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Please note that, in accordance with the law, both a survivor |
You may elect to provide a survivor annuity for more |
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annuity election made at retirement and a survivor annuity |
than one former spouse. The total of the survivor |
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election made before a divorce, terminate upon death or |
annuities must equal either 25% or 50% of your |
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divorce and the annuitant must make a new election (reelection) |
unreduced annuity. |
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within 2 years after the terminating event to provide a survivor |
If you are married, you must have your spouse's consent |
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annuity for a spouse acquired after retirement or for a former |
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spouse. Continuing a survivor reduction, by itself, is not |
to choose this option, because any benefit elected for a |
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effective to reelect a survivor annuity for a spouse married after |
former spouse limits what can be elected for your |
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retirement or for a former spouse. |
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current spouse. (Complete and attach SF 3107-2, |
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Box 4: If you initial Box 4, a person selected by you, |
Spouse's Consent to Survivor Election, to your |
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application.) The maximum combined survivor benefits |
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who has an insurable interest in you, will receive |
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that can be elected for your current and former spouse(s) |
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a survivor annuity upon your death. Insurable |
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is 50% of your benefit. |
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interest exists if the person named may reasonably |
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expect to derive financial benefit from your |
Section E - Insurance Information |
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continued life. A disabled child or a former |
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Item 1b: Indicate whether there is a court order or |
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spouse are persons who might have an insurable |
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interest in you. |
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administrative order currently in effect that |
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If you choose an insurable interest survivor |
requires you to provide health benefits coverage |
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for your child(ren). If you answer "yes", you must |
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annuity, the survivor annuity will be 55 percent of |
submit a copy of the court order or administrative |
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your annuity after your annuity has been reduced |
order. |
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to provide this benefit. The table below shows the |
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reduction percentages. |
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Section F - Other Claim Information |
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Any employee who is not retiring for disability |
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Item 1: If you have applied for, or have ever received, workers' |
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and who can prove good health may elect a |
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compensation from the Office of Workers' |
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reduced annuity to provide a survivor annuity for |
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Compensation Programs, U.S. Department of Labor, |
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a person having an insurable interest in the |
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because of a job-related illness or injury, check the |
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retiree. |
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"yes" box and complete Schedule C. |
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You may elect this insurable interest survivor annuity |
In Schedule C you should provide the following |
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in addition to a regular survivor annuity for a current or |
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information: |
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former spouse. If you elect an insurable interest annuity |
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for your current spouse, you must both jointly waive |
1. If you are receiving or have received |
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the current spouse annuity. Generally, an insurable |
compensation, enter your compensation claim |
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interest annuity cannot be cancelled. However, if you |
number(s), the beginning and ending dates of each |
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elect an insurable interest annuity for your current |
period for which compensation was paid, and |
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spouse because a former spouse is entitled to the |
whether the benefits were a scheduled award, |
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regular survivor annuity (under a court order acceptable |
disability or other type of compensation. |
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for processing or based on your election of that |
2. If you have applied for, but are not receiving |
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survivor benefit for the former spouse), you can |
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convert the insurable interest election for your current |
benefits, indicate whether your claim is pending |
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spouse to a current spouse annuity within two (2) years |
or has been denied and the claim numbers |
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of the former spouse losing entitlement to the regular |
applicable. |
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survivor annuity. |
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3. Indicate whether you agree to notify us if the |
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If you choose an insurable interest annuity, the amount |
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status of your workers' compensation claim |
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of the reduction in your annuity will depend upon the |
changes and whether or not you authorize the |
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difference between your age and the age of the person |
Office of Personnel Management and/or the |
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named as survivor annuitant, as shown in the table |
Office of Workers' Compensation Programs to |
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below. |
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collect any overpayment if we find that you |
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Age of the Person Named |
Reduction |
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were paid, but not eligible for, both compensation |
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in Relation to That of |
in Annuity |
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and annuity benefits covering the same period of |
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time. Without this authorization from you, we |
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Retiring Employee |
of Retiring |
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will not pay your annuity until we can confirm |
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Employee |
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that OWCP is not paying you compensation. |
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Older, same age, or less than 5 years younger |
10% |
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The information requested regarding benefits from |
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the Office of Workers' Compensation Programs is |
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5 but less than 10 years younger |
15% |
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needed because the law prohibits the dual compen- |
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10 but less than 15 years younger |
20% |
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sation which would exist if you received both a |
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FERS annuity and compensation for total or partial |
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disability under the Federal Employees' Compen- |
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15 but less than 20 years younger |
25% |
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sation Act. |
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20 but less than 25 years younger |
30% |
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Section G - Information About Children |
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25 but less than 30 years younger |
35% |
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Complete Section G by providing the names and dates of birth |
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30 or more years younger |
40% |
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of your unmarried dependent children under the age of 22. Also |
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list any child who is over age 22 and incapable of self-support |
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Box 5: If you initial box 5, your former spouse(s) will receive a |
because of mental or physical disability incurred before age 18. |
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Check the box headed "disabled" by the name of each child to |
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survivor annuity upon your death. The maximum |
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whom this applies. Information about your children in your |
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survivor annuity payable to your former spouse(s) is |
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annuity claim file may help to expedite the processing of claims |
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50% of your unreduced annuity. Your annuity will be |
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for survivor benefits in the event of your death. |
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reduced 5% or 10% according to the total benefit you |
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want to provide. |
3 |
Standard Form 3107 |
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Revised May 2014 |