MetLife Statement of Health Form

INSTRUCTIONS FOR THE STATEMENT OF HEALTH FORM AND THE AUTHORIZATION FORM THAT FOLLOW THIS SECTION INSTRUCTIONS TO THE RECORDKEEPER (The Recordkeeper may be the Group Customer, a Third Party Administrator or MetLife.) 1. Fill in the Group Customer Information and Insurance Information on the Statement of Health form. 2. Give the forms to the Employee. INSTRUCTIONS TO THE EMPLOYEE 1. Fill in your name and Social Security # on the Statement of Health form. The Employee's Name and the Employee’s Social Securi ty # must appear on the form. 2. Give the forms to the Proposed Insured to complete and send to MetLife. INSTRUCTIONS TO THE PROPOSED INSURED (The Proposed Insured is the person for whom insurance is being requested. The Proposed Insured may be the Employee, the Employee’s Spouse or the Employee’s Child.) A separate Statement of Health form must be completed by each Proposed Insured. Based on the enrollment form submitted by the Employee, a Statement of Health form is required to complete the employee’s request for group insurance coverage for you, the Proposed Insured. 1. If the Insurance Information Section is not completed, obtain the information before finalizing the form. Contact your Employer/Benefits Administrator if the Life Insurance amounts were not provi ded or to confirm the Life Insurance amounts. 2. Complete the Statement of Health form and sign where indicated by an arrow. 3. Sign the Authorization form where indicated by an arrow. 4. After completion, make a copy of both completed forms for your records and FA X, MAIL or EMAIL the original forms to the address at the right. Emailed forms must be printed and signed before they are scanned and submitted. For QUESTIONS , call MetLife at 1 -800 -638- 6420, prompt 1 (Statement of Health Unit) or email us at [email protected] . Metropolitan Life Insurance Company, Medical Underwriting P.O. Box 14593 Lexington, KY 40512 -4593 FAX: 1 -888 -505 -7446 To submit by Email: [email protected] Note: Additional medical information may be required after MetLife’s initial review of a completed Statement of Health form. The additional information requested may be a physical examination, paramedical exam, or an Attending Physician Report. Correspo ndence will be sent within ten days by MetLife or our approved vendor. Incomplete forms will be returned to you for completion. Some services in connection with your coverage may be performed by our affiliates, MetLife Global Operations Support Center P riv ate Limited and MetLife Services and Solutions, LLC., unless prohibited by state or local law or by mutual agreement with the group customer. These service arrangements in no way alter Metropolitan Life Insurance Company’s obligation to you. Your coverag e will continue to be administered in accordance with Metropolitan Life Insurance Company’s policies and procedures . STATEMENT OF HEALTH FORM Metropolitan Life Insurance Company, New York, NY 10166 GROUP CUSTOMER INFORMATION (To be Completed by th e Recordkeeper) Name of Group Customer/Employer/Association Group Customer # Class Reporting Location # Street Address City State Zip Code INSURANCE INFORMATION (To be Completed by the Recordkeeper) Enrollment year Term Life Insurance Basic Life (Core): Indicate amount subject to medical underwriting $ Supplemental/Optional Life (Buy up): Indicate amount subject to medical underwriting $ Dependent Spouse 1 Life: Indicate amount subject to medical underwriting $ Supplemental/Optional Dependent Spouse 1 Life (Buy up): Indicate amount subject to medical underwriting $ Dependent Child Life: Indicate amount subject to medical underwriting $ Supplemental/Optional Dependent Child Life (Buy up): Indicate amount subject to medical underwriting $ Disability Income Insurance Short Term Disability Benefits Long Term Disability Benefits EMPLOYEE INFORMATION (To be Completed by the Employee) Name of Employee (First, Middle, Last) Social Security # of Employee Employee Retiree Date of Hire (MM/DD/YYYY) Employee 's Basic Annual Earnings $ YOUR INFORMATION (To be Completed by the Proposed Insured) Name (First, Middle, Last) Relationship to Employee Self Spouse Child Male Female Street Address City State Zip Code Date of Birth (MM/DD/YYYY) Daytime Phone # Home Phone # Email Address 1 For Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. GEF0 2-1 ADM (The form number above applies to residents of all states except as follows: Form number GEF09 -1 applie s to residents of Montana ; GEF02 -1 ADM applies to residents of Connecticut, North Dakota and Utah) Please complete all sections of this form. Incomplete forms will be returned to you. Page 1 of 5 SOH -XDP 400S -FL (09/18)