Metlife Life Insurance Claim Form – Fill Out and Use This PDF

Completing Your Claim Statement

Every effort has been made to make completing your claim form as simple as possible. The following examples should make it even simpler. Each beneficiary must submit his or her own claim form.

SECTION A

Here you are asked for information about you and your relationship to the deceased. Your completed form might look like this:

SECTION B

In Section B we ask you to tell us about the deceased. Please be sure that you use the deceasedÕs legal residence address prior to the death. Your completed form might look like this:

If not, state why ___________________________________________________________________________________________

Please make every effort to include with your form an officially certified copy of the death certificate. The absence of the death certificate can cause substantial delays. If your name has changed since the original beneficiary designation please provide supporting documentation.

Once you have completed the form, sign (just as you sign checks) and date it.

The information I have given is, to the best of my knowledge, true and accurate. Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number, and that: (please check one)

⬛The Internal Revenue Service (IRS) has notified me that I am subject to backup withholding as a result of a failure to report all interest or dividends, or

⬛I am not subject (or no longer subject) to backup withholding.

The IRS does not require your consent to any provision of this document other than the certifications to avoid backup withholding.

If the insured was covered under a policy issued in one of the states listed below or if you reside in one of the states listed below, one of the following state warnings may apply to you:

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

If the insured was covered under a policy issued in any state other than those listed above, or if you reside in any state other than those listed above, then the following warning may apply to you:

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Please sign below as you would sign on checks. If you are receiving a Total Control Account, this signature will be placed with your Account.

Return this completed Claim Statement to the EmployerÕs appropriate Benefit Office. Be sure to include an officially certified copy of the death certificate.

Metropolitan Life Insurance Company

One Madison Avenue, New York, NY 10010-3690

BeneficiaryÕs Life Insurance Claim Statement

In order to process your claim as quickly as possible we need some information about you and about the deceased. Each beneficiary must submit his or her own claim statement.

A. Information about you:

1.Your Name (please print or type) _______________________________________________________________________________

2.Your Social Security No. _________________________

5.Your Address ______________________________________________________________________________________________

House NumberStreet NameApt./Box No. (if any)

________________________________________________________________________________________________________

CityStateZip

6. Your relationship to the deceased. You are the ☐ Husband or Wife ☐ Child ☐ Parent ☐ Other __________________________

Explain

B. Information about the deceased:

1.His/Her Name______________________________________________________________________________________________

2.His/Her Residence Address____________________________________________________________________________________

House NumberStreet NameApt./Box No. (if any)

________________________________________________________________________________________________________

4.His/Her Date of Birth ______________________________

The information I have given is, to the best of my knowledge, true and accurate. Under penalties of perjury, I certify that the number shown on this form is my correct taxpayer identification number, and that: (please check one)

⬛The Internal Revenue Service (IRS) has notified me that I am subject to backup withholding as a result of a failure to report all interest or dividends, or

⬛I am not subject (or no longer subject) to backup withholding.

The IRS does not require your consent to any provision of this document other than the certifications to avoid backup withholding.

If the insured was covered under a policy issued in one of the states listed below or if you reside in one of the states listed below, one of the following state warnings may apply to you:

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

If the insured was covered under a policy issued in any state other than those listed above, or if you reside in any state other than those listed above, then the following warning may apply to you:

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Please sign below as you would sign on checks. If you are receiving a Total Control Account, this signature will be placed with your Account.

_______________________________________________________ _____________________________________________

EMPLOYERÕS STATEMENT Ñ To Be Completed by an Authorized Company Representative. Please Type.

On what date did the employee last work? ________________Reason for stopping ___________________________________________

If yes, please provide the approval number. _____________________________________________________________________________

Send check or Total Control Account Package:

As soon as your claim has been processed and approved (and the amount payable to you exceeds $7,500), a Total Control Account will be automatically opened, and you will receive: