Metropolitan Life Insurance Company, New York, NY 10166 ELECTION OF PORTABLE COVERAGE FORM Instructions to the Recordkeeper: (The Recordkeeper is the party designated to maintain records of coverage in effect prior to the Employee becoming eligible to Port. The Recordkeeper may be the Employer, a Third Party Administrator (TPA) or MetLife.) 1. Immediately upon the Employee’s eligibility for Portability, complete Part A below and Column 1 of the table on page 2 and then make a copy of this form. 2. If the Reason for the Portability Eligibility is Death of the Employee or Divorce, complete all of the fields in Part A below with the Spouse/Domestic Partner's information, not the Employee's information. In the column for Amount of Insurance Terminated, leave the Employee amounts blank and enter the Dependent Spouse/Domestic Partner/Domestic Partner and Dependent Child(ren) amounts as applicable. 3. Provide the Employee (or Spouse/Domestic Partner in the event of Death of the Employee or Divorce) with the original or mail it to their last known address. 4. Maintain a copy for your records. Part A – TO BE COMPLETED BY THE RECORDKEEPER Date of This Notice (ex. MM/DD/YYYY): Employer’s Name: Group Customer No.: Employee Name: (First, Middle, Last) Date Coverage Ended: Employee’s Mailing Address: (Street, City, State Zip) Has coverage been assigned? Yes No If yes, please specify coverage assigned and attach a copy of assignment form. If coverage has been assigned this form must be mailed to the owner. Employee’s Basic Annual Earnings: Reason for Insured’s Portability Eligibility: $ Recordkeeper’s Name: Print name of person at Recordkeeper completing Part A: Telephone Number: Part B – TO BE COMPLETED BY THE EMPLOYEE Employee’s Email Address: Employee’s Home Telephone No.: Social Security Number: Date of Birth: (ex. MM/DD/YYYY) Sex (M/F): 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 1 of 3 T7200 (07/19)