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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 "Duplicate" 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)
NOEL JAMES ARTHUR
DATE OF BIRTH (month, day, year)
March 19, 1911
SOCIAL SECURITY NUMBER
083 36 2638
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)
[X]
ELECTION OF OPTIONAL (IN ADDITION TO REGULAR) INSURANCE
I elect the $10,000 additional optional insurance and authorize the required deductions from my salary to cover its cost. I understand that the optional insurance is in addition to my regular insurance.

Mark here if you DO NOT WANT OPTIONAL but do 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 at a later date unless I am then in good health and submit satisfactory medical evidence of insurability. I understand that my regular insurance is not affected by this declination of additional optional insurance.

Mark here if you WANT NEITHER regular nor optional insurance (C)
[ ]
WAIVER OF LIFE INSURANCE COVERAGE
I decline to be insured and I waive coverage under the Federal Employees Group Life Insurance Program. I understand that I cannot elect coverage at a later date unless I am then in good health and submit satisfactory medical evidence of insurability. I understand also that I cannot be insured for more than the $10,000 additional optional insurance unless I have the regular insurance.

4 SIGN AND DATE: IF YOU MARKED BOX "A" OR "B", COMPLETE THE "STATISTICAL STUB." THEN RETURN THE ENTIRE FORM TO YOUR EMPLOYING OFFICE.
SIGNATURE
[Signature]
DATE
16 February 1968

FOR EMPLOYING OFFICE USE ONLY
Effective date of coverage
[Stamp]
93,842 12 92 944

ORIGINAL COPY—Retain in Official Personnel Folder
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