Part C – TO BE COMPLETED BY THE EMPLOYEE DESIGNATION OF BENEFICIARY FOR YOUR LIFE INSURANCE (Dependent Life Insurance is payable as specified in the Certificate) Only check one of the following boxes. I designate the following person(s) as my primary beneficiary(ies) for my portable term coverage(s). With such designation any previous designation of a beneficiary for such coverage is hereby revoked. My designation of beneficiary is on a separate form which is signed, dated and attached. The amount of insurance that is paid to you or your beneficiary will be decreased by any amount of contribution owed to MetLife. Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page. Full Name (First, Middle, Last) Social Security # Date of Birth (MM/DD/YYYY) Relationship Share % Address (Street, City, State, Zip) Phone #: Full Name (First, Middle, Last) Social Security # Date of Birth (MM/DD/YYYY) Relationship Share % Address (Street, City, State, Zip) Phone #: Full Name (First, Middle, Last) Social Security # Date of Birth (MM/DD/YYYY) Relationship Share % Address (Street, City, State, Zip) Phone #: Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100% If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies): Full Name (First, Middle, Last) Social Security # Date of Birth (MM/DD/YYYY) Relationship Share % Address (Street, City, State, Zip) Phone #: Full Name (First, Middle, Last) Social Security # Date of Birth (MM/DD/YYYY) Relationship Share % Address (Street, City, State, Zip) Phone #: Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100% DECLARATION AND SIGNATURE The person signing below acknowledges that they have read and understand the statements and declarations made in this election form. Before signing this election form, please read the warning below: New York (only applies to Accident and Health Insurance): 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 subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ø Ø Signature of Insured/Owner Date Signed (MM/DD/YYYY) Please Note: MetLife needs to receive the original. The signature and date above may not be altered. 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 3 of 3 T7200 (07/19)