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.
Question | Answer |
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Form Name | Metlife Life Insurance Claim Form |
Form Length | 6 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 30 sec |
Other names | metlife claim form download, metlife claim form, metlife group claim forms, metlife death claim forms |
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)
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
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,
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,
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: |
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______________________________________________________________________________ |
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1. |
Your Name (please print or type) |
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JOAN |
R. |
SMITH |
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First |
Middle Initial |
Last |
2. |
Your Social Security No. |
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3. |
Your Date of Birth |
6 |
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28 |
37 |
Your Sex ⬛ Male |
⬛ Female |
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Mo. |
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Day |
Year |
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X |
4. |
Your Phone Number (in case we need to contact you) |
Day (305) |
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5. |
Your Address |
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Area Code |
Area Code |
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MARTIN STREET |
3B |
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_____________________________________________________________________________________________ |
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House Number |
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Street Name |
Apt./Box No. (if any) |
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MIAMI |
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FLORIDA |
33400 |
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_______________________________________________________________________________________________________ |
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State |
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6. |
Your relationship to the deceased. You are the |
⬛ Husband or Wife ⬛ Child ⬛ Parent ⬛ Other _________________________ |
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X |
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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: |
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1. |
His/Her Name |
GEORGE |
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H. |
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SMITH |
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First |
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Middle Initial |
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Last |
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__________________________________________________________________________________ |
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2. |
His/Her Residence Address |
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MARTIN STREET |
3B |
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House Number |
Street Name |
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Apt./Box No. (if any) |
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_______________________________________________________________________________________________________ |
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MIAMI |
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FLORIDA |
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33400 |
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City |
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State |
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Zip |
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3. |
His/Her Marital Status |
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⬛ Single |
⬛ Married ⬛ Widow/Widower |
⬛ Separated ⬛ Divorced |
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4. |
His/Her Date of Birth |
6 |
28 |
37 |
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Mo. |
Day |
Year |
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5. |
His/Her Social Security No. 123/ 45/ 6789 |
6. |
His/Her Employer |
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ABC COMPANY |
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7. |
We need an officially certified copy of death certificate. Is a copy attached? |
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⬛ Yes |
⬛ No |
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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
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 |
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Mo. |
Day |
Year |
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4. |
Your Phone Number (in case we need to contact you) |
Day ( |
)_____________ |
Evening ( |
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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)
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City |
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State |
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Zip |
3. His/Her Marital Status |
☐ Single |
☐ Married |
☐ Widow/Widower |
☐ Separated |
☐ Divorced |
4.His/Her Date of Birth ______________________________
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Mo. |
Day |
Year |
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5. |
His/Her Social Security No. ____ / ___ / ______ |
6. His/Her Employer ________________________________________________ |
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7. |
We need an officially certified copy of death certificate. Is a copy attached? |
☐ Yes |
☐ No |
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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 |
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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.
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Name of Insured Employee |
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Sex |
Last |
First |
Middle |
M or F |
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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 |
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Name of Deceased Dependent |
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M or F |
Dependent Life Insurance |
Last |
First |
Middle |
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Relationship
Spouse______________
Child _______________
Notice: Be sure to consider any reduction formula applicable to each type of Life benefit |
Complete the following if Applicable: |
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☐ Hourly Employee |
or |
☐ Salaried Employee |
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☐ Union Employee |
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☐ |
Group |
Sub |
Claim |
Type of Life Benefits |
Amount |
(Report Number) |
Code |
Pay Point |
Check applicable box(es) |
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(Branch) |
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☐ Basic Life |
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☐ Optional Life* |
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☐ Group Life Plus |
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☐ Group Universal Life** |
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*Optional Life includes Supplemental Life, Additional Life, and Voluntary Life Benefits
**For more information concerning Group Universal Life coverage, please call
☐ Exempt Employee or ☐
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_____________________ |
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If active, enter the effective date of the amount of insurance being claimed. ______________________ |
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If retired, enter the amount of insurance prior to reduction, if any. ________________________ |
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Was the |
Date ____________Reason _____________________ |
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Was life insurance cancelled? |
☐ No ☐ Yes Date ____________Was conversion applied for? ☐ No ☐ Yes ☐ Unknown |
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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 |
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Accidental Death Benefit |
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Survivor Income Benefit |
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If an Annuity Death Benefit is claimed, and |
For groups operated on the ÒAnnual |
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If an Accidental Death Benefit is |
If the deceased employee qualified for |
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such benefit is covered by MetLife, enter |
ExhibitÓ method of billing or if employee |
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claimed, and such benefit is covered |
Survivor Income Benefits, and such |
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Group Annuity |
contributions are reported annually: |
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by MetLife, enter amount of such |
benefits are covered by MetLife, specify if |
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Employee contributions |
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benefit only. |
the claim |
☐ is attached, or |
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☐ will follow |
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for prior exhibit year $______________ |
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$_____________________________ |
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Contract No. ________________________ |
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Employee contributions |
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Amount of Regular Life Insurance |
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and Cert. No. ________________________ |
for current |
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should be entered above. |
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exhibit year $_____________________ |
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Total employee |
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contributions $ ___________________ |
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_______________________________________________________________ |
__________________________________ |
__________________________________ |
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Signature of EmployerÕs Authorized Representative |
Date |
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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 |
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
¥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
¥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 |
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