Metropolitan Life Insurance Company, New York, NY 10166 Personal Physician Information Personal Physician’s Name: Address (Street, City, State, Zip Code): Telephone: ( ) – Date of last visit (MM/DD/YYYY): / / Reason for visit: Prescription Informa tion Are you currently taking any prescribed medications? Yes No If yes, list the medications. Medication: Condition/Diagnosis: Prescribing Physician’s Name: Telephone: ( ) – Address (Street, City, State, Zip Code): Medication: Condition/Diagnosis: Prescribing Physician ’s Name: Telephone: ( ) – Address (Street, City, State, Zip Code): Check here if you are attaching another sheet for any additional medications. SECTION 2 Please provide full details below for each “Yes” answer to questions 5 through 11u in Section 1. If you need more space to provide full details, attach a separate sheet with the information and sign and date it. Delays in processing your application may occur if complete details are not provided. MetLife may contact you for additional or missing information. Check here if you are attaching another sheet. Your name Employee’s Name Your Date of Birth / / Question Number Condition/Diagnosis Please list any medication prescribed that you did not already identify in the Prescription Information above. Date of Diagnosis (Month/Year) Date of Last Treatment (Month/Year) Type of Treatment Treating Health Professional Physician’s Name: Date of last visit: Reason for visit: Address Street City State Zip Code Telephon e: ( ) - Question Number Condition/Diagnosis Please list any medication prescribed that you did not already identify in the Prescription Information above. Date of Diagnosis (Month/Year) Date of Last Treatment (Month/Year) Type of Treatment Treating Health Professional Physician’s Name: Date of last v isit: Reason for visit: Address Street City State Zip Code Telephone: ( ) - GEF0 9-1 HEA (The form number above applies to residents of all states except as follows : For m number GEF09 -1 applie s to residents of Montana ; GEF09 -1 HEA applies to residents of Connecticut, North Dakota and Utah) Please complete all sections of this form. Incomplete forms will be returned to you. Page 3 of 5 SOH -XDP 400S -FL (09/18)