LTD STD Claim Physicians Statement

Dx Disability Claims Attending Physician Statement Use this form to provide us with the information we need from you and your physician to process your claim for disability benefits. Metropolitan Life Insurance Company Things to Know Before You Begin • You should complete and sign Section 1 of this form before giving it to your physician. If the form is sent directly to your physician, you may have your physician complete Section 1 for you. Section 2 MUST be completed by your physician. • Submitting an incomplete form may delay processing your claim. • Some physicians may charge for completion of this form. Any such charge is your responsibility. • New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be Please write the claim number on subject to a civil penalty not to exceed five thousand dollars and any additional documents you the stated value of the claim for each such violation. send. SECTION 1: Claim Information (To be completed by the person submitting the claim, or by the physician if received directly.) Claimant First Name Middle Name Last Name Date of Birth (mm/dd/yyyy) Customer Name Occupation Physician First Name Last Name Physician Phone Number Claim Number Authorization For Physician to Share My Medical Information I authorize my physician to release to MetLife Disability any information collected in the course of examining or treating me as a patient. Claimant Signature Date (mm/dd/yyyy) APS-STDLTD-5320 (06/20) Page 1 of 7

REQUIRED information in case pages get separated: Claimant First Name Middle Name Last Name Claim Number SECTION 2: Information About Your Patient's Health (To be completed by the physician providing treatment for the disability condition.) • Please provide all applicable information requested about your patient. The information you share will be used in making a decision about your patient's claim for disability benefits. • After you complete this form, please submit it along with office notes and results from any diagnostic testing related to your patient's condition (e.g., x-ray, lab tests, EKG or MRI). See Section 4 below for instructions on how to submit this completed form and any supporting documents to MetLife Disability. History Of Your Patient's Condition First date of treatment for this condition (mm/dd/yyyy) Most recent date of treatment (mm/dd/yyyy) What is the cause of your patient's symptoms? (Check one) Injury Illness Pregnancy (Type of birth - Check one below) Cesarean Natural Birth Not yet delivered: Expected delivery date (mm/dd/yyyy) List any other physicians or specialists you referred your patient to: First name Last name Specialty Phone number Is your patient's condition work-related? Yes No Did you advise your patient to stop working? Yes On date (mm/dd/yyyy) No Has your patient been hospitalized for this condition? Yes On date (mm/dd/yyyy) No Facility Name Address City State ZIP About The Diagnosis And Treatment Of Your Patient Primary Diagnosis Code Description Secondary Diagnosis Code Description APS-STDLTD-5320 (06/20) Page 2 of 7

REQUIRED information in case pages get separated: Claimant First Name Middle Name Last Name Claim Number List the symptoms your patient reported to you. List your clinical findings and reports. (Please include copies of results when you return this form to us) Describe the treatment plan you recommend for your patient. If surgery has been performed or is anticipated, provide: CPT-4 procedure code Description Date (mm/dd/yyyy) List any medications prescribed: Medication name Dosage About Your Patient's Restrictions and Limitations Your patient's dominant hand (Check One): Right Left How many hours in a workday can your patient: Hours (0 to 8) Continuously Intermittently Breaks Frequency Duration Sit Stand Walk Climb Twist/Bend/Stoop Reach above shoulder level Reach front and side at desk level Perform find finger movements Perform eye/hand movements APS-STDLTD-5320 (06/20) Page 3 of 7

REQUIRED information in case pages get separated: Claimant First Name Middle Name Last Name Claim Number How many hours in a workday can your patient lift or carry: Hours (0 to 8) Continuously Intermittently Breaks Frequency Duration Up to 10 lbs. 11 to 20 lbs. 21 to 50 lbs. 51 to 100 lbs. Over 100 lbs. How many hours in a workday can your patient push or pull: Hours (0 to 8) Continuously Intermittently Breaks Frequency Duration Up to 10 lbs. 11 to 20 lbs. 21 to 50 lbs. 51 to 100 lbs. Over 100 lbs. Can your patient operate a motor vehicle? Yes No Is your patient at maximum medical improvement? Yes No Please make any additional notes. About Your Patient's Prognosis Have you advised your patient when they can return to work? Yes (Check all that apply) To regular occupation. On date (mm/dd/yyyy) Full-time Part-time Modified duty To any other occupation. On date (mm/dd/yyyy) Full-time Part-time Modified duty No (Please explain) List any restrictions to work or activity. (Please be as specific as possible.) APS-STDLTD-5320 (06/20) Page 4 of 7

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

Dx Disability Claims Fraud Warnings Before signing this claim form, please read the warning for the state where you reside and for the state where the insurance policy under which you are claiming a benefit was issued. Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies to the extent required by applicable law. Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Idaho, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud as provided in RSA 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. APS-STDLTD-5320 (06/20) Page 6 of 7

Oregon: Any person who knowingly presents a materially false statement of claim may be guilty of a criminal offense and may be subject to penalties under state law. Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Vermont: Any person who knowingly presents a false statement of claim for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. APS-STDLTD-5320 (06/20) Page 7 of 7