you were divorced from the deceased, give the date (mm/dd/yyyy)

10. How many times were 11. Give the name of

you married?

‘each spouse (include all marriages)

12, How was marriage terminated?

13. Date mariage was terminated

(Check one in each case) (mmldd/yyyy)
Death Divorce

| Death Divorce
Death Divorce

Previous editions are usable

(continued on the other side)

Page 3

Form FE-6
Revised Janvary 1999
OFEGLI Form in Adobe Acrobat PDF (1/99)


miade by the Insurance Cumpany under the provisions of this para-
graph shall be made only if all premiums then accrued under this
Policy have sctually been received by the Insurance Coumany.

In determining the aggregate amount of mortality and other
claim charges for item (3) above. there shail be included all pay>
ments of claims made of approved hy the Office in goort faith. the
amount of pending and unreported claims ar the end of the policy
year for which the statement is made, a3 estimated by the Insurance
Company, and alt charges on account of the excess mortality costs
to be expected under individual policies issued pursuant to Section
6 hereof. The changes for such excess mortality costs shall be at
the rate of $65 fur each $1.000 of life insurance insued under any
wuch policy, which rate may be changed by che Insurance Company,
with the approval of the Policyholder, fur any pulicy year after
the first,

The aggregate amount of expense and risk chances to he ine
cluded in item (4) above shall not exceed the maximum amounts
specified in the Schedule below. Such maximum charges are appli-
cable to the first policy year and shall be continued for subsequent
policy years except that they may be redetermined by the Policy
holiler for any policy year either by agreement with the Insurance
Company oF upon written notice given to the Insurance Conymny
at least one year in advance of the beginning uf the policy year for
which such redetermined maximum charges are to he effective.

Seweocng or Maxisee Expexaz ano Rise CxAacrs

Lem Maxieworn Charey

The actual accrue amount of

8 taxes directly attributable tn the
& . premiums, amounts of insurance
c in force. or reserves uncer this
- Policy, as determined hy the ine
ry
a
. didn Expense of nasinte-
8 nance and operation
- of the Office
o
¢ .
a (iti) Other expenses Prddet-of Hreminmn,
x
a ia oe rau
mo
ry
a

“Premiums”, as used io the furegoing Schedule, meats the ayggre
xate amount of premiums actually accra! under this Volicy for a
policy year unier the peevisions of Section 15 hereol. There <hall
be included as “Taxes”, as uel in the foreguing Scherlule,
ance Department fers which are directly attrilamtalile ti thin
to the extent approved hy the Policyhoider.

‘The records of the Insurance Company as have a hearmg on the
annual scrounting furnished to the Volicyholder shall be open to
inspeenon by the Policyholder at any reasonable sine.

Sectiva 16. VISCONTINUANCE OF THIS POLICY.—
‘This Policy may le discoatmued iny the Policyholder at any time,
subject 10 the provisions of subsection (D) of Section 14 hereol.

This Policy may be discontinued by the Insurance Company if

(a) the Insurance Company requests the Policyholder to re-
determine the tencative average Group Life Insurance premium rate
33 provided in Section [4 hereof and 2 new tentative premium rate
satisfactory to the Insurance Company is not agreed upon. in which
event such discontinuance shall take effect a» of the end of the day
preceiiing any premium due ilate thereafter specified by the Insur-
ance Conipany jrrovicet] auch premium cue date ia at least 60 days
after rereit hy the Policyholder of written notice uf such dis
suntinuanee, of

(hy the Pulicyhokler toes net agree to any change proposed by
the Insurance Conmpany in accordance with Section 15 hereof in
the rate of interest applicable to the Contingency Keserve of in the
rate of charge for excess morality costs under individual policies
issued to Section 6 hereof, in which event such discun-
tinuance shall take effect as of the end of the then current policy
year, of

(61 the Insurance Coniany does nut agree to the hasis ale
termined fy the Pulicyholler in accurlance with Section 14 hereui
for readjustment of the Schedules of Rasic Prentium Rates, ut the
Teaurance Cumpany dues not agree to any change in the maximum
expense and risk charges prqmeed by the Policyhukler in accurd-
ance with Section 1S herent. in either of which events sch dina
tintance shall take effect ax of the end of the pol
ately preceding the policy year for which such
ties of Haske Premium Rates ur propamed masinnat expense ant
Tink changes were tw he effective, of

(4) che Insurance Conmpany gives written notice wf mach dine
contimaance ta the Volicyhulier, at least (0 days rive wo the ex
of any policy year, in which event such discontinuance shall ake
effect as of the end af auch juicy vwar. provided that, if nntice of

diecontnnmney rem braun of a change in thet tne

— sac tatice may be
xriven oo earlier than the date of enactment «f the change in said
Act, in which erent such disuntinuance shall take effect, tnles
otherwise mutually agreed between the Insurance Conmany and the
Policyholder, on the effective date of the change in the .\ct or the
date 60 ilays after receipe of such written notice by the Pulicyhokter,
whichever date i later.

Section 17, RENEWAL PRIVILEGE.—This Policy is issued
fur a peruel contenencing with the dase of issue and ending with
the day inwurdiately preceding the next following renewal date, oa

Form G.198s
Mig. 1883

SEE AMEND, 4%


DO NOT DETACH

_—
FEGLI

Claim for Death Benefits
Federal Employees’ Group Life Insurance Program

_—
FEGLI

(You should zot use this form to claim Option C-Family Benefits. Please use form FE-6 DEP to claim those benefits.)

Instructions to claimant
General
Please read these instructions carefully, and type or print in ink.
if you need assistance in completing this claim, contact the
deceased’s last employing office, or the Office of Federal
Employees’ Group Life Insurance (OFEGLI), 200 Park Avenue,
New York, NY 10166-0188. You may call the OFEGLI service
representatives, toll-free, at 1-800-OFE-GLIA (1-800-633-4542)
or (212) 578-2975.
OFEGLI needs the information requested on this form to
adjudicate your claim for benefits under the Federal Employees’
Group Life Insurance Program as authorized by chapter 87, title
5, U.S. Code. Interest payments are considered income for
Federal income tax purposes. Interest will be reported to the
Internal Revenue Service in accordance with the provisions of
Sections 6041 and 6042 of the Internal Revenue Code of 1954.
Provision of the information is voluntary; however, failure to
supply all of the requested information may delay or prevent
action on your claim.
Order of payment
OFEGLI will pay applicable benefits as follows:
If the deceased assigned ownership of his/her insurance, then

First, to the beneficiary(ies) designated by the deceased’s
assignee(s), if any;

Second, if there is no such beneficiary, to the deceased’s
assignee(s), if any.

If the deceased did not assign ownership and there is a valid
court order on file, OFEGLI will pay benefits in accordance
with that court order.

If the deceased did not assign ownership and there is no valid
court order on file, then

First, to the beneficiary(ies) designated by the deceased;

Second, if there is no such beneficiary(ies), to the widow
or widower of the deceased;

Third, if none of the above, to the child or children of the
deceased, with the share of any deceased child
distributed among descendants of that child;

Fourth, if none of the above, to the parents of the
deceased in equal shares, or the entire amount to the
surviving parent;

Fifth, if none of the above, to the executor or
administrator of the deceased’s estate;

Sixth, if none of the above, to the other next of kin of the
deceased entitled under the laws of the domicile of the
deceased at the time of death.

Completion of the claim

Each claimant must submit a separate claim form,

All claimants must answer Part A. If the deceased designated
you on Standard Form 2823 (formerly Standard Form 54) as a
beneficiary, you need not answer Parts B through E. Otherwise,
it is important to answer all questions. Omissions or incomplete
answers will delay settlement of your claim. If the answer to
any question is “No” or “None,” so state. Be sure to fill out the
information under Special Note on page 2 and complete Part F
on page 4.

Previous editions are usable

J

Evidence required

You must submit with this claim a certified copy of the
death certificate that contains the cause and manner of
death. You may obtain the certificate from the Bureau of Vital
Statistics or equivalent agency. Failure to submit a certified
copy of the death certificate will delay settlement of your claim.
In addition, if the deceased designated a beneficiary and a
receipted copy of either Standard Form 2823 or Standard

Form 54 “Designation of Beneficiary” is available, you should
submit the receipted copy with your claim.

If an executor or administrator is filing this claim on behalf of
the estate of the deceased, you must submit a copy of the court
appointment papers.

OFEGLI will let you know if you need to submit other
evidence.

Manner of payment

If the amount payable to you is less than $7,500, OFEGL] will
send you a single check for the entire amount.

If the amount payable to you is $7,500 or more, OFEGLI will
open a Money Market Option Account in your name. You will
receive a checkbook giving you complete control of and
immediate access to all of your funds. You may write checks for
all or part of the money in your account beginning the first day
you receive your checkbook. The Money Market Option
Account offers a number of benefits which are explained

on page 2.

Where to send the claim

If the deceased was employed at the time of death

Send your completed claim to the deceased’s employing office.
That office must certify the deceased’s insurance status at the
time of death.

If the deceased was retired or receiving Federal Workers’
Compensation benefits at the time of death

Send your completed claim to OFEGLI, 200 Park Avenue, New
York, NY 10166-0188.

OFEGLI will adjudicate your claim upon receipt of insurance
certification from the Office of Personnel Management.

Instructions to the employing agency
It is the agency's responsibility to assist the deceased’s
beneficiary or next of kin in properly completing this claim.
The agency should forward the completed claim and all
required supporting evidence to OFEGLI, 200 Park Avenue,
New York, NY 10166-0188, together with:
1. The original of the Agency Certification of Insurance Status
(SF 2821); .
2. The original of all Designation of Beneficiary forms
(SF 2823 or SF 54), if any;
3. All court orders on file, if any;
4. Any other documents (except payroll records) bearing on the
deceased employee’s insurance status,

EXHIBIT

Fora FE-6
Revised January 1999
OFEGLI Form in Adobe Acrobat PDF (1/99)


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No. 17000-G bearing date of August 27, 1954 end issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyholder)

pursuant to the Federal Employees’ Group Life Insurance Act of 1954, is hereby amended os follows:
AMENDMENT __33

Effective December 15, 1961, by adding immediately after the third sentence of the third
paragroph of Section 15 thereof, the following:

“If in ony policy yeor It is anticipated that a payment for such deposit would
be made ot the end of thot policy year in accordance with the provisions of
the preceding sentences, partial instalments of such payment may be made by
the Insurence Company during thet policy yeor in swch amounts ond ot such
times a3 may be mutually ogreed upon between the Insurance Company ond
the Policyhalder.”

The foregoing amendment is to be attcched to and made port of ssid Group Policy.

Signed ot Vasnington, D. C. this 29th doy of _ December 19 6.
Mary V. Yenzel UNITED STATES CIVIL SERVICE COMMISSION
(Witness) (Policyholder)
by Jonn W. Macy, Jr.

(Space Below For Use of Metropolitan Life Insurance Company Only)
Signed at _Hev York, X.Y. this__L7th day of __ January 19 62

METROPOLITAN LIFE INSURANCE COMPANY,

Kart. He thabeck

€..G. Arlinghaus
(Registrar)

Form G. 1985-31 ; @ O P Y



‘ “276
Section 9. OUZ DATE, COMPUTATION, AND PAYMENT OF PREXZUMS.—-The preniizs due on
and af the cate of issue of this Supplemantary agreement for the ‘ssurance
provided hereunder shall be decermined and shall be payable in accordance vith che
provisions of the Group Policy, as specified in che applicable provisions of
chapter 87 of title $, Cotted Scates Code. : .

Ta che computarion of the aggregate prezium due under this Supplementary Agreement
on any due date, the Insurance Company tay use average premium rates based op the
presius rates then in effecc. ~

Section 10. INCORPORATION IN GROUP POLICY AND RENEWAL PRIVILEGE.--This-
Suppiementary Agreenent is attached to and sade a part of the Group Policy for a
period comencirg with April 1, 1981 and ending with the day immediately preceding
© mext followizg seneval date of the Group Policy, on which renewal date and os
each subsequent reneval dace this Supplementary agreement shall be reneved to
coatioue in force as a part of che Group Policy for a further term extending
through the day imsediately preceding the cext following renewal date, unless the
Policyholder shall at least sixty days prior to said reneval date give the
Insurance Compasy uritren nocice that such reneval shall not be made. Renewal is
conéitioned upon renewal of the Group Policy and upon the payment of the Family
Life Insurance premiums then due as set forth in Section 9 hereof and based upon
suck premiua rates as may then be applicable. 7 ‘

Section ll. CONFORMITY WITH LaW.-~If any provisions required by chapter 87 of
title 5, United States Code, to be contained in this Supplementary Agreement are
not ‘specifically contained herein, then such provisions shall be deened part of
this Supplementary Agreement as though sat forth herein at length.

IN WITNESS WHEREOF, the Metropolitan Life Insurance Company has caused this
Supplementary Agreement co be executed tris 2g th, day
of A/S te take effect as of the first day of April, 1981 ,
which lase date is che date cf issue of this Supplementary Agreenen:.

marry P./Kamen gern J, Crecesn
Secrnary Prasicere sng Creat Gxeczve Cicer
Countersigned 19
By,

Uicensed Agent

Form G.1985-A


Skip Parts D and & if you are a designated beneficiary or the deceased’s widow or widower. i
Part D. Information About the Deceased’s Next of Kin

hip, and address of

(a) Widow or widower; (c) If there are no children, list the parents; if one or both

(b) If there is no surviving widow or widower, list the child parents are deceased, so state and give the date of death;
or children of all the deceased’s marriages (include (d) If there aré no suryivors in (a) through (c), list the next of
adopted children and children born out-of-wedlock) and kin who may be'capable of inheriting from the deceased
the descendants of any deceased child or children (brothers, sisters, descendants of deceased brothers, sisters,
(use additional sheets if necessary); etc.). (Use additional sheets if necessary).

Name Age Relationship to Full address

the deceased

Fill in items 2 and 3 only if any of the persons listed above are under age 18.

2. If the court appointed a guardian for the estate of | Name 3. If the court did not
any minor children above, give the name and appoint a guardian for
address of the guardian and attach a copy of the | Address (Number, street, apt. no.) the estate of any minor
court appointment papers, Natural parentage or . children, will it appoint
custody as a result of a divorce do not City, state, ZIP code one later?
constitute guardianship. Yes No

Part E. Information About the Deceased’s Estate

1. If the court appointed an executor | Name 2. If the court did not
or administrator to settle the appoint an executor or
deceased's estate, give his/her Address (Number; street, apt. no.) administrator “i it
name and address and attach a appoint one later
copy of the court appointment City, state, ZIP code
papers. Yes No

Part F. Your Certification (Everyone must complete this part.)
1. Are you claiming accidental death benefits (did the deceased die solely through violent, external, and accidental means)?
If “Yes”, submit coroner’s and police reports, news clippings, and any other available reports concerning the accident.
OFEGLI cannot consider a claim for such benefits if the deceased separated or retired before

the accident. Yes fy, No
2. Backup Withholding Has the IRS notified you that you are subject to income tax backup
withholding as a result of a failure to report all interest or dividends? Yes VA No
If the amount payable to you is less than $7,500, OFEGLI will send you Please be sure you complete the Date (mm/dd/yyyy)
a check, information on page 2
under “Special Note” 4) qT-A (a (

Hf the amount payable to you is $7,500 or more, OFEGLI will open a money
market account in your name, giving you complete control of and Your signature (Depot print)
immediate access to all of your funds. You may write checks for all or part

of the money in your account when you receive your checkbook. See page 2 [Your name (Pleas print)

for more information. CBICER kevin Xoves

I certify under the penalties of perjury that all statements made in this claim] Address (Number, strget, apt. no.
are true, correct and complete to the best of my knowledge, information, | 3/9 CHicAg 0 Ye ez H
and belief, and that I did not suppress or withhold evidence necessary to City, state, ZIP code

settle this claim. CnePark tL bse

Your Social Security Number 3 is ITHGIGES/3/9 Y | Daytime telephone no. Evening telephone no.
Estate/Trust Identification (773 )SY2 21567 | ¢ 793 SOF ~53 3g
Number ~ - Area Code Area Code

Warning—If you knowingly and willfully make any materially false, fictitious or fraudulent statement or representation on this form, or conceal a
material fact related to the requests for information on this form, you may be subject to a monetary fine or imprisonment for not more than five

years, or both, under 18 U.S.C. 1001. Form FES
Revised April 2001
Do not use previous editions Page 4 ‘OFEGLI Form in Adobe Acrobat PDF (04/01)


-10-

AMENDMENT 64° (Continued) .
PART LIB = SCHEDULE OF BASIC INSURANCE, EXCLUSIVE GF OPTION A - STANDARD INSURANCE
GFIZON $ = ADDITIONAL LIFE ND ASTER FIMST DAE OF FIRST PAY
GINS ON OR AFTER cero2ER 1, 3981 - (COST=NUED)

~

rvease in the asousz of Zasic Life Insurance sez forsh is ites (2)
all also be applicable to aa Exployee, under age 45, who 4s retized
ceiving compessatios under subchapter 1 of chapter 81 of cicle 5,
tes Code provided such Ixployee elected to continue Sasic: Life
tine he/she decase eligitie to continua such ‘asurance
Bt or receipt of couparsstion benefics.

3

Usdced
lasutasce att
because of retiz

* lf the Ansual Compensation referred to is not a sultisle of $1,000 it shall de
taken to the next higher sulcziple of $1,000 for the purpose of this provision.”

The foregoing amendment is to be attached to and nade part of said Group Policy.

Signed azashingzon, D.C. this 228 day of November 19 83

OFFICES OF PERSONNEL MANAGCEENT
(Policybolder)

By. Revie J. Burns

(Space Belov for Use of Metropolitan Life Insurance Company Only)

Signed az New York, New York this 29th day of Novenber 19 a3
METROPOLITAN LIFE INSURANCE COMPANT,
G eng /, (ae,
Marry ® [Ramen
Shavcon Wit ttonces
(Aagistrar) Secresery

~—' GOPY


2.

“which renewal date and on each sulmyuent renewal date this Policy
shall be renewed, subject to the terme of Section 16 hereof. for 6
further term extending through the day immediareiy preceding the
next following renewal date. unless the Policyhuller shall at least
gr cixty days pinor to aaitl renewal date give the Insurance Company
" written noice that such renewal shalt not he made, Renewal is
@ camulitioned upon the payment of the preniums then due as coms
3 uted in the manner yet fnrth in Section 14 bereof and based upon
2 such Schedules of Premiums as may then he appiicable,
& renewal date” ax used in this Policy
due date in the

layer, there shall he an equitable ailjusiment uf the
Hf the amount of insurance applicable tw such Eniployee
in accordance with Section 4 hereof woukl have been alfected by
such mnissatement of age, the amon insurance on such Ear
puyee shall be adjusted te the amwant te which such Employer
would have heen entitled at hin correct axe.

Sect MV ARTICIP ATION DIVIDENDS, —This Paliey
is & participating contract and the Insurance Conipany shall dev
termine annually the dividend, if any, wy which this Policy may be
entitled, Any such divichend! shall be paid in cash to the Pulicyholder
of, upon written request by the Pulicyholder, shall be applied
toward the payment of premiums In either event, an amount equal
to the excess, if any, of the [mpluyees’ axgregate contributions
toward the cost of the insurance provided hereunder over the net
cnst of such insurance shall Le distribute! or applied by the Hulicy-
holder fur the sole benerit uf the Employees

Section 20. OPTIONAL MODES OF SETTLEMENT.

at the death of the Employee, made to and accepted
the whole or any part af the amount of insu

teath of any Employee insured hereunder yi he rerained by the

AVEHD 43, 55,

tied mumber of yesseTshown in the following table) as may be
i vlesied, the Gyerinstalmerst being payable immediately upua the
death of the Employee, The amount of such instalments shall be

snt-ort

Pz $1,000 oF Imsuaance

Amount of Each
Nemper of Year (Per 9.000 of
1 $1,000.00
2 $05.61
3 Rad
4 238.29
3 20897
10 110.37
1s 77.38
2a 6130

‘The amounts payable under the foregoing
upon an assumed interest earning of 214 per
Upon any renewal of this Policy, of wi
Policy are changed, the Insurance Company,
foregoing Schedule, s Schedule of Inst
of Insurance based upon a diferent
. such new Schedule shall not be spplis
+ the date of such substitution,

I the Insurance Company 4

y substitute for the
Payments per $1,000
interest earning, but
$0 elections made prior

unpaid instalments shall, dnless otherwise specified in the election
of such instalment payments, be commuted at the rate of compound
interest upon which based the Schedule of Instalment Pay-
ments per $1,000 of ¢ used to determine such instalment
ated sum shall be paid to the estate of

other than one of those specified above

may be arran /it the Beneficiary or other person entitled to ree
ceive payment sf amounts due at the death of the Employee, after
the death of the Employee. and the Office mutually agree thereon,
Information ing suc other possible modes of settlement

d by the Office upon written request.
nt election shall be allowed under which the instal-

3 bode ol salemest cel of any poynent thernde,
ce Company and the payments under the optional mode of

ent shall not be subject to claims of any creditor of any
phyee. nor to execution or other legnl process 00 behalf of any

Form G.1985

) ‘Aug. 1954

‘SEE ame. 43, 53


Section 6- (Concisued)

death of the Exployee before payment shall de cade, such payment shall be made to

the person or persons encitled to che Lise Insurance (exclusive of Option A ~

Standard Lise Insurance and Option 3 - Additional Life Insurance) in force on

account of the Explovee as provided iz Section 1] of the Group Policy. If an

tadividual policy has en issued in accordance with the foregoing provisions of

this Section 6, asy payoent made under the provisions of this paragraph will be

reduced by the amovst ef insurance for wvoich such individual policy was issued,

valess such individual policy is surrendered without claim thereunder to the |
dasurance coupany vkich issued such policy.

Section 7.° AGENTS; ALTERATIONS.--No Agent cf the Insurance Company is authorized
t0 alser or anend chis Supplenercary Agreement or to vaive any of its provisions. |

No change in chis Supplementary Agreesent shall be valid unless evidenced by
asendnent hereto signed by the Policyholder and by the Insurance Company.

Section 8 RECORDS--INFORMATION TO BE FURNISHED-~DET=R-CNATION BY TEE
POLICYEOLDER.-=The Policyholder shall furnish or cause to be furnished to. the
Office such information concerning Employees and the Family Members on. whose
account such Exployees ara insured as =ay reasonably be considered to have a
bearing on che administrarion of the insurance hereunder. The records of the
Policyholder as have a bearing on che insurance hereunder shall be open for-
inspection by the Office at any reasonable cine.

For the purposes of this Supplementary Agreement, determination by the Policybolder
of the following shall be conclusive:

(1) The classification of any person as being within the definicion of the
term “Enployee” in Section 1 hereof.

(2) The effective datas of Exployee's Fantly Life Insurance in accordance
. with Section 2 heracs.

(3) The fact and date of (1) separation of an Employee from the service, (11)
a pay status or son~pay status of an Enployee, and (iif) cessation of an
Eaployee's classification as av Eaployes as defined in Section 1 hereof.

(4) The conditions and specifications referred to in the second paragraph of
Section 3 hereof, ss relating to continuation of Family Life Insurance
after retirement or while che Exployee is receiving benefits under
subchapter 1 of chapter 81 of title 5, United States Code.

Records and files which relate to the administration of the insurance under this
Supplementary Agreement and are taintained by che Office, including claim files,
shall be subjece co such general disposal program as may be agreed upon by the
Policyholder and the Office.

Fora C.1985-4


sudscicucing for icen (3) epzaars

ton 6 of said Supplementary Apress: Forn G.19é5—=4, tne follewizy:

forms

"(Z) such individual policy shall 5¢ upon one of che
custecarily issued dy the
farson, except Tears insursi
osher form of Live Insurance

The foregoing amendment is to be attached to and made part of said Croup Policy.

Signed at_ Washingcon, D. C. chis 26th day of Juns 13.85

OFFICE OF PERSONNEL MANAGE: EXT
(Policyholder)

By. Kevin J. Burns

(Space Below for Use of Metropolitan Life Insurance Company Only)

Signed ac New York, New York chis Ist day of October 19 8S

METROPOLITAN LIFE INSURANCE COMPANY,

Sherron Williamson Lig /, an

(Registrar) Harry 2,
3: nen

Tora 6.198561

COPY.


Certified Copy of a Death Record

DECEDENT'S BIRTH NO. | REGISTRATION 3 STATE OF ILLINOIS. STATE FILE
DISTRICT NO. “ Sk NUMBER
REGISTERED 4 MEDICAL CERTIFICATE OF DEATH
nuMeeR YZ,
Type or Print in OS FIRST MIDOLE a LAST ISEX JOATEQF OEATH (MONTH, DAY, YEAR)
PERMANENT INK
elena | OSKAL Jones __|,MalelJuly 05, 200/
Hospital (or Physicians COUNTY OF Oo K AGE LAST UNDER YEAR| UNDER DAY _[DATEDE BIRTH wontn oky, veaRy
la cums) [0s T-8AYS ~THOURS | HIN
INSTRUCTIONS 4. Cook Sa, ol 5b, i Sc. laly 16 2 79.39
CITY, TOWN, Nak DISTRICT NUMBER HOSPITAL OR OTHER INSTIT)TION-NAME [iF NOT JN EITHER, GIVE STREET AND NUMBER) if HOSP. OR INST, INDICATE DOA
rth ital “Worthiake \cTnpalient
A. | = Northlake. wVeneor Hospital Northlake _|c
BIRTHPLACE (CITY ANO STATE OR: MARRIED. NEVER MARRIED, INAME OF SURVIVING SPOUSE (MAIDEN NAME, iF WiFE) (P2Eie NT mr
DECEASED FOREIGN COUNTRY) wroge®. DIVORCED (SPECIFY) ARMED FORCES? (YES
Clarksdale. Ms a. Married a. Maxine Clark 8. Yac
8 SOCIAL SECURITY NUMBER reg OCCUPATION |KIND OF BUSINESS OR INDUSTRY JEDUCATION (SPECIFY ONLY HIGHEST GRADE COMPLETED)
beteeeeceeee ElomgnarySeconanry (012) Colageti-eor5 +)
c 10339 30-8220 iiaLaborer MPost Offic tad
° RESIDENCE (STREET ANDNUMBER) CITY, TOWN, TWP, OR ROAD | SsmcT NO. INSIDE CITY COUNTY
— . INSIDE
Bees tga 5317 W. Van Buren 13. Chicago te. Yes 136. Cook
VF . : af DE RACE (WHITE, BLACK, AMERICAN |OF HISPANIC ORIGIN? (SPECIFYNOOR YES-I YES, SPECIFY CUBAN, MEXICAN, PUERTO RICAN, &
inois 5064: wom Taek”
i3e. 13f. t4ab 14b._ XINO- OYeEsS SPECIFY:
FATHER-NAME, fitiie ~_ MIDOLE MOTHER-NAME FIRST MIDDLE (MAIDEN) LAST
PAR og
. 15. Jones 16. Ada Sanders
INFORMANT'S NAME (TYPEORPRINT) RELATIONSHIP MAILING ADDRESS (STREET ANONO. ORAF.D., CITY OR TOWN, STATE, ZIP)
iza, Maxine Jones : Bi fo 176
18. PARTI, otha dsasea sapere thal causedthe death. Oo aotantorihe mado of ying, suchas cardiac or respiratory area, ERASE
Immediate Cause (Final
disease or candiion
tesutg in death) ry) __SEPSAS
DUE TO, ORAS ACONSEQUENCE OF
CONDITIONS, IF ANY
WHICH GIVE ise TO (b) CAR-1D1O MYOPATHY
IMMEDIATE CAUS! ONG QUETO, ORAS ACONSEQUENCE OF
Seater Fee ONDE =
wo. _Crokosary ARIERY DISEAST.
SATE i nS aaa anatma on eon UL resutting In the underlying cause givenin PART |. Autor | WERE AUTOPBY FINOINGS AVARABLE PRIOR
SMO} [cou snouor curser ceano(rtonc
2M, DECUBITI rsd [see
DATE OF OPERATION, IF ANY | MAJOR FINDINGS OF OPERATION: If FEMALE, WAS THERE A PREGNANCY IN PAST
THREE MONTHS?
20a. 20b. 20c. YESO NO
H(DID) (BHO ROT] ATTEND THE DECEASED = (MONTH, DAY, YEAR) fae praale aa aly tie HOUR OF DEATH
AND LAST SAW HIM/HER ALIVE ON _ EXAMINER NOTIFIED? geo
2ta. Jury OF, 2004 21b. at. 4°26 4M. ow
‘TO THE BEST OF MY KNOWLEDGE, DEATH OCCURRED AT THE TIME, DATE AND PLACE AND DUE TO THE CAUSE(S) STATED. DATE SIGNED (MONTH, DAY, YEAR)
22a. SIGNATURE p> Aevkenantt. 2, JULy 08,200)
NAME AND ADORESS OF CEATIFIER (TYPEORPRINT) 7 . ILLINOIS LICENSE NUMBER
226, 2133 S- ern Poth AVE, BER Ls e4o2.. 224, O36~95 7106
NAME OF ATTENDING PHYSIGIANIFOTHER THANCERTIFIER __(TYPEORPAINT; NOTE: IF ANINJURY WASINVOLVEDIN THIS
DEATHTHE CORONER On MEDICAL EXAMINE
23. MUST BE NOTIFIED,
BURIAL, CREMATION, \CEMETERY OR CREMATORY~NAME LOCATION CITYOR TOWN ‘STATE DATE = (MONTH, DAY, YEAR).
REMOVAL (SPECIFY) 4 4
24a, Burial 24b0akridae. zi.Hiliside Illinois ~ 281 y12 2001.
P pisposiTion | FUNERAL HOME NAME 'STAEET AND NUMBER OR FO. ‘ciFYOR TOWN STATE ‘aP
DISPOSITION A on
asa, AeA, Rayner & Sons 5911 W. Madi son Street Chicago, Illinois 60644
FUNERAL DIRECTOR'S sett FUNERAL DIRECTOR'S ILLINOIS LICENSE NUMBER
» G
25. b> = D| tip ve, 31009 35%

TOGA REGISTRARS JGNATURE [OAT FREDBY LOCAL REGISTRAR MONTH OAV, YEAR)
26a, >. : wen ele f2, 200

R200 (Rev. 5/89) tinois Department of Public Health—Divigion of Vital Records : (GASEDGN 19890 S. STANOAROCERTIFICAT

I HEREBY CERTIFY THAT the foregoing is a true and correct copy of the death record for thr decedent named at item 2, and that th

record was established and filed in my office in accordance with the provisions of “UA Viral vie Act,

DATE SIGNED

AT BROADVIEW, ILLINOIS 60155 ,Minots OFFICIAL TITLELOCAL REGISTRAR OF VITAL STATISTI

The original record of this death is permanently filed EXHIBIT ‘ENT OF PUBLIC HEALTH at Springfield, Coun
clerks and local registrars are authorized to make certl riginal record, The Illinois statutes provide that t
certification of a death record by the Department of Pu ounty clerk shall be prima facie evidence of the fac

therein stated,


AMENDMENT 37_=_ (Continued)

(10) ‘The contractor will notify each labor union or reoresentative
of workers with which he has a collective bargaining agreement or other
contract understanding, that the contractor Is bound by the tens of
Section SO3(a) of Title ¥ of Public Law 93-112, the Rehabilitation Act of
1973, and Is commited to take affirmative acticn to employ and advance in
employment physically and mentally handicapoed Individuals.

(11) The contractor agrees to submit a copy of his attirmetive action
program to the Assistant Secretary for Exloyment Standards within 90 days
. after the award to him of a contract or subcontract.

(12) The contractor agrees to submit 8 summary report to the Assistant
Secretary for Empicyment Standards, by March 31st of each year during per=
formance of the contract, ang by March 3ist of the year following completion
of the contract, in the form prescribed by the Assistant Secretary, covering
omployment and complaint experience, accommodations made-and all steps taken
to effectuate and carry cut the commitments set forth in the affirmative
action program.”

The foregoing amendment Is to be attached to and made part of sald Group Policy.

Sicned at Washington, D.C. ths 1th day of dune 19.75.

UNITED STATES CIVIL SERVICE COMMISSION

(Pol feyholder)

By ROBERT BE. HAMPTON,

{Space Below For Use of Metropolitan Life Insurance Company Only)

Signed at_New York, New Yorke this 19th day of June 19_ 75,

METROPOLITAN LIFE INSURANCE COMPANY,

Bcd Ass20

Ooneia A Coed
Richard D. Zinke Senier Vice-Prescen and Secretary

(Registrar)

Form G,1985-32 C@ PY ~


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY NO. 7000-6 bearing date of August 29, 1954 and Issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Poticyholider)

pursuant to chapter 87 of title 5, United States Code, is hereby amenced as follows:

Ettective January !, 1976,
A. Sy acding at the end of Section 4 therect, the following:

“In addition to the amounts of Lite Insurance and Insurance for Oeath or
Dismemberment by Accidental Means, if any, In accordance with the pro~
visions of tne preceding subsections (A) or (8), whichever Is epolicabie,
the Office shall pay interest, as determined by the Insurance Company to
the Beneticiary of record or claimant, as specified In Section i! hereot,
on

(1) any Getayed payment of claims paid tn one sun from
the cate of death of the Employee to the date of the
payment of such claims, and

(11) any delayed payment of optional modes of settlement,
as specified in Section 20 hereot, from the date of death
of the Employee to the effective date ef the supplementary
contract issued in connection with such options! modes of
settienent,

provided, in either case, the Employee's death occurs on or after January |,
1976, and provided turtner, that:

{. no Interest shali be payadie on delayed payment of claims uncer
The Insurance tor Death or Olsmemberment by Accidental Means
tor any joss other than loss of life, and

2. no Interest shat! te payable for periods (a) In excess of two
years or (b) when payment has been prevented pursuant to
orders, cequiations or advice of the United States Government,
and

3. ne interest shat! accrue for any period during which payment
Ss Gelayed cue to the inability to locate the claimant; however
payment of interest wil! be considered when @ proper claimant
files proof of claim under the terms of the Group Polley.”

Form G. 1985-34 ( 0) [P Y


METROPOLITAN ‘LIFE INSURANCE COMPANY

————$

GROUP POLICY

Sa, 27000-G hearing date of \uyust 29, 1952 ard insured w

UNITED STATES CIVIL SERVICE COMMISSION

(tteneny CALLED TH

POLICYHOLDER)

pursuant to the Fereral Kamployees’ Group Life Insurance .\ct ‘of 1984, is hereby amended as follows:

AMENDMENT |
iffective an of the date of insure of said Group Molicy, by sue
stimting for item (4) of the fit paragraph af Section 3 therent.

the fullowing :
(3) The day immediately preveding the date the Fmphiyse n=
ters un active duty in ae with the Army, Navy. Air Force,
Marine Curps. o Coast Guard of the ”

AMENDMENT 2
Liffeetive as uf the date of iastte uf nai

Gran
A. By substituting for the second sentence of the secant paras
graph of Section 3 therenf, the following :

~The iti
are: ta) the

fur continuation of insurance alter retirement
ployee niust be entitle! tu aud have met all reynites
mediate annuity under any oi the Retire-
vent System listed in Scheie If attached to this Molicy as a poet
herenf, and (h) the Enployee imnuat either he retired fur disability
we have completert 15 years of creditable service, inchuling as part
oi such creditable service, if the Employee at retirement as cute
pleted at lewt live seats ui creditable civilian service, permtly uf
Inmetable active service if Force, Marine
Corps, or Cosat Guiril uf the United States.

M. Hy subtitenee
teu Li therou, the

for item (41 of the second paragraph af Sexe
Messing :

that any such Fi
pleted at leant 15 years of creditable service.
part of such creditahte service, if the Employee at retire
tugnt has completed at feast five years of creditabie ©
service, perivds of hunurable active service in the Army,
Navy, Vir Force, Marine Cun. of Coat Guant of the
United States, and city that any such Employee's aimunty
has terminated and the date af such terminanen,

AMENDMENT 3

tive ax of the date of issue of sail Geoup Colicy, by sub
stinating for the expten “Schethe of Lasers” and fur the pruvisiens
Appearing

“Semana oe Lawes

Fue lees of life, the full samint of Inairance for Death of fis
tnetberment hy \evidental Means in force ont accuunt of the Eine
Hyer, in accuntauce with Section $ herd, at the sate of the
Kmpdoyee's death, of at the date of ceation of such insurance if hie
death sacurs after such eesation, shall be payable ax provide! in
this sulmection (13).

For any of the fullu lonver, the full amount of Insurance for
Death of Dismemberment hy .\ceidental Means in force on account
of the Employee, in arcurtince with Sevtion 4 hereof, at the date
nf the accident shall be payable as provided in this sutmertion (8):

Total and Irrecoveralle Lame of Sigit of Hoth Eyes:

Lone of Both Hands hy severance at ur ahove wrint-joints

Loss of Both Feet by severance at or above ankle-joints

Lanna of One Hand and of One Knut ly severance at ar above
wists and ankle-joints respectively

Such kms ef One Hand or af One Foot together with Tatal aut
Irrecoveratte [ams of Sight of Ome Eye.

For any af the fullowing krves, uneshalf the anwain of Insurance
far Death of Dinnembernent hy Acvidentat Meana in farce on
acount of the Employee. in agcurdance with Section 4 herent, at
the date of the arvident shall he payable as prided in this sule
section (H)2 = .

Loss of One Hand by severance at of above wrists

Tana of One Enut hy severance at ne above anklesoint

Total and Irrecuverable Lars of Sight of One Kye.

Uf the Employee ahall snfler more than ame af the omnes set iuvetle
iu thin subsection (Ih) Tesiit_of any onc, 4. then the
aggregate amount payable for all such kmaea, saber than hin af
life, shall nt excoed the fall amount af Insurance lor Death or Dis-
meniberment by Accidental Means in force om acewunt ui the
“amployee. in accurtiance with Sectiun 4 bereuf, at the date of the
aeviclent: andl the anenint peuyalie foe bios of life eesalung front the
Sune accident shall nt exceed the excens, if any. of the full anwune
of lasarance for Death or Disnembenveut by Accilental Mean
in force on arcuunt of the Employee. itt accordance with Section 4
herme. at the date of the Kauployee’s death, of at the date of cose
tien of such insurance if his death uvcurs after wich cresation, over
the aggregate amount payable for all ether lvees sutiered ara
result of such agcident. Any pasent fur kiss af lite made by the
Oice prive to eecerpt ly the Ctfve uf clan hy ar ow beball af dhe
Employee or-his estate fur any other kines sutfered hy the
ployee asa result of the sume accident shall diachange any liah
af the Insurance Cunmpany with respect ty all sich other knees te
the extent of the anvaunt of payment noule for bins uf lite.

Ifany Employee has suffered prior to the date uf insue herevf,
does thereafter sulfer. the lors of one hand ly severaner at ur aluive
the wrint-juint, of of une fuut hy severance at ur alawe the ankle jit,
fr the tutal and ierevuverable kins of sight of nue eye, the busiranee
for Death oe Dismewberment by Accidental Means hereuuter on
auch Kauphiyee shall he insuerl der contitanest ive the jul await ape
plicable to hin in accuntance with Sevtion + berm, (wevidedd, how +
ever. that the anwunt oof such instirance payable fur the subsespient
lama of coe Tenn of af one fae at the sight asd one eye as procubet
in this subsection (10) shall be oneshali of sacle dull susan.”



METROPOLITAN LIYE INSURANCE COMPANT

GROUP POLICY NO» 37000-G bearing date of August 29, 1954 and issued to

. OFFICE OF PERSONNEL MANACEENT
(Herein called the Policyholder)

pursuant to chapter 87 of title $, United States Code, is hereby anended as

follows:

AMENDMENT 63

Effective July 1, 1983,

Ae By substituting for the last paragraph of Section 4 thereof, as azended,

the followings:

“(C) In addition to the avounts of Life Insurance and Insurance for Death

or Disuemberment by Accidental Means, if any, in accordance vith the
provisions of the preceding subsections (A) or (3), . whichever is

applicable, the Office shall pay interest, as determined by th

Insurance Company to the Beneficiary of record or claimant, as
specified in Section II hereof, on

(4) any delayed paynent of claims paid in one sum; said interest
shall accrue only from the thirty-first day following the date of

death of the Employee to the date of the payment of such clains;
and

(12) any delayed paynent of optional nodes of settlement, as specified
ia Section 20 hereof; said interest shall accrue only from the
thirty-first day following the date of death of the Puployee to
the effective date of the supplesentary contract issued in
connection with such optional modes of settlement,

provided, in either case, the Pxpleyee's death ‘Occurs on or after July 1,
1983, and prowided further, that:

i. so inte:

Insurance for Death or Dismemberment by accidental Means for any loss other
than loss of iffe, and

st shall be payable on delayed payment of claims under the

no interest shall be payable for periods (a) in excess of two years or (b)

vhen payment has been prevented pursuant to orders, regulations or advice *
of the United States Goverment, and

Bo interest shell accrue for any period during which payment is delayed due
to the inability to locate the claimant; however payment of interest will
be considered vhen a proper clainant files proof of claim under the terns
ef the Group Policy.°

Form G.1983-40


METROPOLITAN LIFE INSURANCE COMPANY

GROUP POLICY No, 17000-G bearing date of August 29, 1954, and rssued to
UNITED STATES CIVIL SERVICE COMMISSION
CReAPES CnGrte PIE ae vttON DR
pursuant in the Feileral Eanpbasers Gorm |e bisuranice Act of 1984, is hereby samenled ay fellows

AMENDMENT f¢
Ritective fur the polie year evn

“Neenen 21 SCUED

yencing Navember 30, 1958. snietiniting for Sevtion 21 thereot the iniluwing’
OF BASIC PREMIUM RATES

Se sacor tti Wersny Basie Link Ixsre ayer

Pansies Rates Pre $1,000 mance

Vtugeews’ Ver
N

\eared rarest . N
Premiun Nordelay Premran Hirttiay Premium liethdae _
30.08 5 SOK 35 0a 73

os 36 ay % A] 76 3.69
oo . 9 2 7 st 7 4.00
» Ss 2 $3 a7 x 433
9 39 2 39 3 ec)
oo 40 a «0 1.02 20 3.07
10 4 2s at ay al Sa8
10 2 2 a2 1.20 2 $93
10 43 » a 1.30 x3 6a
ee a
aT) a8 a) a 152 xs 737
42 ai Ms tw 168 Ne ROS
Az v7 3s “7 Ww x7 8.68
a2 8 at ux 19s Sy 9.35
aa | Renee # . 2.10 sid ~ 10.06
it 30 38 70 22R 9 1081
at sl aI 7 247 n 161
AS 32 33 zt 2.68 92 1243
16 33 om) 33 290 93 13.33
ata Ss bt 74 3s os W277

The bi-weekly basic premium rate for Insurance fur Death of Dismemberment by Accidental Means
shall be $0.0231 per $1,000 of the fill amount nf auch Insurance.”

The foregoing Schedules of Basic Premium Rates shall remain in effect for policy years subsequent to the policy year conse
wing November 30, 1958 subject tw further Feadjusiment as jirovieled in sulmecuon (A) of Section 14 of said Group Policy.
in accordance with the second paragraph of Amendment 15 attached ty said G: Policy as a part thereof, it is agreed that
the foregoing reduction in Basic 1.ile Insurance Premium Rates shall not of itself operate wo change the figure used for the Maximum
Risk Charge in the “Schedule of Maximum Expense and Risk Charges” in Section 1$ of said Group Policy, and that otherwise the
second paragraph of said Amendment 15 shail remain fully operative with respect to any future reduction or rertuctions in a basic
Jremium race of tentative average premium rate.

The foregoing amendment is to be attached to and made pert of said Group Polk
Sigmed at Washington, D. C. this... 2558... m

. Dy PERAK Te LAIR
(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)
Signed at... THY KEK Me Xenia this, 25 tb.__._.day of. September 19.88.
METROPOLITAN LIFE INSURANCE COMPANY,

woe I G ) P Y . hop anna

Term GIL mtaly 10tbmentar ow Be


-2-
AMEN OMENT 49 (Continued)

D. By deleting the last sentence in Item (3) of the first porograph of Section 3
thereof,

E. By substituting “subchapter | of chopter 81 of title 5, United States Code”
for *the Federal Employees’ Compensation Act®

(1) In the Fint sentence of the second paragroph of Section 3
thereof,

(2) In the first sentence In Item (8) of the second parograph of
sald Section 3, and

(3) In the first parograph of Section 11 thereof. .
F. By substituting "law" for “Act”
{1) In the fint perograph of ‘Section 2 thereof, .

(2) In the first ond third sentences In Item (8) of the second
porogreph of Section 3 thereof, and .

(2) in two ploces in Item (d) of the second perogroph of
Section 16 thereof.

The foregoing amendment Is to be attoched to and mode part of said Group Policy.

Signed at _ Washington, D.C. this Sth day of october 19_ 68.
UNITED STATES CIVIL SERVICE COMMISSION
olicyhoider}
By. sJomn_W, Macy, Jry

(Space Below For Use of Metropolitan Ufe Insurance Compony Only)

Signed of Nev york, Nev York this 2th dey of __ october 19 68
METROPOLITAN LIFE INSURANCE COMPANY,

Mb. Mittiabeck

R. Ma: Jr.
stron)

Form G.1985-24 e (0) P Y


Section 4. (Continued)

If the Policyholder receives wri: notice from the Employee that his/her Family
Lise Insurance hereunder is not to be conzianued after retirement or entitlement to
benefits under subchapter 1 of chapter 81 of title S$, United States Code, che
provisions of this paragzaph shall be null and void and of so effect and no such
insurance shall be provided for the Esployee after retirement or entitlement to
such benefizs.

The cera “effective reduction date” seans the first day of the second calendar
soncth after (1) the date the Buployee's Family Life Insurance on account of his/her:
Family Members vould othervise have ceased because of the bappening of the event
specizied in eicher of items (1) or (2) of the first paragraph of Section 3 hereof
or (2) the Exployee's 65th birthday, whichever cccurs later. .

€j—Zn-additien—to—the—-asount—of—Fanily—Life—lnsurecce,—io—any,—_is_accordance—vith-
the provisions of the preceding subsections (A) or (3), whichever is applicabl
the Office shall pay interest, as determined by che. Insurance Company,” to t
Enplo or claizast, as specified in Section 11 of che Group.-Policy, on. any
delayed paysenc of clains paid in one sum from the date of-‘deach of any Family
Mesoer to the dace of the payment of such claim, provided” thats

1. no interest shall be payable for periods (a) in excess of tvo years or (b)
vhen payment has been prevented pursuant to orders, regulations or advice
of the United States Goverment, and

vo interest ‘shall accrue for any period during vbich payment is delayed
due to bility to locate the claimant; hovever paymast of interest will
- be considered vhen a proper claimant files proof of claia under the terms
———of-chis-Supplementary-Agreenent - —

sec amend 65
w

See

Section 5. INSURING CLAUSE.--Upon receipt by the Office of satisfactory proef, in
writing, that any Family Mexber shall have died while the Exployee is insured
heteunder for Family Life Insurance on account of such Family Member, the Office
shall pay, subject to the terms hereof, the amount of Family Life Insurance, if
any, (plus interest, if any, aa determined by the Insurance Company) in force
hereunder on account of such Family Member in accordance vith Section 4. hereof, at
the dace of death of such Fanily Member. Payment shsll be made to the Employee
immediately after receipt of such proof. In the event of che death of the Employee
afrer the death of an insured Family Meaber, but before such payment 13 made, such
payment shall be made to the person or persons entitled to che Life Insurance
(exclusive of Option A - Standard Life Insuranc ad Option B - Additional Life
Insurance) in force om sccount of the Employee as provided in Section ll of the
Group Policy. .

Form G.198S-A


METROPOLITAN LIFE INSURANCE COMPANY

Group Policy No. 17000-G bearing date of August 27, 1954 ond Issued to

UNITED STATES CIVIL SERVICE COMMISSION
(Herein called the Policyholder)

pursvant to the Federal Employees’ Group Life Insurance Act of 1954, Is hereby amended as follows:
AMENDMENT 33

Effective February 26, 1963 by subitituting for item (5)
of Schedule A attached to tad Group Policy as a part thereat, the following:

*(5) Secsanc! of emergency employees whose employment Is of uncertain
or purely temporary duration or who ore employed for brief periods
ot intervals, but this does not exclude employees having career=
conditions! or ecrees oppaintments who are employed under a cooper=
tive work =study program of ot least one yeor's_duration which
requires the employee to be in pay status during not less than one=
third of the total time required for the completion of the program."

The foregoing amendment is to be attached to and made part of said Group Policy.

Signed at Washington, D. C. this 30th doy of April 19 63
Helen 0, Thrin UNITED STATES CIVIL SERVICE COMMISSION
(Wimess) “{Folleyholder) —
by Joun W, Macy, Jr.

{Spece Below For Use of Metropoliton Life Insurance Company Only)
Signed at __ New York, ¥.Y. this z7th doy of Mey 19 69

METROPOLITAN LIFE INSURANCE COMPANY,

C. , Arlinghaus Keas€. Hethubeck
(Registrar)

Form G.198545

COPY


=
FEGLI

Claim for Death Benefits

Federal Employees’ Group Life Insurance Program

—)
FEGL!

(Do not use this form to claini Option C-Family Benefits. Please use form FE-6 DEP to claim those benefits.)
’ *
Instructions

General

The Office of Federal Employees’ Group Life Insurance (OFEGLI)
pays claims under the Federal Employees’ Group Life Insurance
Program. “We” and “our” on this form refer to OFEGLI.

FEGLI death benefits are not subject to Federal income tax, but the
interest that we pay on those benefits is subject to such tax. We will
report all interest payments to the Internal Revenue Service.

Who receives the death benefits?

We will pay benefits in the following order of payment:

If the deceased assigned ownership of his/her life insurance to
someone else (generally by filing an RI 76-10, Assignment form),
then we will pay:

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

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

If the deceased did not assign ownership and there is a valid court
order on file with the agency or OPM, as appropriate, we will pay
benefits according to the court order.

If the deceased did not assign ownership and there is no valid court order
on file with the agency or OPM, as appropriate, then we will pay:

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

Second, if none, to the deceased’s widow or widower;

Third, if none of the above, to the deceased’s child or children
and 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 deceased’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 deceased’s estate;

Sixth, if none of the above, to the deceased’s other next of kin,
entitled under the laws of the state where the deceased lived.

How will I receive benefits?

If you're entitled to less than $7,500, we will mail you a check.

If you're entitled to $7,500 or more, we will open a money market
account in your name and mail you a checkbook. You may write
checks for some or all of the money in your account as soon as you
receive the checkbook. See page 2 for details.

How do I complete this form?

Please type or print legibly in ink.

If you need help completing this form, call our service
Tepresentatives, toll-free, at 1-800-OFE-GLIA (1-800-633-4542).

Here is a summary of what parts of the form you must complete:

Then Complete These Parts of the Form:
If you are A |B |c [ec ]op [se | F | Page
a: 13) | 4413 2
Designated |v v vi[v
Beneficiary
Widow or vilv|[vule vi|ly
Widower
All Others viviyv vi[vultvlyv

Don’t skip any questions you’re supposed to answer. That will delay
our action on your claim. If a question doesn’t apply, write “N/A” or
“not applicable”. If the answer is “No” or “Unknown”, write that.

If you are completing this claim on behalf of someone else (such as a
minor), complete items 1-3 of Part C with that person’s information,
not yours. In Part F and page 2, sign your own name “on behalf of”
the other person. Fill in your name, address and phone numbers.
However, the Social Security Number should be the other person’s, not
yours.

What else do I have to submit?

In addition to this claim form, you must submit a certified copy of th
deceased's death certificate that contains the cause and manner of
death. (However, if you know for sure that another claimant is
submitting the deceased’s death certificate, you don’t have to). You
can get the certificate from your city or state’s Bureau of Vital
Statistics or equivalent agency. We cannot process your claim until we
receive the certified death certificate.

Please submit an English translation of any foreign language death
certificate,

In addition, send us all Designation of Beneficiary Form(s) (SF 2823
and/or SF 54) that you may have which show the agency receipt date
‘on the bottom.

If you are an executor or administrator filing this claim on behalf of
the deceased’s estate, send us a copy of the court appointment papers.
‘We will let you know if we need anything else.

Where do I send this form and other documents?

If the deceased was employed at the time of death ,

Send everything to the deceased’s employing office. We will process
your claim after we receive certification from the agency. However, if
you are the deceased’s widow(er) and the agency told you to send
your claim form and other documents directly to us, you should do
that. Please include copies of any letters you received from the agenc
that mention death benefits.

If the deceased was retired or receiving Federal Workers’
Compensation benefits at the time of death

Send everything to OFEGLI, P.O. Box 2627, Jersey City, NJ
07303-2627.

Instructions to the employing agency
Forward the completed claim, death certificate and court appointmen
papers, if any, to OFEGLI, P.O. Box 2627, Jersey City, NJ 07303-
2627, together with: .
1. The original Agency Certification of Insurance Status (SF 2821);
2. The original Designation of Beneficiary form(s) (SF 2823 or

SF 54), if any;
3. All court orders on file, if any; and
4. All other FEGLI forms (for example, SF 2817 or RI 76-27 electio

forms, RI 76-10 assignment form, etc.)

EXHIBIT

a


jective as of the date of issue ui said Grontp Policy. by sub
sutuemg for tems (81.099. 101, ella, 24, 11d). Oise and
(15) of Schedule B attached to said Gr y ava part thereni.
the fullowing:

System { Social Security
stem
Health Service

(8) Old Age and Survivers [nau

19) Cuast and Geodene Surv
(10) System for Onicers of the Br
(UL) Lighthouse Retirement SystemTM

AMENDMENT $
Uiffeetive July 16, 1Y85.

A. Hy subsututing for item (11) of Schedule .\ attached to said
Group Paliey a» a part thereui, the fullowing:

“ULLy Prior to July 16, 193 ployees serving in cooperation
with non-Feleral agencies who are paul in whole of in
part from non-Federal funds.”

L. By substituting fur the first paragraph oi Section 2 thereof.
the ivilowing:

“Nevnum 2. ECTIVE DATES OF INSURANCE.—The
“erieetive date’ referred to in this Section 2 shall he the first day uf
_ the first pay pened which begins aiter .\uguat 28, 1954, except that
on the case of Hinployees in the en vi the Hoard of Governors
vi the Federal Reserve System, the ‘effective date’ shall be the
est slay uf the firat pay period which begins after September 25,
19154, and except that in the case ui Eanployees serving in cuoperas
tun with non-Feleral agencies who arc juaiel in whole of in part
irom wwn-Federal iunla, the ‘eticctive date’ shall be the date or
dates on oe alter fuly 16 prescribed by the Policyhokter for
any yromp af such employees.

C. By adding to the second imragranh af Section 13 thereni, the
fulhowing item (5):

“184 The “efleonve date’ reierred to 1n the fist paragraph of
Section 2 hereof. for any group of Emplovees vening in
cooperation with non-Federal agencies who are paid in
whole or im part front non-Ferleral funds.”

AMENDMENT 6

Effective August 11. 1955, by adding to Section 22 thereoi. the
following:

“as amended August 11. 1955."

AMENDMENT 7

Effective Auguot 11, 1955. hy substituting for Section 23 thereol.
the following:

“Section 23. CONFORMITY WITH LAW.=t any provnions
required hy the Federal Employees’ Group Life Insurance Act of
1984 (other than the provisions of Section 10 thereoi), as anrended
s\ugwet 11, 1955-49 be contained in this Policy are not specifically
contained herein. then such provisions shall be deemed part of this
Policy as though set forth herein at length, No amendment to said
Act enacted aiter August 11, 1955 shall have any effect on the rights
or liabilities of the Policyholder or the Insurance Company under
this Policy except pursuant to appropriate amendment to this Policy
aigned by the Policyholder and hy the Insurance Company “

AMENDMENT 8
Effective Noventh tituting the figure “0.30%.
for the figure “0.33 of the “Schedule of Maxi-

mum Expense and Risk Charges” in Section 15 thereof.

‘The foregoing amendments are to be attached to and mace part of said Group Policy.

Wasnincrox, D.C.

Signed at... this, Bint

aay,

Mary J. Angiuis

(Winsomns

day of... 19,58,

UNITED STATES. CIVIL SERVICE COMMISSION

By. Philip Young

(SPACE BELOW FOR USE OF METROPOLITAN LIFE INSURANCE COMPANY ONLY)

Secretary.

Signed at__New York, BY. this_Tyenty-eignth day of... MAY.
METROPOLITAN LIFE INSURANCE COMPANY
C. G. Ariinghaus
‘heparan
Fos COPY
Nov. 1955 ”

PRINTED 1 U.S.A.


METROPOLITAH LIFE INSURANCE COMPANY

GROUP POLICY lo. 17000-G bearing date of August 29, 1954 enc issued te

WAITED STATES CIVIL SERVICE COMW4SSION
(Herein caiied the Poll cyholcer)

pursuant to chapter 87 of titie 5, United States Code, is hereby anenced as follows:

AMENDMENT 36
Ettective July 1, 1973,

A. dy adging “Cincluding adequate provision for adjustment, as specified
in the next tollowing paragraon, in charges previously made on account of excess
mortality costs uncer indivicual policies Issued pursuent to Section 6 herect)”
immed. ly following "all charges accrued hereuncer" in the tifth sentence of the
third paragraph of Section 15 thereof.

BU. By substituting for the last sentence of the fourth paragraph of
said Section 1S, the tol lowing:

"The charges for such excess aortallty costs shell be as fol low

(1) As fo Individual policies issued prior to July |, 1973:

Such charge snail be at the rate of $63 for each $1,000 of ite insurance
tasued uncer each suc policy.

{2} As To Individual policies Issued on or after July 1, 1973:

A tentative charge, differentiating between (1) life Insurance Issued
unger any such policy which is attributaole to the Emioyee's Lite
Insurance nereuncer exclusive ot optional Lite Insurance, and (11)
lite insurance Issued uncer any such policy which is attributaple

to the Exployes's optional Lite insurance hereunder, will oe

made as of the cate of Issue of each such policy. Such tentative
charge will be subject To periodic adjustment on the basis of actual
and projected mortality experience under such individual policies
during the ten years following issue of any such policy. The rates
at which initial tentative charges are mace, and the methods tor
Subsequent adjustments in such tentative charges, wiil be deters
mined from time to time by mutual agreement between the Policynoider
and the Insurance Company.

COPY

Form G.1985-31


PAGE 97





Form Approved

: : Designation of Beneficiary OMB No, 3206-0136
FECL , . Warning
Bowater pioyees Federal Employees' Group Life Insurance Program Read instructions on back of

duplicate before filing in this for

Date af birth of Insured (Month, day, year)

ONES eter — Lh ddlg (73F

Social Security number “atin

= ‘An employee Retired or an peewirg OwcP www semen oF receiving Federal
The Insuredis: ____| > Ke applicant for enefits or an Employees’ Compensation, give "CSA*,
Tetirement applicant for OWCP "CSI", or OWCP claim number,

Place an "X" in the benefits

appropriate box. CSA) A 378. EZ LF :

Department or agency in which the Insured Is presently employed (if retired, former department or agency):
Department or agency ye, 2) qo | Bureau Division Location (City, state and ZIP code)

_ Fé) of CARL STREAM,
Lot The GRUB AN LLLOEY- 98

Jam canceling any and all previous Designations of Beneficiary under the Federal | understand that this Designation of Beneficiary, if vai, will remain rh force and
Employees' Group Life Insurance Program and am now designating the beneficiary or effect, unless of until canceled by me in writing, or untit such time as itis automatically
beneficiaries named below to receive any amount of Life Insurance and Accidental cancaled (see back of Part 2). If this designation form is determined invalid for any
Death insurance due and payable at the Insured’s death, teason, the next prior valid designation form will be given full force and effect. if no

such prior form exists, the proceeds will be distributed under the order of precedence,
Lunderstand that if | have previously validly assigned my insurance, any or, if the insurance has been assigned, to the assignee(s).

designation completed by me is not vatid and has no force and effect.

ee

© Percent or fraction to be paid to
each beneficiary

“Type or print frst name, middle initia, and | Type or print address (Including ZIP code)
last name of each beneficiary of each beneficiary

Relationship

LE | SBT OH BULEW ST.
MEXINE Tiles Ki Chases, L) bvtien, Uke |/00

Ctbeutse I. Liste k Teas cE, CO Et | S04 60%

LS

. Print or type your name and address [Please check. [Check only one: [Please check:
(including ZIP code) r Ih am:
. ~ ~ (have not assigned my insurance,
have the Insured I have signed this form in the presence of the two witnesses who
= X | have sighed below.
nd have not | _Jan Assignee >X || Neither witness is named as a beneficiary.
elected Living If designated shares to be paid to more than one beneficiary,
Benefits. the shares add up to 100%. (Dollar amounts are not acceptable.)
For each type of insurance (Basic Life, Option A-Standard, and Option B- (2) | understand that if none of the designated beneficiaries is living at the time of
Additional): (1) | hereby direct, unless otherwise indicated above, that if more the Insured's death, the proceeds will be distributed under the order of
than one beneficiary is named, the share of any beneficiary who may precedence, or, if the insurance has been assigned, to the assignee(s),
predecease me or become disqualified for any reason from receiving a share of
the benefits shall be distributed equally among the surviving beneficiaries, or thereby specifically reserve the right to cancel or change this designation of
entirely to the survivor. beneficiary at any time without knowledge or consent of the beneficiary(ies).
Signature of Insured/Assignee (Only the Insured/Assignee may sign, Signatures by guardians, conservators or Date of execution (Month, day, year)

through a power of attorney are not acceptable.)

SE Tem be. £, ©,

“Signature of witness ye ~~ {Number and street —_—— (City, state and ZIP code
Aa Bary laystee Gear ee cet)
Signature of wi lumber and street , State anc code

VOL "Fl... 10 bikiw! bd, Clecez, / Cities le COST

Date of receipt official Title

a Régeiving an

See back of Part 2 for instructions on where to file this form. ‘ederal Employees’ Group Life insurance.

LIS Offine ef Deremerad Meme neee ces sient wanna maa conn ATR


Section 1, DEFINITION OF CERTAIN TERMS USED IN
THIS POLICY.—The term “Employee” means an appointive or
> elective officer or employee in or under the execuuve, judicial. or
legislative Uranch of the United States Government, inci Ka
United States Government owned or controlled corporation, and
of the municina! government of the District of Columbia. exciuding

2B, 40, 41, 48, 46h

fied in Schevule A attached hereto as a part hereof.
The term “Office” means the Office of Federal Emplovees’

Vieoup Lite Insurance which is the admuniatrative ufice established
ly the Insurance Company with respect to this Policy. The post
office adiress of the Office is 330 Fourth Avenue, New York 10,
N. ¥, The Insurance Cumpany shall have the right tu change the
auklress of the Office upon three months’ notice in writing to the

Paticyholder.

emors of the Federal Reserve Syatem. the
the first dsy of the first pay period which bemns after

in any ease any employee in any of the groups oi employees speci= _

“The insurance hereunder on each Employee on the roll of his
‘employing office on the day beiore the effective date specified in the.
first paragraph of this Section 2 shall become effective on such ei
fective date if he is then in a pay starus or is in a non-pay status
which has nor extended continuously for 12 months, provided that
lire that date he has not given written notice to his enmploying
office that he desires not to be insured hereunder.

SEE AMEND, 5, 46,51 SEE AMEND. Uf, 14, 14, 21,

jcfined in Section | hereol on or after the effecive date
apecified in first paragraph of this Section 2 shall hecome ef-
iective on the firThday he is in a pay status unless on of before auch
first doy he has gived«riiten notice to his employing office thar he
« desires not to be insured or had previously given such a
notice which remains

The insurance hereunder on
pay status, on of after the effective

a
a

extended continuously for more than 12
fective on the frst day he is in such pay status un!
auch Grst day be has given written nocice to his empidyi

that he desires not to be insured bereunder of had previously

SEE AMEND.

An Employer who bas given written notice tw an employing
offer that he desires not to be insured bereunder may cancel such
notice and become insured hereunder only if he makes written re-
quest to his employing office for such insurance prior to his $Oth

birthday and not leas than one year aiter the effective date of such
notice, and furnishes at his own expense evidence of insurability
satisfactory to the Offct. The insurance on any such Employee shall
become effective on the firs day be is in a pay status following the
date his request for insurance is approved provided he ‘scquires
such a pay status effective within 3] days following the date of such
approval. Any Employee who must meer the requirenrents of this
paragraph as a condition to becoming insured hereunder and who
ceases ty be an Employee as defined in Section | hereof without
such requirements having been met shail continue to be subject tu
the same requirements if at any time he subsequently becomes an
Employee as defined in said Section 1.

_ Section 3, CESSATION OF INSURANCE.—The insurance
on any Employee-insured bercunder shall automatically cease, ¢x-
cept as specified in the next following paragraph. on the earliest of
the following dates:

(1) The date of his separasion from the setvice.

(2) The date of expiration of a period of twelve months af cur
tinuous nof-pay status of the Employee.

under the Servicemen's In-
demnity Act of 1981 (65 Stat of entering
soiliene

(4) The date the Employee ceases to be an Employee as defined
in Section 1 hereof for any reason other than the happen-
ing of any of the events specified in items (1), (2) of (33
preceding.

(5) The last day of the pay period during which the employing
office of the Employee receives written notice from him that
he desires not to be insured hereunder.

(6) The date of discontinuance of this Policy.

because of the happening of the event specified in either
¢ (2) of the preceding paragraph and the Employee

payment had continued st the same race as
ment, shall be continued of reinstated from the di)
such conditions until the date specifed in the

Form G.1985
‘Aug. 1954

SEE AMEND, 31, 46

SRE AMEND. 1, 14, 46, 4954


‘ 22s
Section 3. CESSATION OF INSURANC:
respect to any Family Menbe
the next following paragraph, on the

The Exployee's Family Life Insurance hereunder
11 automatically cease, excepto a8 specified in
earliest of she following dates:

(1) The date of che Explovee's separation froz. the service. .

(2) ‘The date of expiration of a period cf tveive months cf non-pay status of the-
Exployee.

(3) ‘The day dmnediately preceding the date the Enployee enters on active duty or
active duty for training as a member of a uniformed service, unless the period
of such duty is covered by milicary leave with pay from his/her civilian
posicion.

(4) The dase of che Exployee's death.

(2) The dace the Enployee ceases to be an E=ployee as defined in Section 1 hereof
for any reason other than the happening of any of the events specified in
items (1), (2), (3) or (4) preceding.

(6) The day immediately precedirg the date such person ceases to be & Fanily
Member as defined. .

(7) The date of discontinuance of this Supplementary Agreement oz of the Group
Policy. .

(8) The last day of che pay period during which the employing office ef the
Eaployee receives written notice from the Employee that he/she desires not to

be insured hereunder.

(9) The last day of the pay period during which che employing office of the
Exployee determines that the Exployee's periodic pay, amnuity, or compensation
for work injury is insufficient to cover his/her required contributions to the
cost of the Family Life Insurance hereunder.

Hovever, if the Esployee's Family Life Insurance op account of his/her fanily
Menbers would cease because of the happening of the event specified in either of
items (1) or (2) of the preceding paragraph and the Employee meets the conditions
for continuance of his/her Family Life Insurance after retirement or vhiie
receiving benefits under subchapter 1 of chaprer 81 of title 5, United Staces Code,
as such conditions are specified in the regulation of the Policyholder promulgated
pursuant to chapter 87 of citle 5, United States Code, his/her Faaily Life
Lasurance shall be continued or reinstated for che amount of insurance and period
of time specified in said regulation.

Forn 6.1985-a


AMENDMENT 43. (Continued)

A poyee mey not casign, tronsfer, or encumber his rights under
the optional mode of settlement elected, or ony poyment thereunder,
ond, to the extent permitted by lew, the amount tetcined by the in-
surence Compony and the payments under the optional mode of settles
ment shall not be sublect to claims of ony creditor of ony peyes, nor
to execution er other legal process en behalf of any creditur of eny
poyee.°

a

a

a foregoing amendments are to be cttachad te and made part of sold Group Polley.

Signed at Washington, D.C. this 22nd day of Oecember 19.65
Mary V. Wenzel UNITED STATES CIVIL SERVICE COMMISSION
(Witness) (ollcyholder)
by John W. Mocy, Jr.

(Spoce Below For Use of Metropalitan Ufe Insurance Compony Only)
Signed at__New York, N.Y. this fourteenth —_ day of Jonvery 19-66

METROPOLITAN LIFE INSURANCE COMPANY,

Mlté. Hiethubecke
tewowy

Wm. H. Meyer, Jr.
agiitres}

COPY

Form G.1985+18


DELORES WILLIAMS PAGE 82

10/26/2081 10:42 |. L/736281522 pg 1 773 Tes B2z6 P.aa

PAGE 1 OF 2

OSKER K. JONES
312 Chicago Avenue, Unit 2-H
Oak, Park, Itlinols 60302
Telephone # 708-763-0813

THIS LETTER TO BE SENT VIA FAX TO THE FOLLOWING FAX # 204-398-7950

Ostober 28, 2001
Mr. George Viegelmann

Case Management Specialist

Office of Federal Employees’ Group Life insurance
P.O. Box 2627

dorsey City, New Jersey 07303-2627
RE: DECEASED INSURED: Mr. Osker Jones - CSA#A3786243 - CLAIM# 20010708048
Dear Mr. Viegaimann:

This letter is regarding the telephone conversation today (10-2601) with a FEGLI
representative within your office, and the subsequent conversation by the same person by
with you, regarding non receipt by you or your office, of my letter which was dated end sent
on October 7, 2001.

This letter was sent to your address mentioned above, via Certified Mall with a Return Recalpt,
Number 7004 0380 0002 7806 8067. This letter was rocelved by FEGLI representative, named,
M. Rodriguez on October 18, 2004.

Please consider my statemont listed below to be a reiteration of my pravious letter which was
dated October 7, 2001.

The Designation of Baneficlary, for Federal Employess’ Group Life Insurance, Standard Form
2823, Rev, July 1995, that wae executed on September 5, 2000, which bears the “signature
appearing as that of Osker Jones as the Insured, 1S NOT THE SIGNATURE OF MY FATHER
OSKER JONES, 88# 339-320-8220, who was born July 18, 1939. 1 AM STATING THAT THE
SIGNATURE I9 FRAUDULENT AND NOT THAT OF MY FATHER OSKER JONES.

Also, please note on the Designation of Beneficiary Form, the section that beors the caption of
“STATEMENT of INSURED or ASSIGNEE”. This section, which required the printing or typing
Of the Insured’s name and address WAS NOT COMPLETED. Also the portion within the same
section of the form that required the “checking” by my father, which wouid have Indicated
that he was the “Insured” or “An Agsignee” WAS ALSO NOT COMPLETED. IF MY FATHER,
OSKER JONES HAD ACTUALLY SIGNED THE FORM, YOU CAN BE ASSURED THAT HE
WOULD HAVE COMPLETED ALL PORTIONS OF THE FORM THAT REQUIRED INFORMATION
AND COMPLETION BY HIM. HE DID NOT SIGN THIS BENEFICIARY FORM THAT WAS DATED
SEPTEMBER &, 2000.


3. By substicut. for the lest peragraph of Sec sa 4 of Supplenentary
Agreement Form C.198$-A, attached to said Group Policy as @ part thereot,
the following:

“(C) In addition to the amount of Family Life Insurance, if any, in
accordance with the provisions of the preceding subsections (A) or (B),
whichever is applicable, the Office shall pay doterest, a8 deternined by
the Insurance Company, to the E=ployee or claimant, a8 specified in Section
11 of the Group Policy, on any delayed payment of claims paid in one sun;
said dnterest shall accrue only from the thirty-first day following the
dete of death of any Family Member to the date of the peyzent of such
claim, provided that:

. 1. no tnterest shall be payable for periods (a) ‘ta excess of two years or
(+) when payment has been prevented pursuant to orders, regulations or
advice of the United S: js Government, and

2. no interest shall accrue for any period during which payment is delayed
due to inability to locace the claimant; hovever payment of interest
will be considered vhen a proper claimant files proof of clain under the
terms of this Supplementary Agreement.” .

The foregoing amandsent is to be attached to and mad@ part of said Croup
Policy. .

Signed at Washington, D.C. this leth day of august 19 ss

OFFICE OF PERSONNEL MANAGEMENT
¢ cyholder)

. 2y.
(Space Below for Use of Metropolitan Life Insurafce Company Only)

Signed at Nev York, N.Y. this st day of___ August 29 ga
METROPOLITAN LIFE INSURANCE COMPANE

Ah em oo, Yoay Lhiaaice coal

Fora 6.1985-40



-i-

AMENDMENT 45 (Continued)

Item Meximum Caorge
(b) Risk Cherge For any polley year beginning prior to November 30, 1958 =
0.6% of Promivers; .

For ony policy yeor beginning on of suisequent to November
30, 1958 but prior te July 1, 1967 + 0.5% of Premiums;

for ony policy year beginning on or subsequent to July I,
1967 = 0.4% of that port of Premiums for the policy yeor
which Is not In excess of $190 million, plus 0.2% of thet
port of Premiums for the polley year which Is In excess of
$190 million .*

The foregoing anendment Is to be attached to and mode port of ssid Group Polley.

Signed at Washington, 0. ¢. this First dey of April 1968
UNITED STATES CIVIL SERVICE COMMISSION
(Policyhoider;
y John W. Macy, Jr.
(Spoce Belew For Lia of Metropolitan Ufe insurance Company Only)
Signed ot _New York, N.Y. this fifth dey of Apel 19 68

METROPOLITAN LIFE INSURANCE COMPANY,

Mec. MeUoabecde
Wm. H. Meyer, Jr. Saomary
9 stra)

Form G 1985-2) CG (0) [P Y .