Metropolitan Life Insurance Company, New York, NY 101 66 DECLARATIONS AND SIGNATURES By signing below, I acknowledge: 1. I have read this Statement of Health form and declare that all information I have given, including any health information, is true and complete to the best of my knowledge and belief. I und erstand that this information will be used by MetLife to determine insurability. 2. I have read the applicable Fraud Warning(s) provided in this Statement of Health form. Signature of Proposed Insured Print Name Date Signed (MM/DD/YYYY) If a child proposed for insurance is age 18 or over, the child must sign this Statement of Health. If the child is under age 18, a Personal Representative for the child must sign, and indicate the legal relationship between the Personal Representative and the proposed insured . A Personal Representative for the child is a person who has the right to control the child’s health care, usually a parent, legal guar dian, or a person appointed by a court. Signature of Personal Representative Print Name Date Signed ( MM/DD/YYYY ) Relationship of Personal Representative Sign Here Sign Here GEF09 -1 DEC (The form number above applies to residents of all states except as follows : Form number GEF09 -1 applies to residents of Montana ; GEF09 -1 DEC applies to residents of Connecticut, North Dakota and Utah) Please complete all sections of this form. Incomplete forms will be returned to you. Page 5 of 5 SOH -XDP 400S -FL (09/18)