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~ et ant a al ELECTION, DECLINATION, OR WAIVER | IMPORTANT OF LIFE INSURANCE COVERAGE | AGENCY INSTRUCTIONS | FEDERAL EMPLOYEES GROUP LIFE INSURANCE PROGRAM | ON BACK OF ORIGINAL | ——— Te | TO COMPLETE THIS FORM— - i FOLLOW THESE GENERAL INSTRUCTIONS: ° | * Fead the back of the “Duplicate” carefully before you filf in the form. i * Fi''in BOTH COPIES of the form. Type or use ink. * Du not detach any part. | y) FILL IN THE IDENTIFYING INFORMATION BELOW {please print or type): mh NAME (Iasi) (first) ~~ (middie) T | DATE OF BIRTH (month, day, year) T SOCIAL SECURITY NUMBER | Hoover, J. Edgar ‘January 1, 1895 _ | {5TT leo {1 | 1114 | | EMPLOsk. VFPARTMENT OR AGENCY LOCATION (City, State, ZIP Code) | Federal Bureau of Investigation Washington, D, C, 20535 | 3 MARK 4N 'X" IN ONE OF THE BOXES BELOW (do NOT mark more thon one): Mark here ELECTION OF OPTIONAL (IN ADDITION TO REGULAR) INSURANCE \ if you a . . | elect the $10,000 additional optional insurance and authorize the required deductions | WANT BOTH { | from my salary, compensation, or annuity to pay the full cost of the optional insurance. | | optiona! and | j This optional insurance is in addition to my reguler insurance. | I regular (A) | 'asurance A | Mark hert: DECLINATION OF OPTIONAL (BUT NOT REGULAR) INSURANCE : if you } decline the $10,000 additional optional insurance. | understand that | cannot elect op- : . op DO NOT WANT tional insurance until at least 1 year after the effective date of this dectination and uniess OPTIONAL but at the time | apply for it 1 am under age 50 and present satisfactory medical evidence | do want of insurability. | understand also that my regular insurance is not affected by this deciina- | | , (B} tion of additional optional insurance. egular insuranc - | “dark here WAIVER OF LIFE INSURANCE COVERAGE ! if you | desire not to be insured and | waive coverage under the Federal Employees Group Life | . WANT NEITHER insurance Program. | understand that | cannot cancel this waiver and cbtain reguiar in- regular > surance until at least 1 year after the effective date of this waiver and unless et the time i apply for insurance | am under age 50 and present satisfactory medical evidence of in- | ) optiona, (C) = surability. | understand also that | cannot now or later have the $10,000 additional “ysurance optional insurance unless | have the regular insurance. ; ; [a SIGN A''O DATE. IF YOU MARKED BOX “A™ OR "C™, | FOR EMPLOYING OFFIC NLY t | COMPLETE THE “STATISTICAL STUB."" THEN RETURN | ---—-- tofticial receiving ——— seme) | THE ENHREFORM TO YOUR EMPLOYING OFFICE. SIGNATL KE (do rot print) - | | | | | | Pp fier: oo | ah a _ a . | -bruary 5, 1968 } See Tebte of Effective Dates on back of Original ORIGINAL COPY—Retain in Official Personnel Folder sTamaen fom, eT JANUARY i until 1 14, 1068) oe ;