Question	Answer
Form Name	Metlife Life Insurance Claim Form
Form Length	6 pages
Fillable?	Yes
Fillable fields	123
Avg. time to fill out	26 min 6 sec
Other names	metlife death claim form, metropolitan life insurance company claims, metlife beneficiary claim form, metlife life insurance claim form

A. Information about you:
				______________________________________________________________________________
1.	Your Name (please print or type)					JOAN	R.	SMITH
						First	Middle Initial	Last
2.	Your Social Security No.		123-45-6789
3.	Your Date of Birth		6		28	37	Your Sex ⬛ Male	⬛ Female
			Mo.		Day	Year		X
4.	Your Phone Number (in case we need to contact you)						Day (305) 555-6728 Evening ( 305) 555-1234
5.	Your Address		21-15				Area Code	Area Code
5.	Your Address		21-15				MARTIN STREET	3B
		_____________________________________________________________________________________________
			House Number				Street Name	Apt./Box No. (if any)
		MIAMI					FLORIDA	33400
	_______________________________________________________________________________________________________
			City				State	Zip
6.	Your relationship to the deceased. You are the					⬛ Husband or Wife ⬛ Child ⬛ Parent ⬛ Other _________________________
						X		Explain

B. Information about the deceased:
1.	His/Her Name	GEORGE			H.			SMITH
			First		Middle Initial			Last
		__________________________________________________________________________________
2.	His/Her Residence Address		21-15		MARTIN STREET			3B
			House Number		Street Name			Apt./Box No. (if any)
	_______________________________________________________________________________________________________
			MIAMI		FLORIDA			33400
			City		State			Zip
3.	His/Her Marital Status		⬛ Single	⬛ Married ⬛ Widow/Widower				⬛ Separated ⬛ Divorced
4.	His/Her Date of Birth	6	28	37
		Mo.	Day	Year		______________________________________________
5.	His/Her Social Security No. 123/ 45/ 6789			6.	His/Her Employer		ABC COMPANY
7.	We need an officially certified copy of death certificate. Is a copy attached?							⬛ Yes	⬛ No
								X

3.	Your Date of Birth ________________________________			Your Sex ☐ Male ☐ Female
	Mo.	Day	Year
4.	Your Phone Number (in case we need to contact you)			Day (	)_____________	Evening (	)_____________
				Area Code		Area Code

	City		State		Zip
3. His/Her Marital Status	☐ Single	☐ Married	☐ Widow/Widower	☐ Separated	☐ Divorced

	Mo.	Day	Year
5.	His/Her Social Security No. ____ / ___ / ______		6. His/Her Employer ________________________________________________
7.	We need an officially certified copy of death certificate. Is a copy attached?			☐ Yes	☐ No
	If not, please state why_______________________________________________________________________________________

Notice: Be sure to consider any reduction formula applicable to each type of Life benefit	Complete the following if Applicable:
in-force when entering the amount of Life benefits for which claim is made.	☐ Hourly Employee	or	☐ Salaried Employee

	☐ Union Employee	or	☐ Non-Union Employee


Was employee ☐ active or	☐ retired? Date retired _______________Annual base pay_____________________
If active, enter the effective date of the amount of insurance being claimed. ______________________
If retired, enter the amount of insurance prior to reduction, if any. ________________________
Was the employer-employee relationship terminated before death? ☐ No ☐ Yes		Date ____________Reason _____________________
Was life insurance cancelled?	☐ No ☐ Yes Date ____________Was conversion applied for? ☐ No ☐ Yes ☐ Unknown
Was a Total and Permanent Disability claim ever filed with MetLife for this employee?		☐ No ☐ Yes

Joan Rose Smith	January 20, 1992
Beneficiary Signature	Date

Annuity Death Benefit			Accidental Death Benefit		Survivor Income Benefit

If an Annuity Death Benefit is claimed, and	For groups operated on the ÒAnnual		If an Accidental Death Benefit is	If the deceased employee qualified for
such benefit is covered by MetLife, enter	ExhibitÓ method of billing or if employee		claimed, and such benefit is covered	Survivor Income Benefits, and such
Group Annuity	contributions are reported annually:		by MetLife, enter amount of such	benefits are covered by MetLife, specify if
	Employee contributions		benefit only.	the claim	☐ is attached, or
	Employee contributions				☐ will follow
	for prior exhibit year $______________		$_____________________________		☐ will follow
Contract No. ________________________	for prior exhibit year $______________		$_____________________________
Contract No. ________________________	Employee contributions		Amount of Regular Life Insurance
	Employee contributions		Amount of Regular Life Insurance
and Cert. No. ________________________	for current		should be entered above.
and Cert. No. ________________________	exhibit year $_____________________
	exhibit year $_____________________
	Total employee
	contributions $ ___________________
_______________________________________________________________		__________________________________		__________________________________
Signature of EmployerÕs Authorized Representative		Date		Telephone No.

© 1988 Metropolitan Life Insurance Company Total Control Account¨ is a registered service mark of Metropolitan Life Insurance Company	DC-TCA5-SBC
18000208126 (0399)

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

Metlife Life Insurance Claim Form PDF Details