LTD Claim Employee Statement

Group Disability Long Term Disability claim form employee statement Metropolitan Life Insurance Company Instructions for completing the claim form: • Complete all applicable areas of the claim form. • If you are the Authorized Representative, include a copy of the legal document(s) authorizing you to act on the Employee/ Claimant’s behalf. • Sign the claim form. • Fax this form to expedite your claim – retain original for your records. • *Contact MetLife at 888-444-1433 for any questions you have on completing this form. SECTION 1: Personal information First name (Must answer) Middle initial Last name Employer (Must answer) ID number (If applicable) Address City State ZIP code Date of birth (mm/dd/yyyy) Sex Social Security number (Must answer) M F We require a street address for our records if a P.O. Box is your mailing address Home phone number Mobile phone (Optional) Occupation Marital status Tax exemptions Personal email Married Single Other Dependent information Spouse First name Middle name Last name Date of birth (mm/dd/yyyy) Social Security number Children First name Middle name Last name Date of birth (mm/dd/yyyy) Social Security number Page 1 of 9 EES-LTD-5323 (08/20) Fs/f