this form is considered sensitive but unclassified (sbu) when filled in . federal employees’ group life insurance (fegli) program election

This form is considered Sensitive But Unclassified (SBU) when filled
in .
FEDERAL EMPLOYEES’ GROUP LIFE INSURANCE (FEGLI) PROGRAM ELECTION FORM:
EXTENSION OF COVERAGE WHEN CALLED TO ACTIVE DUTY
Name of Employee:
 
Date:
 
You must make your election on this notice and return it to your
assigned Staffing Specialist in Human Capital and Talent Management,
Human Capital Services Center, Civil Service Staffing (HCTM/HCSC/CSS),
Human Capital and Talent Management, Foreign Service Center, Foreign
Service Staffing (HCTM/FSC/FSS), or Human Capital and Talent
Management, Center for Performance Excellence, Executive Resources
(HCTM/CPE/ER), as appropriate, before the end of your 12 months in
non-pay status or your FEGLI coverage will automatically terminate at
that time.
5 U.S.C. 8706(d), Continuation of Life Insurance Coverage for Federal
Employees Called to Active Duty, Pub. L. 110-181. 122 Stat. 345
authorizes the continuation of FEGLI coverage for an additional 12
months, up to a total of 24 months, for Federal employees called to
active duty in the uniformed services.
We have determined that you are eligible to continue your FEGLI
coverage.
Currently, if you are in a non-pay status on the Agency rolls while on
active duty, the FEGLI coverage continues free for 12 months. If you
separate to go on military duty, for FEGLI purposes, you are also
considered to be in non-pay status. FEGLI continues free for 12 months
or until 90 days after military service ends, whichever date comes
first. At that time, the coverage terminates, subject to a 31-day
extension of coverage and the right to convert to an individual
policy.
The new law allows you to continue FEGLI coverage for an additional 12
months. Then, it will end with a right to convert to an individual
policy. During the additional 12 months of coverage, you must pay both
the employee and agency share of premiums for Basic coverage and the
full premium for any Optional coverage (there is no Agency
contribution). The new law allows coverage to continue only for the
additional 12 months.
You have two choices: (1) Elect to have your FEGLI coverage terminate
at the end of the first 12 months of non-pay status or (2) elect to
continue the coverage for an additional 12 months and agree to pay the
premiums for this additional time period.
If you wish to continue your FEGLI coverage for an additional 12
months, you must agree to the following terms and conditions. Please
indicate your election on this notice by writing your initials next to
your election, and print your name and provide your full signature
where requested.
TERMINATION: If you indicate in the notice that you elect to terminate
your FEGLI coverage at the end of the first 12 months in non-pay
status, or if we do not receive a completed election form from you
prior to the end of the first 12-month period, your FEGLI coverage
will be terminated at the end of 12 months in non-pay status. Your
coverage will continue for an additional 31 days at no cost to you.
During those 31 days, you will be eligible to convert to an individual
policy and you will be given information regarding your right to
convert to an individual policy.
CONTINUATION: If you elect to continue your FEGLI coverage, you must
pay the premiums, both the employee and agency share, for Basic
coverage and the full premium for any Optional coverage, for the
additional 12 months of coverage. You must make payment arrangements
with your employing agency before you leave for active duty service.
I have read this notice, and I understand my choices.
I elect to terminate my FEGLI coverage at the end of 12 months in
non-pay status, subject to a 31-day extension of coverage and the
right to convert to an individual policy. I understand that the
coverage will be reinstated automatically upon my return to work in
pay and duty status in a FEGLI-eligible position.
I elect to continue my FEGLI coverage for an additional 12 months
after completion of my first 12 months in non-pay status. By choosing
to continue coverage I agree to pay the applicable premiums, both the
employee and the Agency share for Basic coverage and the full premium
for any Optional coverage, for each additional month after the first
12 months in non-pay status. My failure to pay the premiums within the
required timeframe will constitute a voluntary cancellation of my
coverage, subject to the 31-day extension of coverage and the right to
convert to an individual policy.
Employee Name
 
Employee Signature
Date
 
Employing Agency Representative Name
 
Employing Agency Representative Signature
Date
 
If you have any questions, contact   at  .
[Insert name and phone number of agency contact]
Distribution of copies AID Form 411-3:
Original – Employee
Copy – HCTM/HCSC/CSS, HCTM/FSC/FSS, or HCTM/CPE/ER Records
Copy – M/CFO/P
PRIVACY ACT STATEMENT
Authority: 5 U.S.C. 8706(d), Continuation of Life Insurance Coverage
for Federal Employees Called to Active Duty, Pub. L. 110-181. 122
Stat. 345; 22 U.S.C. Ch. 32, Foreign Assistance, Subchapter I,
International Development; 22 U.S.C. Ch. 52, Foreign Service.
Principal Purpose: USAID collects this information to administer
personnel operations associated with employees being called to active
duty in the Unformed Services, specifically for the continuation of
Federal Employees’ Group Life Insurance (FEGLI) coverage for an
additional twelve months (up to a total of 24 months) for Federal
employees called to active duty in the uniformed services.
Routine Uses: Information in your records may be disclosed outside of
USAID in accordance with any current and future blanket routine uses
established for the systems of records applicable to this collection.
Use and disclosure of your information outside of USAID may also occur
in accordance 5 U.S.C. 552a(b) of the Privacy Act of 1974.
Disclosure: Disclosure is voluntary, however failure to provide this
information before the end of twelve months in non-pay status will
automatically terminate FEGLI coverage.
System of Record Notice: USAID-1 Foreign Service Personnel Records, 80
FR 11387, April 2, 2015.
AID 411-3 (xx/2018) Page 1 of 2

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