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

The Metlife Life Insurance Claim Form is designed to keep you informed on the progress of your claim. It allows you to track the status of your claim by providing a quick and easy way for you to check the status online.

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Metlife Life Insurance Claim Form PDF 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.

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

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
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

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 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.

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:

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**
			☐ 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
	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.

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.

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)

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filling in metlife death claim form part 1

Write down the required particulars in City, State, Zip, His, Her, Marital, Status Single, Married, Widow, Widower Separated, Divorced, His, Her, DateofBirth Day, Year, His, Her, Social, Security, No His, Her, Employer and Yes section.

Filling out metlife death claim form step 2

Type in any details you need in the space Beneficiary, Signature and Date.

Completing metlife death claim form step 3

In the box Certificate, Number, Date, of, Death Day, DateofBirth, Day, Last, Name, of, Insured, Employee First, Sex, Middle, Mor, F Name, of, Employer Division, or, Subsidiary, and, Location DateofBirth, and Sex, record the rights and obligations of the sides.

metlife death claim form Certificate, Number, DateofDeath, Day, DateofBirth, Day, Last, NameofInsuredEmployee, First, Sex, MiddleMorF, NameofEmployer, DivisionorSubsidiaryandLocation, DateofBirth, and Sex fields to fill out

Look at the sections NoYes, If, yes, please, provide, the, approval, number Annuity, Death, Benefit Accidental, Death, Benefit Survivor, Income, Benefit Contract, No and, Cert, No Total, employee, contributions is, attached, or, will, follow Date, and Telephone, No and next fill them in.

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