Federal employees enrolled in Federal Employees' Group Life Insurance use this form to claim benefits after losing a limb or eyesight in an accident. The treating physician or other provider completes Part C, documenting the injuries, any amputation or vision loss, and the dates. The agency then certifies pay and coverage and sends the claim to OFEGLI.
The employee completes Part A, the employee's statement, and the human resources office completes Part B, the agency certification of basic pay and Option A coverage. The physician or other health care provider completes and signs Part C.
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Claim for Dismemberment Benefits, Federal Employees' Group Life Insurance (FEGLI) Program
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Part C, the physician's statement, is completed by the employee's physician or other health care provider who treated the injury. It records the dates of the accident, first consultation and last treatment, the nature and extent of injuries, and the amputation or vision findings, and is signed with office details.
Items 13 to 19 ask for uncorrected and corrected vision before the accident, the date vision was irrecoverably reduced to 20/200 or less with correction, vision on the last exam, whether operation or treatment could restore useful vision, any enucleation date, and a chart of contracted visual fields.
Yes. If the employee is physically or mentally unable to complete the claim, someone else can complete it and attach a short explanation. Parts A through C still describe the employee, but the person completing the form signs with their own address and phone number.