Part B (continued) – ELECTION OF PORTABLE COVERAGE FORM To be Completed by the Employee (For each Type of Coverage, please indicate whether you want to continue, discontinue, To be Completed by the Recordkeeper increase, or decrease the amount of insurance in the shaded column. Select just one (Shaded areas to be completed by the Recordkeeper). option for each Type of Coverage). Continue Discontinue Decrease coverage coverage coverage I want to continue the I want to discontinue the I want to decrease my Amount of Insurance same amount of insurance in the shaded insurance in the shaded Terminated insurance in the shaded column. column by the following Type of Coverage Insert the actual $$ column. amount. amount of coverage (i.e. (Ex. $30,000 means you $50,000) want to decrease your insurance amount in column 1 by $30,000). Employee 1,2 Basic Life $ – $ 3 Life: $ – Life: $ Basic Life and AD&D AD&D: $ – AD&D: $ Supplemental/Optional Life $ – $ Supplemental/Optional Life Life: $ – Life: $ 3 and AD&D AD&D: $ – AD&D: $ Voluntary AD&D $ – $ Employee Only Employee + Dependents 1,2,4 Dependent Spouse/Domestic Partner Dependent Life $ – $ 3 Life: $ – Life: $ Dependent Life and AD&D AD&D: $ – AD&D: $ 3,5 Voluntary AD&D $ – $ 2,4 Dependent Child(ren) Dependent Life $ – $ 3 Life: $ – Life: $ Dependent Life and AD&D AD&D: $ – AD&D: $ 3,5 Voluntary AD&D $ – $ 1 The maximum amount the employee can continue on a portable basis is $1,000,000. The maximum amount the spouse/domestic partner can continue on a portable basis is $250,000. 2 In order to port coverage for yourself or your dependents, you must have had that coverage under your former plan at the time of your coverage termination. 3 AD&D coverage is not available without Life Insurance coverage. AD&D amount selected will be equal to the Life Insurance amount and must be in effect at time of termination. However, your VAD&D amount can be more than your Life insurance amount. 4 Subject to state limits, the Dependent Spouse/Domestic Partner amount can be greater than the Employee Amount. For Employee and Spouse/Domestic Partner coverage: Spouse/Domestic Partner minimum is $2,500. The Child minimum is $1,000. 5 Use these fields only when Voluntary AD&D is being requested for the Spouse/Domestic Partner and/or Child because of the death of the Employee or divorce. NOTE: All coverage amounts are subject to applicable state laws. Please retain a copy of the fully-completed form for your records and return the original to MetLife Customer Service Center. If you have any questions, please call 1-888-252-3607 Monday – Friday between the hours of 8:00 a.m. and 11:00 p. m. (EST). (Continued on Following Page) EP12 Page 2 of 3 T7200 (07/19)