Metlife Life Insurance Claim Form – Fill Out and Use

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.

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

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:

© 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:

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