AUTHORIZATION This Authorization is in connection with an enrollment in group insurance and informati on required for underwriting and claim purposes for the proposed insured(s) ("employee", spouse, and /or any other person(s) named below). Underwriting means classification of indi viduals for determination of insurability and / or rates, based upon physic ian health reports, prescription drug history, laboratory test results, and other factors. Notwithstanding any prior restriction placed on information, records or data by a proposed insured, each proposed i nsured hereby authorizes : • Any medical practitioner, facility or related entity; any insurer; MIB Group, Inc (“MIB”); any employer; any group policyholder, contract holder or benefit plan administrator; any pharmacy or pharmacy related service organization; any consumer reporting agency ; or any government agency to give Metropolitan Life Insurance Company (“MetLife”) or any third party acting on MetLife's behalf in this regard: • personal information and data about the proposed insured including employment and occupational information; • medical information, records and data about the proposed insured including information, records and data about drugs prescribed, medical test results and sexually transmitted diseases; • information, records and data about the proposed insured related to alcohol and drug abuse and treatment, including information and data records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2; • information, records and data about the proposed insured relating to Acquired Immunodeficiency Syndrome (AIDS) or AIDS related conditions including, where permitted by applicable law, Human Immunodeficiency Virus (HIV) test results; • information, records and data about the proposed insured relating to mental illness, except psychotherapy notes; and • motor vehicle r eports. Note to All Hea lth Care Providers: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of t he individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive serv ices. Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form or s ooner if prescribed by law. The proposed insured may revoke this authorization at any time. To revoke the authorization, the proposed insured must write to MetLife at P.O. Box 14069, Lexington, KY 40512- 4069, and inform MetLife that this Authorization is revoked. Any action taken before MetLife receives the proposed insured's revocation will be valid. Revocation may be the basis for denying coverage or benefits. If the proposed insured does not si gn this Authorization, that person's enrollment for group insurance cannot be processed. By signing below, each proposed insured acknowledges his or her understanding that: • All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to MIB . Such information may also be disclosed to and used by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insurance applied for or on existing insurance with MetLife, or disclosed as otherwise required or permitted by applicable laws. • Medical information, records and data that may have been subject to federal and state laws or regulations, including federal rules issued by Health and Human Services, setting forth standards for the use, maintenance and disc losure of such information by health care providers and health plans and records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2, once disclosed to MetLife or upon redisclosure by MetLife, may no longer be covered by those laws or regulations. • Information relating to HIV test results will only be disclosed as permitted by applicable law. • Information obtained pursuant to this authorization about a proposed insured may be used, to the extent permitted by applicable la w, to determine the insurability of other family members. • A photocopy of this form is as valid as the original form. Each proposed insured (or his/her authorized representative) has a right to receive a copy of this form. • I authorize MetLife, or its reins urers, to make a brief report of my personal health information to MIB. Signature of Proposed Insured Date Signed (MM/DD/YYYY) Print Name State of Birth Country of Birth If a child proposed for insurance is age 18 or over, the child must sign this Authorization form. 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 guardian, 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 AUTH -XDP110S -NW (09/18)