Life Beneficiary Form

Group Term Life Insurance Beneficiary Designation Metropolitan Life Insurance Company Things to know before you begin • This form MUST be signed before you return it. You MUST return all See "SECTION 3 - Signature" on page 8. pages of this form. SECTION 1: Insured information Customer number Employer name/Group policyholder name First name Middle name Last name Address - Street City State ZIP code Date of birth (mm/dd/yyyy) Phone number SSN SECTION 2: Beneficiary and plan information • You MUST designate at least one primary beneficiary for each coverage in which you enroll. A person may only be listed once. Anyone listed in the primary section cannot be listed in the contingent section. • The sum of the Primary Beneficiary percentages MUST equal 100%. The sum of the Contingent Beneficiary percentages MUST equal 100%. Dollar amounts, fractions and decimals will not be accepted. • If you need more space for additional beneficiaries, attach a separate page. Include all beneficiary information, and sign/date the page. Please complete each coverage section and all sections that pertain to the type of beneficiary you are designating. Basic life - Beneficiary designation I elect that the beneficiary designation indicated below applies to the Basic Life plans insured by MetLife: A. Individual beneficiaries Primary beneficiary - Your first choice to receive your life insurance proceeds in the event of your death. If any primary beneficiaries predecease you, that person's share will be equally divided among any remaining primary beneficiaries. First name Middle initial Last name Share % Address - Street City State ZIP code Relationship to employee Social security number Date of birth (mm/dd/yyyy) Phone number Page 1 of 8 GR-TR-BENE-EMP-M (12/18) Fs/f