REQUIRED information in case pages get separated: Claimant First Name Middle Name Last Name Claim Number If we need more information, who's the best person at your office to contact? (Please provide name and phone number/extension.) SECTION 3: Physician's Signature and Information First Name Last Name Address City State ZIP Degree or Specialty Office Phone Number Office Fax Number Tax ID Signature of Physician Date (mm/dd/yyyy) SECTION 4: How to Submit this Form Please send all of the pages of this form and any supporting documents, adding the claim number to the top of each page, to MetLife Disability by: Mail: Fax: MetLife Disability 1-800-230-9531 PO Box 14590 Lexington KY 40512-4590 APS-STDLTD-5320 (06/20) Page 5 of 7