Paid Family & Medical Leave Certification Form

Page 1 of 5 Fs/f PFML-CERT-FORM (12/21) Paid Family & Medical Leave Certification Form Metropolitan Life Insurance Company Things to Know Before You Begin • Please complete Sections 1 before giving this form to the medical provider. • To ensure benefit payments and/or (where applicable) job protection, MetLife requires that you submit a timely and complete certification based on your leave reason. • Remember to add your First and Last Name along with the claim form number to all pages so that we can match this certification with your absence request. Reminder: Forms marked as lifetime, unknown, as needed, indeterminate or the like, may be returned as incomplete. SECTION 1: Employee Information Employee - First Name Middle Name Last Name Claim Number Employer Name Dates of Leave: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Continuous Intermittent Reason for Leave My own serious health condition (including disability) ICD-10 Diagnosis Code To bond with a child Military Exigency Safe Leave (CT only) Organ/Bone Marrow Donor To care for a family member due to a serious health condition Qualified Leave reason may vary by state 1. Relationship to Employee: (approved family member may vary by state and FMLA program) Self Parent in law Grandchild Child (under 18) Spouse Sibling Child (over 18) Domestic Partner Other Parent Grandparent Description if Other 2. For CT and MA: If care of Family member, did the Illness or Injury incur in the line of military duty? Yes No Authorization and Signatures By signing below, I certify that the intent of the information in this document is to support my need to be absent from work due to the qualifying reason checked above. Signature Date (mm/dd/yyyy)

Page 2 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number Section 2: Certification of Serious Health Condition (Employee’s own medical or family member) To be completed by the healthcare provider. Patient's - First Name Middle Name Last Name Date of Birth (mm/dd/yyyy) (required) Gender ICD-10 Diagnosis Code Does the patient have a serious health condition that prevents them from performing the material and substantial duties of their job? Yes No Check and complete all that apply: Condition due to pregnancy Estimated Due Date (mm/dd/yyyy) Child's Date of Birth (mm/dd/yyyy) Place of Birth (city, state) Is the claimant pregnant (when condition itself is not pregnancy) ? Yes No Is the condition due to organ or bone marrow donation? Yes No Dates you treated patient for condition: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Will patient need treatment visits at least twice per year due to condition? Yes No Expected duration of condition: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Condition lead to hospital admittance: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Intermittent absence details: Will the employee listed above require an intermittent absence and/or reduced work schedule to care for your patient’s (the employee/’s family member) serious health condition? If so, please check the box below and provide approximately how long your patient will need the intermittent support outlined below. Frequency: times per Week, Month Year Length of Episode Minutes Hours fully day(s) In the space provided below or in an attached page, please describe relevant medical facts, if any, related to the condition for which the employee seeks leave from work (i.e., pregnancy complications, or any regimen of continuing treatment such as the use of specialized equipment) .

Page 3 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number In the space provided below or in an attached page, please describe the care needed for the patient and why such care is medically necessary. If care is for an adult child, List ADLs or IADLs your patient requires support to perform (i.e., cooking, toileting, travel to appointments) . Please Read: GINA Disclaimer: 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, 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 services. Fraud Notice: Any person who knowingly and with intent to injure, defraud, or deceive any person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information is/may be guilty of a crime and may be prosecuted and punished. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. By signing below, I attest that I am the treating health care provider to the listed patient. The clinical information I am providing is in regard to the dates of absences listed above. I certify that my patient’s family member (employee) must be absent from work or have a modified work schedule due to this condition. License Number State Business Name Address City State ZIP Phone Number Email Signature of Heathcare Provider Date (mm/dd/yyyy)

Page 4 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number SECTION 3: Child Bonding: (Only complete if leave reason is to bond with a child) Select the type of documentation provided. Copy of Birth Certificate Healthcare provider certification (Section 2) Copy of placement documents for Adoption/Foster care SECTION 4: Military (Only complete if leave reason is for Military Exigency or Military Caregiver leave) Service Member Affiliation: Army Navy Air Force National Guard Marine Corps Other: Active Reserves Veteran Service Member Rank Unit Check all that apply Service member is on the Temporary Disability Retired List (TDRL) Service member is on the Permanent Disability Retired List Illness or Injury incurred in the line of duty Check the appropriate reason for leave Childcare and School Activities Military Events and Related Activities Short Notice Deployment Counseling Post Deployment Activities Financial and Legal Parental Care Rest and Recuperation Bereavement Additional activities as described Check one of the following and attach the indicated document to support that the military member is on covered active duty or call to covered active duty status: A copy of the covered military member's active duty orders is attached. Other documentation from the military certifying that the covered military member is on active duty orders (or has been notified of an impending call to active duty) in support of a contingency operation is attached. I have previously provided my employer with sufficient written documentation confirming the covered military member's active duty or call to active duty status in support of a contingency operation.

Page 5 of 5 Fs/f PFML-CERT-FORM (12/21) Employee - First Name Middle Name Last Name Claim Number SECTION 5: Safe Leave (To be used if the employee is impacted by family violence. Complete only if filing for leave for non-medical reasons. If you have a medical reason, please file under Section 1.) Check one of the following and attach the indicated document to support your leave: Documents for a civil or criminal proceeding relating to family violence Other documentation to support your claim such as proof of care from a victim service organization or relocation due to safety Signed written statement from applicant certifying that the applicant is taking leave for one of the following reasons: 1. To obtain services from a victim services organization, 2. To relocate due to such family violence, or 3. To participate in any civil or criminal proceedings related to or resulting from such family violence. Description of the purpose for this leave (To be completed by the employee) : Third Party Signature I attest I am an Attorney, an employee of the Judicial Branch's Office of the Victim Services or the Office of the Victim Advocate, or a licensed medical professional or other licensed professional I am attesting that the applicant named in this document is a victim of family violence. Print - First Name Middle Name Last Name Organization Name Signature Date (mm/dd/yyyy) SECTION 6: How to Submit This Form Mail: MetLife Disability, P.O. Box 14590, Lexington, KY 40512-4590 Fax: 1-800-230-9531