MetLife Notice of Group Life Insurance Conversion Privilege Form

Notice of Group Life Insurance Conversion Privilege Metropolitan Life Insurance Company This Notice is not a conversion application or policy Instructions Instructions to Policyholder/Recordkeeper: Complete this Notice and provide a copy to the employee when group coverage terminates or reduces. If coverage has been assigned, provide notice to the Assignee. Instructions to Eligible Person: You may convert your coverage to an individual life insurance policy, which will be issued without medical examination if you apply for it and pay the required premium within the application period. Application Period: The application period is based on the date your group coverage terminates and the date of this Notice. Generally, you have 31 days from the date group coverage ends to apply for conversion. However, if this Notice is dated more than 15 days from date of termination, your application period is extended for an additional 15 days. If the 15-day extension applies to you, it will not exceed more than 91 days from the date group insurance was terminated. The conversion application period is time-sensitive. If you are interested in converting your group coverage, you can meet with a specially-trained financial professional and complete an application. MetLife has an arrangement for third party financial professionals to explain your options. Call us at 877-275-6387 to arrange for a third party financial professional to contact you directly. Eligible Person / Employee Information Date of This Notice (mm/dd/yyyy) Date Group Coverage Terminates or Reduces (mm/dd/yyyy) ► Insured First Name Middle Name Last Name Relationship to Employee Gender Date of Birth (mm/dd/yyyy) Self Dependent Male Female ► Owner (If certificate is assigned) First Name Middle Name Last Name Gender Date of Birth (mm/dd/yyyy) Male Female ► Dependent (If applicable) First Name Middle Name Last Name Gender Date of Birth (mm/dd/yyyy) Male Female Address City State ZIP G685 Page 1 of 2 NW xCA, MI, MN, NV, NY JY2662.SCRE (06/20) Fs/f

Phone Number Date Group Life Benefits Became Effective for Insured (mm/dd/yyyy) Reason for Termination: Termination of Employment Termination of Group Policy or Class Retirement No Longer an Eligible Dependent Total Disability Coverage Information If the group policy or a class under the Complete the relevant column based on the event policy is ending, complete the applicable triggering conversion. If coverage is ending due to fields below. The amount of coverage termination of employment available for conversion is the lesser of If an accelerated benefits option claim was paid, or eligibility, or is reducing, the amount lost, or $10,000, provided the reduce the amount available for conversion by the complete the applicable insured was covered under the plan for at ABO claim amount. fields below. least five years. Group Policy Coverage Amount. Cannot Exceed Coverage Type Report Number Coverage Amount $10,000 Basic Life Supplemental Life Dependent Spouse Life Dependent Child Life Group Universal Life Group Variable Universal Life Survivor Group Policyholder Name Address City State ZIP Phone Number Authorized Group Policyholder Representative (Print) First Name Last Name G685 Page 2 of 2 NW xCA, MI, MN, NV, NY JY2662.SCRE (06/20) Fs/f