ELECTION, DECLINATION, OR WAIVER OF LIFE INSURANCE COVERAGE FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM
IMPORTANT AGENCY INSTRUCTIONS ON BACK OF ORIGINAL

TO COMPLETE THIS FORM—

1 FOLLOW THESE GENERAL INSTRUCTIONS:
- Read the back of the "Duplicates" carefully before you fill in the form.
- Fill in BOTH COPIES of the form. Type or use ink.
- Do not detach any part.

2 FILL IN THE IDENTIFYING INFORMATION BELOW (please print or type):
Name: (last) (first) (middle)
DATE OF BIRTH (month, day, year): SOCIAL SECURITY NUMBER:
EMPLOYING DEPARTMENT OR AGENCY:
LOCATION (City, State, ZIP Code):

3 MARK AN "X" IN ONE OF THE BOXES BELOW (do NOT mark more than one):

Mark here if you want BOTH optional and regular insurance [A]
ELECTION OF OPTIONAL (IN ADDITION TO REGULAR) INSURANCE
I elect the $10,000 additional optional insurance and authorize the required deductions from my salary, compensation, or annuity to pay the full cost of the optional insurance. My regular insurance is not affected by this election.

Mark here if you WANT OPTIONAL but do not want regular insurance [B]
DECLINATION OF OPTIONAL (BUT NOT REGULAR) INSURANCE
I decline the $10,000 additional optional insurance. I understand that I cannot elect optional insurance later unless I am under age 50 and present satisfactory medical evidence of insurability. I understand also that my regular insurance is not affected by this declination of optional insurance.

Mark here if you WANT NEITHER regular nor optional insurance [C]
WAIVER OF LIFE INSURANCE COVERAGE
I do not want to be insured and I waive coverage under the Federal Employees Group Life Insurance Program. I understand that I cannot cancel this waiver and obtain life insurance later unless I am under age 50 and present satisfactory medical evidence of insurability. I understand also that my regular insurance is not affected by this waiver of optional insurance.

4 SIGN AND DATE. IF YOU MARKED BOX "A" OR "C," COMPLETE THE "STATISTICAL SLIP." THEN RETURN THE ENTIRE FORM TO YOUR EMPLOYING OFFICE.
SIGNATURE (do not print):
Cecil J. Klonham
DATE: 18 July 1968

FOR EMPLOYING OFFICE USE ONLY
OFFICIAL RECEIVING DATE STAMP:

DUPLICATE COPY—For Agency Use