Form FE-6 DEP "Claim for Death Benefits - Metlife"

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Download Form FE-6 DEP "Claim for Death Benefits - Metlife"

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Statement of Claim — Option C
Family Life Insurance
Federal Employees’ Group Life Insurance Program
Instructions
General
The Metropolitan Life Insurance Company (MetLife) pays claims for the Federal Employees’ Group Life Insurance (FEGLI)
Program through its administrative office, the Office of Federal Employees’ Group Life Insurance (OFEGLI). “I” and “you” refer
to the individual completing this form.
How do I complete this form?
Read the instructions carefully.
Please type or print legibly in ink.
Complete parts A, B, C, and page 3.
What else do I have to submit?
In addition to this claim form, you must send a certified copy of the deceased’s death certificate that contains the cause and manner
of death. You can get the certificate from your city or state’s Bureau of Vital Statistics or equivalent agency. MetLife cannot process
your claim until it receives the certified death certificate. MetLife will let you know if it needs anything else.
What should I do if I need help completing this form?
If you need help in completing this form, you may contact MetLife/OFEGLI’s customer service representatives, toll-free, at
1-800-OFE-GLIA (1-800-633-4542).
Where do I send this form and other documents?
Please do not send your claim form and other documents directly to MetLife/OFEGLI.
If you are an active employee, send everything to your employing office.
If you are retired or receiving Federal Workers’ Compensation benefits, send everything to:
Office of Personnel Management (OPM)
Retirement Operations Center
Attention: FE6-DEP
Boyers, PA 16017
How will I receive benefits?
If your claim is for less than $5,000, MetLife will mail you a check.
If your claim is for $5,000 or more, you must choose one of two payment options: (1) a check, or (2) a MetLife Total Control
Account (TCA), an interest bearing account set up in your name and administered by MetLife. This account is not insured by the
Federal Deposit Insurance Company (FDIC). The choice is yours. See Page 2 for details. See Page 3 to make your selection.
What should I do if I no longer want Option C-Family Life Insurance?
If you are an active employee, contact your employing office’s servicing human resources office.
If you are retired or receiving Federal Workers’ Compensation benefits, write to:
Office of Personnel Management (OPM)
Retirement Operations Center
Attention: Annuity Adjustment Section
Boyers, PA 16017
Please include your retirement or compensation claim number and be sure to sign your letter.
Instructions to the employing agency/retirement system
Complete Part D of this claim form.
If the claim requires that you determine eligibility for foster children or disabled children older than age 22, first review
the definitions on page 5 and then complete Part D of this claim form. Please note that MetLife does not need the background
documentation.
Send the completed claim form and certified death certificate to:
MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080
Form FE-6 DEP
Revised
2013
Page 1
Do NOT use previous editions
OFEGLI Form in Adobe Acrobat PDF (12/13)
Statement of Claim — Option C
Family Life Insurance
Federal Employees’ Group Life Insurance Program
Instructions
General
The Metropolitan Life Insurance Company (MetLife) pays claims for the Federal Employees’ Group Life Insurance (FEGLI)
Program through its administrative office, the Office of Federal Employees’ Group Life Insurance (OFEGLI). “I” and “you” refer
to the individual completing this form.
How do I complete this form?
Read the instructions carefully.
Please type or print legibly in ink.
Complete parts A, B, C, and page 3.
What else do I have to submit?
In addition to this claim form, you must send a certified copy of the deceased’s death certificate that contains the cause and manner
of death. You can get the certificate from your city or state’s Bureau of Vital Statistics or equivalent agency. MetLife cannot process
your claim until it receives the certified death certificate. MetLife will let you know if it needs anything else.
What should I do if I need help completing this form?
If you need help in completing this form, you may contact MetLife/OFEGLI’s customer service representatives, toll-free, at
1-800-OFE-GLIA (1-800-633-4542).
Where do I send this form and other documents?
Please do not send your claim form and other documents directly to MetLife/OFEGLI.
If you are an active employee, send everything to your employing office.
If you are retired or receiving Federal Workers’ Compensation benefits, send everything to:
Office of Personnel Management (OPM)
Retirement Operations Center
Attention: FE6-DEP
Boyers, PA 16017
How will I receive benefits?
If your claim is for less than $5,000, MetLife will mail you a check.
If your claim is for $5,000 or more, you must choose one of two payment options: (1) a check, or (2) a MetLife Total Control
Account (TCA), an interest bearing account set up in your name and administered by MetLife. This account is not insured by the
Federal Deposit Insurance Company (FDIC). The choice is yours. See Page 2 for details. See Page 3 to make your selection.
What should I do if I no longer want Option C-Family Life Insurance?
If you are an active employee, contact your employing office’s servicing human resources office.
If you are retired or receiving Federal Workers’ Compensation benefits, write to:
Office of Personnel Management (OPM)
Retirement Operations Center
Attention: Annuity Adjustment Section
Boyers, PA 16017
Please include your retirement or compensation claim number and be sure to sign your letter.
Instructions to the employing agency/retirement system
Complete Part D of this claim form.
If the claim requires that you determine eligibility for foster children or disabled children older than age 22, first review
the definitions on page 5 and then complete Part D of this claim form. Please note that MetLife does not need the background
documentation.
Send the completed claim form and certified death certificate to:
MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080
Form FE-6 DEP
Revised
2013
Page 1
Do NOT use previous editions
OFEGLI Form in Adobe Acrobat PDF (12/13)
Claim for Death Benefits
Federal Employees’ Group Life Insurance Program
Understanding Your Life Insurance Payment Options
If your claim is for less than $5,000, Metropolitan Life Insurance Company (MetLife) will mail you a check.
If your claim is for $5,000 or more, you have an important choice to make regarding how you wish to receive
the payment. On Page 3, you must select one of two ways to receive your payment:
• Check (mailed to you through the U.S. Postal Service)
• MetLife Total Control Account (TCA) - an interest bearing account set up in your name and
administered by MetLife.
The MetLife TCA is a settlement option offered by MetLife for the payment of claims. A MetLife TCA is
not a checking, savings, or money market bank account. Since your MetLife TCA is not a bank account,
it is not insured by the FDIC or any government agency. Instead, MetLife guarantees the full amount in
your MetLife TCA, including all interest earned. MetLife’s guarantee is further backed by your respective
state insurance guaranty association. Maximum guarantee limits vary from state to state and may change
over time. If you choose a MetLife TCA, the relationship is between you and MetLife, not with the federal
government or any of its agencies.
The MetLife TCA offers you a minimum guaranteed annual effective interest rate, meaning that MetLife
commits to pay you at least that specified rate of interest on the money in the account. You begin earning
interest the day the MetLife TCA is created. Interest is earned daily, but is not credited until the last day of
the month. The interest rate offered on the MetLife TCA may be better or worse than the prevailing market
rates. The MetLife TCA is a product offered by MetLife on which the company may make a profit. You pay
no monthly maintenance fees on a MetLife TCA.
You have complete control of, and access to, the entire amount of your insurance proceeds. You can
withdraw the full amount from the MetLife TCA at any time. The information packet you receive will
include a draft book (similar to a checkbook). At any time and at no cost, you can write drafts (similar
to checks) from a minimum of $250 up to the full balance of your account. In addition, you will receive
periodic activity statements, and you can designate a beneficiary for your account. If you choose the MetLife
TCA settlement option, you will receive more detailed information when the account is opened.
Please keep pages 1 and 2 for your records
Form FE-6 DEP
Revised December 2013
Page 2
Do NOT use previous editions
MetLife OFEGLI Form in Adobe Acrobat PDF (12/13)
Claim for Death Benefits
Federal Employees’ Group Life Insurance (FEGLI) Program
Part 1: Select Method to Receive Your Payment
Please SELECT ONE method of settlement in order to receive your payment. By selecting below, you confirm that you have read
the enclosed materials on both FEGLI payment options (Check and MetLife Total Control Account).
M
Check
Your payment will be sent via the U.S. Postal Service to the address you enter below.
M
MetLife Total Control Account (TCA)
You are eligible for a MetLife TCA if your payment is for $5,000 or more. MetLife TCA is not a bank account and is not
FDIC-insured. See Page 2 for more details.
lf no box is checked above (and your payment is $5,000 or more), a MetLife Total Control Account will be established in your name
and your payment will be deposited on your behalf.
Part 2: Enter the Following Information to Receive Payment
Please complete, in ink, the information below. This information is needed to send you a check or to open your MetLife Total Control
Account. Even if this information is provided elsewhere on this form, you must also provide it here.
Your signature
Your name (please print)
Address (number, street, apartment number)
City, State, ZIP Code
Your Social Security Number
or
Estate/Trust/Tax ID Number
Date (mm/dd/yyyy)
Daytime telephone number
Evening telephone number
(
)
(
)
Area Code
Area Code
Please return pages 3 through 5 to OFEGLI
Form FE-6 DEP
Revised December 2013
Page 3
Do NOT use previous editions
MetLife OFEGLI Form in Adobe Acrobat PDF (12/13)
Statement of Claim — Option C
Family Life Insurance
Federal Employees’ Group Life Insurance (FEGLI)
Part A. Information about You
(Last)
(First)
(Middle)
2. Date of birth (mm/dd/yyyy)
1. Your name
3. Social Security Number
4. Department or agency in which last employed, including bureau or division
5. Location of last employment (City, state, ZIP code)
6. Are you retired and receiving a monthly annuity under any Federal civilian retirement system?
Yes
No
If “Yes”, provide the Claim number (CSA, CSF, CSI)____________________________________
*Special Note: Social Security monthly payments are not Federal civilian retirement annuities.
If “Yes”, provide the effective date of Retirement ______________________________________
(mm/dd/yyyy)
Part B. Information about the Deceased Family Member
1. Deceased’s full name
(Last)
(First)
(Middle)
2. Date of birth (mm/dd/yyyy)
3. Date of death (mm/dd/yyyy)
Complete Items 4 through 9 if this claim is for your spouse
4. Date of marriage (mm/dd/yyyy)
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. (City and state)
Yes
No
Yes
No
Complete Items 10 through 13 if this claim is for your child
10. Child’s marital status
11. Child’s relationship to you
Foster child
Single
Legitimate child
Stepchild
Disabled dependent child 22 yrs. or over
Married
Adopted child
Recognized natural child
Other (Specify) ____________________
12. If the deceased was a stepchild, recognized natural child, or foster child
13. If the deceased was a recognized natural child and was not living with
was the child living with you at the time of death?
you at the time of death, did you provide financial support for the child?
Yes
No (Explain on separate sheet)
Yes
No (Explain on separate sheet)
Part C. Your Certification
If your claim is for less than $5,000, MetLife will mail you a check.
Your name (Please print)
If your claim is for $5,000 or more, you must choose one of two
________________________________________________________________
payment options. See Page 2 for details. See Page 3 to make your
Address (Number, street, apt. no.)
selection.
________________________________________________________________
FEGLI death benefits are not subject to Federal income tax, but the
City, State, ZIP code
interest that MetLife pays on those benefits is subject to such tax.
MetLife will report all interest payments to the Internal Revenue
________________________________________________________________
Service.
Your Social Security Number
or
Estate / Trust / Tax ID Number
-
-
-
Under penalty of perjury, I certify:
1. That the number shown on this form is my correct taxpayer identification number; and
2. That I am NOT subject to backup withholding because: (a) I have not been notified by the Internal Revenue Service (IRS) that I am
subject to backup withholding as a result of a failure to report all interest or dividends; or (b) the IRS has notified me that I am no longer
subject to backup withholding.
If you are currently subject to backup withholding, check this box:
3. I am a U.S. citizen or a U.S. resident for tax purposes.
Check one:
Yes
No
If you are not a U.S. citizen or resident for tax purposes, we will send you a W-8BEN that you are required to complete to certify your
foreign status.
The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup
withholding.
_____________________________________________________
______
___________________
______
___________________
(
)
(
)
My signature (Do not print)
Area Code
Daytime telephone no.
Area Code
Evening telephone no.
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 FE-6 DEP
Revised December 2013
Page 4
Do NOT use previous editions
OFEGLI Form in Adobe Acrobat PDF (12/13)
Part D. Employing Agency/OPM Certification of Insurance Status
• Employing agency completes items 1, 2 and 4 through 8 for Active Employees
• OPM completes all items 1 through 8 for Retirees and Compensationers
1. Did the insured have Option C on the date of death of the family member?
2. Did the insured indicate in Part B - Item 11 that the deceased was a foster
child or disabled dependent child?
No
Yes
If “Yes” provide effective date of election _____________
(mm/dd/yyyy)
No
Yes
If “Yes” mark the box to show the number of multiples
If “Yes” do you certify that the child qualifies for Option C coverage?
1
2
3
4
5
No
Yes
If the insured is retired or receiving compensation, complete items 3a. through 3c.
3a. What is the effective date of the insured’s retirement or receipt of
3c. What was the insured’s Option C election?
compensation? ____________________
(mm/dd/yyyy)
Number of multiples for full reduction
1
2
3
4
5
3b. What is the insured’s date of birth? _____________________
1
2
3
4
5
Number of multiples for no reduction
(mm/dd/yyyy)
4. Agency Name
5. Agency Mailing Address
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Number, Street
Agency Telephone Number
_______________________________________________
________
____________________
(
)
City, State, ZIP code
Area Code
I certify that the information I gave in Part D of this form is correct and that I obtained it from the employee’s/retiree’s/compensationer’s official records.
6. Name of authorized agency official
7. Signature of authorized agency official
8. Date signed
(Please print)
(Do not print)
__________________________________________
__________________________________________
___________________________________________
(mm/dd/yyyy)
Send this completed claim form and certified death certificate to: MetLife, OFEGLI, P.O. Box 6080, Scranton, PA 18505-6080
Definition of Terms
Disabled dependent child age 22 years or over means a child who was incapable of self-support because of a mental or physical
disability that existed before the child became 22 years of age.
Foster child means a child living with you in a regular parent-child relationship where you are the primary source of financial
support for the child and expect to raise the child to adulthood. A child placed in your home by a welfare or social service agency
under an agreement where the agency retains control of the child or pays for maintenance does not qualify as a foster child.
Grandchildren, as such, are not eligible family members. However, grandchildren can qualify as foster children if they meet all of
the requirements.
Recognized natural child means a child born out of wedlock whom you recognized as your child during the child’s lifetime.
In addition, at the time of the child’s death, he/she must have either lived with you in a regular parent-child relationship or been
dependent on you financially.
Regular parent-child relationship means that you exercise parental authority, responsibility, and control over the child by caring
for, supporting, disciplining, and guiding the child, including making decisions about the child’s education and health care.
If you have any questions concerning your child’s eligibility for coverage, you must contact your employing agency or retirement
system, and not MetLife/OFEGLI.
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Form FE-6 DEP
Revised December 2013
Page 5
Do NOT use previous editions
OFEGLI Form in Adobe Acrobat PDF (12/13)