Metlife Insurance Claim Form Details

Did you know that Metlife is one of the largest life insurance providers in the world? In fact, they have been in business for over 140 years. If you need to make a life insurance claim, it's important to know what forms you will need to fill out. The Metlife life insurance claim form is one of the most common forms used by policyholders. In this post, we'll take a closer look at the form and provide some tips on how to complete it. Keep in mind that every policy is different, so be sure to consult your own policy document for specific instructions. When making a life insurance claim with Metlife, you will likely need to fill out their Insurance Claim Form (ICF).

This information can help you comprehend better the details of the metlife life insurance claim form before you start filling it out.

QuestionAnswer
Form NameMetlife Life Insurance Claim Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesmetlife claim form download, metlife claim form, metlife group claim forms, metlife death claim forms

Form Preview Example

Dear Beneficiary:

We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created a settlement option, the Total Control Account¨ Money Market Option, to give you the time you need to best decide how to use your insurance or annuity proceeds.

The insurance or annuity contract may have provided other settlement options for payment of the proceeds. Unless the contract owner or insured preselected a specific method of settlement, your right to choose any of these other settlement options is preserved while your money is in a Total Control Account. If a settlement option was preselected for you, more information will be provided as your claim is processed.

If the amount of proceeds payable to you is $7,500 or more, a Total Control Account will be opened in your name once your claim is approved, unless a different settlement option was selected. You will receive a personalized ÒcheckbookÓ and a Customer Agreement, which gives you additional information regarding your Account in an easy to read question and answer format. By using one of your personalized Òchecks,Ó you can draw a draft on your Total Control Account for the entire amount at any time. Information regarding the other settlement options available will also be provided.

While your money is in a Total Control Account, it is guaranteed by MetLife. You can access all or part of the insurance proceeds at any time, simply by writing one of your checks. You are not charged for checks, there are no transaction or monthly fees and there are no penalties for withdrawing all or part of your money.

We hope that the Total Control Account will help you rest a little easier knowing that your money is safe, earning a competitive rate, and accessible to you when you need it, giving you time to make financial decisions that are right for you. Please read the additional information regarding the Total Control Account provided on this form.

If you have further questions about the Account, MetLifeÕs Investment and Fiduciary Services Department is available every business day at (908) 634-9594 or through its toll-free number, 800-MET-SAVE (800-638-7283). Hearing impaired callers with a TDD can call (908) 636-4349 or 800-229-3037.

Once again, we extend our condolences and assure you that we will make every effort to help you in every way we can.

Please complete the Beneficiary Life Insurance Claim Statement section of this form. Then ask your employer to complete the EmployerÕs Statement section and mail this form to:

MetLife

SBC Life Claims

P.O. Box 6122

Utica, NY 13501-6122

The TOTAL CONTROL ACCOUNT¨ Money Market Option

Designed to Put YOU in Complete Control of Your Life Insurance Proceeds

The Total Control Account provides É

SAFETY

¥The entire amount of your Account, including all interest earned, is fully guaranteed by MetLife.

COMPETITIVE RATES

¥The Account earns interest at money market rates that are responsive to current market conditions.

¥Interest is compounded daily and credited monthly. (Generally, the interest earned will be subject to income tax.)

FREE CHECKING

¥You can write checks from a minimum amount of $250 up to the full amount in the Account at any time.

¥There are no monthly service or transaction charges. There is no charge for printing or reordering checks.

CONVENIENCE

¥A personalized checkbook provides you with easy and immediate access to the funds.

¥You will receive a monthly statement, showing all transactions, interest earned and the balance in the Account.

FLEXIBILITY

¥You can withdraw all or part of your money at any time, without penalty or loss of interest.

¥There are no limits on the number of checks you can write each month.

¥You can name a beneficiary to receive money held in the Account, in case something happens to you.

FULL SERVICE

¥Beneficiary Service Representatives are within easy reach to answer any questions you may have about your Account. YouÕll be able to call them, toll-free, every business day, 8:00 a.m. - 6:00 p.m. Eastern Standard Time.

TIME TO DECIDE

¥Your rights to elect all other available MetLife settlement options* are preserved. You may, at any time, place some or all of the money in your Account in any other available option.

¥MetLife has a range of settlement options for you to choose from, including Guaranteed Interest Certificates. You will receive complete information on all settlement options which are available to you along with the Total Control Account checkbook.

*If the insured designated an alternative settlement option, that designation will be carried out. In this case, more information will be provided to you as your claim is processed.

The Total Control Account gives you:

Safety ¥ Security ¥ Convenience ¥ Flexibility

Free Checking ¥ Competitive Interest

If the proceeds payable to you are less than $7,500 Ñ and the insured did not designate a settlement option, payment is usually made by a single, lump-sum check.

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:

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

 

 

 

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

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:

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

 

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.

Joan Rose Smith

January 20, 1992

Beneficiary Signature

Date

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) _______________________________________________________________________________

First

Middle Initial

Last

2.Your Social Security No. _________________________

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

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______________________________________________________________________________________________

First

Middle Initial

Last

2.His/Her Residence Address____________________________________________________________________________________

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

________________________________________________________________________________________________________

 

City

 

State

 

Zip

3. His/Her Marital Status

Single

Married

Widow/Widower

Separated

Divorced

4.His/Her Date of Birth ______________________________

 

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_______________________________________________________________________________________

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.

_______________________________________________________ _____________________________________________

Beneficiary Signature

Date

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

Certificate

Number

Date of Death

Mo. Day Yr.

Date of Birth

Mo. Day Yr.

 

Name of Insured Employee

 

Sex

Last

First

Middle

M or F

 

 

 

 

Name of

Employer ______________________________________________

Division or

Subsidiary ______________________________________________

and Location

Social Sec. Number

If Different from Cert. No.

This Line Across for Dependent Claims Only

Date of Birth

Mo. Day Yr.

Sex

Amount of

 

Name of Deceased Dependent

 

M or F

Dependent Life Insurance

Last

First

Middle

 

 

 

 

 

Relationship

Spouse______________

Child _______________

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

Group

Sub

Claim

Type of Life Benefits

Amount

(Report Number)

Code

Pay Point

Check applicable box(es)

 

 

 

(Branch)

 

 

 

 

 

Basic Life

 

 

 

 

 

 

 

 

 

 

 

 

Optional Life*

 

 

 

 

 

 

 

 

 

 

 

 

Group Life Plus

 

 

 

 

 

 

 

 

 

 

 

 

Group Universal Life**

 

 

 

 

 

 

 

 

 

 

*Optional Life includes Supplemental Life, Additional Life, and Voluntary Life Benefits

**For more information concerning Group Universal Life coverage, please call 1-800-523-2894.

Exempt Employee or Non-Exempt Employee

Occupation ___________________________________________________

Is there any transaction pending which will affect the payee or the amount payable? If yes, give particulars:

____________________________________________________________

____________________________________________________________

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

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

If yes, please provide the approval number. _____________________________________________________________________________

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

 

 

 

 

 

will follow

 

for prior exhibit year $______________

 

$_____________________________

 

Contract No. ________________________

 

 

 

Employee contributions

 

 

Amount of Regular Life Insurance

 

 

 

 

 

 

 

and Cert. No. ________________________

for current

 

 

should be entered above.

 

 

exhibit year $_____________________

 

 

 

 

 

 

 

 

 

 

Total employee

 

 

 

 

 

 

contributions $ ___________________

 

 

 

 

_______________________________________________________________

__________________________________

__________________________________

Signature of EmployerÕs Authorized Representative

Date

 

Telephone No.

Send check or Total Control Account Package:

Directly to Beneficiary(ies)

Other: ___________________________________________

___________________________________________

___________________________________________

___________________________________________

Please attach any enrollment forms and beneficiary designations you retained. If a beneficiary is deceased, a copy of his or her death certificate is required. If you have any questions, please contact the MetLife administrator responsible for your group.

© 1988 Metropolitan Life Insurance Company Total Control Account¨ is a registered service mark of Metropolitan Life Insurance Company

DC-TCA5-SBC

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:

¥A booklet which includes your Customer Agreement spelling out the exact terms of your Account in an easy-to-read question-and-answer format.

¥A brochure describing other Settlement Options available, at no cost to you, including Guaranteed Interest Certificates.

¥A Total Control Account card is included for your convenience when calling your Beneficiary Service Representative on our toll-free number.

¥A Confirmation Certificate, showing the amount of life insurance proceeds placed in your Account, your Account number, the current interest rate, effective annual yield, and a Beneficiary Designation form.

¥Personalized checks give you immediate access to your money. You may write checks, payable to anyone, for any amount of $250 or more, to cover immediate expenses or for any other purpose. Meanwhile, the funds you donÕt use right away are safe at MetLife

and continuing to earn competitive money market interest.

© 1988 Metropolitan Life Insurance Company Total Control Account¨ is a registered service mark of Metropolitan Life Insurance Company

DC-TCA5-SBC

18000208126 (0399)