Metlife Statement Of Health Form – Fill Out and Use

Send directly to MetLife,

not to Liazon.Metropolitan Life Insurance Company, New York, NY

SBC Medical Underwriting, PO Box 14593, Lexington, KY 40512-4593 To be Completed by the Employer

Employer Name				Customer Number	Reporting Location Number
Employer’s Street Address				City	State	Zip Code
Employee Name	First	MI	Last	Employee E-mail Address	Social Security Number

To be Completed by the Applicant (A separate form must be completed for each Applicant)

Insurance is for:			Applicant Name	First	MI	Last	Male	Date of Birth (mm/dd/yy)
Employee	Spouse	Child					Female
Street Address					City			State	Zip Code

Total Insurance Requested (To be completed for each Applicant)

Basic Life (or Core) $				Optional Life (or Buy-Up) $				Short Term Disability $
Dependent Life (or Buy-Up) $				Long Term Disability $

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ADM

Medical Information - Please complete all questions below. Omitted information will cause delays. “You” and “Your” refers to the person for whom insurance is requested.

1. Your: Height

feet

inches

Weight

lbs.

7. Have you ever been diagnosed or treated by a member of the medical profession for Acquired
Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?	Yes	No

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Address:

Phone Number:

Give full details for “Yes” answers. If more space is needed for full details, attach a separate sheet, sign and date it.

Question		Dates of			Name of Physician or Name of Clinic or Hospital
Number		Treatment	Diagnosis/Condition	Duration	and Complete Address, Including Zip Code

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CA/NY

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Declaration — I have read this Statement of Health and declare that all information given above is true and complete to the best of my knowledge and belief. I understand that this information will be used by MetLife to determine my insurability.

Fraud Warning:

If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.

New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Kansas and Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement may have violated state law.

In any other case, read the following warning.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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.

					Sign & Date
					Here
Applicant	Signature		Date (Mo./Day/Yr.)
	Medical Information Form Will Not Be Processed Without Accompanying Authorization Form.
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AUTHORIZATION

In connection with an enrollment for group insurance, for underwriting and claim purposes regarding the proposed insureds (the proposed insureds are the employee, spouse, and any other person(s) named below), notwithstanding any prior restriction placed on information, records or data by a proposed insured, each proposed insured authorizes:

•Any medical practitioner, facility or related entity; any insurer; the Medical Information Bureau, Inc. (MIB); any employer; any group policyholder, contract holder or benefit plan administrator; or any government agency to give Metropolitan Life Insurance Company (“MetLife”) or any third party acting on MetLife's behalf in this regard:

•personal information and data about the proposed insured;

•medical information, records and data about the proposed insured including information, records and data about drugs prescribed, medical test results and sexually transmitted diseases;

•information, records and data about the proposed insured related to alcohol and drug abuse and treatment, including information and data records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2;

•information, records and data about the proposed insured relating to Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions including, where permitted by applicable law, Human Immune deficiency Virus (HIV) test results; and

•information, records and data about the proposed insured relating to mental illness, except psychotherapy notes.

Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form or sooner if prescribed by

law. Unless permitted by applicable law, the proposed insured cannot revoke this authorization: (1) to the extent that MetLife has taken action relying on the authorization; or (2) if MetLife obtained the authorization as a condition to the proposed insured obtaining insurance coverage. In all other cases, the proposed insured may revoke this authorization at any time. To revoke the authorization, the proposed insured must write to MetLife at SBC Administration, P.O. Box 14593, Lexington, KY 40512-4593 and inform MetLife that this Authorization is revoked. Any action taken before MetLife receives the proposed insured's revocation will be valid. Revocation may be the basis for denying coverage or benefits. If the proposed insured does not sign this Authorization, that person's enrollment for group insurance cannot be processed.

By signing below, each proposed insured acknowledges his or her understanding that:

•All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to MIB. Such information may also be disclosed to and used by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insurance applied for or on existing insurance with MetLife, or disclosed as otherwise required or permitted by applicable laws.

•Medical information, records and data that may have been subject to federal and state laws or regulations, including federal rules issued by Health and Human Services, setting forth standards for the use, maintenance and disclosure of such information by health care providers and health plans and records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2, once disclosed to MetLife or upon redisclosure by MetLife, may no longer be covered by those laws or regulations.

•Information relating to HIV test results will only be disclosed as permitted by applicable law.

•Information obtained pursuant to this authorization about a proposed insured may be used, to the extent permitted by applicable law, to determine the insurability of other family members.

•Each proposed insured has a right to receive a copy of this form.

A photocopy of this form is as valid as the original form.

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