Request for Paid Family & Medical Leave

Page 1 of 4 Fs/f MET-PFML (11/21) Request for Paid Family & Medical Leave (MET-PFML) - Part A Metropolitan Life Insurance Company SECTION 1: Employee Information (To be completed by Employee) 1. Legal First Name Legal Middle Name Legal Last Name 2. Other Last Names, if Any, Under Which Employee Has Worked 3. Mailing Address City State ZIP Country (if not U.S.A.) 4. Social Security Number Employee ID 5. Date of Birth (mm/dd/yyyy) 6. Primary Phone Number 7. Email 8. Gender Male Female Not Designated/Other 9. Preferred Language if Other Than English Other Paid Family and Medical Leave (PFL or PML) Request 10. a. Reason for Leave: My Own Serious Health Condition (including disability) Bond With Child Safe Leave Care for Family Member Military Qualifying Event • If care of Family member, did the Illness or Injury incurred in the line of military duty? Yes No b. 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 11. Dates of Leave: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Please complete the PFML Certification to support the qualifying leave reason. 12. Will the leave include a reduced leave schedule or intermittent leaves? Yes No 13. Notice a. Did you provide notice to your employer? Yes No b. If so, when and to whom?

Page 2 of 4 Fs/f MET-PFML (11/21) Name of Employee Requesting PFML First Name Middle Name Last Name Employee ID 14. If providing less than 30 days advance notice from the estimated PFML start date, please explain. SECTION 2: Employment Information (To be completed by Employee) 15. Business Name 16. Date of Hire (mm/dd/yyyy) 17. Phone Number 18. Work Location - Street Address City State ZIP 19. Are you still actively at work? Yes No Termination Date (mm/dd/yyyy) 20. Average Quarterly Wage (This data will be requested of both employee and employer) 21. Scheduled Work Week: M Tu W Th F Sa Su 22. Is your schedule: Regular Variable ? 23. Will you receive company paid leave or benefits during the leave? Yes No If yes, list 24: Are you currently receiving Unemployment? Yes No 25. Are you currently receiving Workers' Compensation Benefits? Yes No Disclosure Statement: Information regarding PFML benefits received by the employee, such as payments received and types of leave, will be provided to the employer. SECTION 3: Declaration and Signature Any person who files an application for leave or benefits containing any materially false information, or conceals information for the purpose of misleading MetLife concerning any material fact may be subject to penalties. I am hereby making a request for paid family and medical leave benefits under applicable state law. My signature affirms that the information I am providing is true and accurate to the best of my knowledge and belief. Signature of Employee Date (mm/dd/yyyy)