Critical Illness Insurance Claim Form

Metropolitan Life Insurance Company

Attn: Critical Illness Insurance Product

P.O. Box 80826

Things to know before you begin

Lincoln, NE 68501-0826

• If you are submitting a claim for a Critical Illness which you have

Toll Free Phone:

not yet reported to us, please complete this claim form. Once we

1 866 626 3705

receive a completed claim form we consider this Critical Illness to

have been reported to us. Return completed form by fax, mail or

Fax Number: 1 855 306 7350

on-line at ().

• Anytime you are submitting a claim to us, please provide us with

Please complete Sections 1 through

supporting documents from the provider related to the Critical

4. Review, sign and date pages 4

Illness for which a claim is being made. The supporting documents

and 5. Complete Section 7 on the

must include: 1) the diagnosis; 2) pathology reports, surgical notes,

Physician’s Attachment. Your physician

must complete the remainder of the

lab results, or clinical records that support the diagnosis of the

Physician’s Attachment (all of Section

covered condition and 3) the date(s) of diagnosis.

8) and return the completed form.

Supply information about the certificateholder.

SECTION 1 - Certificateholder Information

Certificateholder Name (First, Middle Initial, Last Name)

Certificate Number

Address - Street

City

State

Zip Code

Date of Birth (Month/Day/Year)

Gender

Social Security Number

Male

Female

Cell Phone Number

Daytime Phone Number

Evening Phone Number

EMAIL Address (optional)

Employer Name

Supply information about the patient.

SECTION 2 - Patient Information

Same as Section 1 (If you check this box, you do not need to complete this section. You may skip to Section 3.)

Spouse

Child

Patient Name (First, Middle Initial, Last Name)

Home Address - Street

City

State

Zip Code

Date of Birth (Month/Day/Year)

Gender

Social Security Number

Male

Female

CII-CLM-GENERIC-NW (05/15) Fs

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Critical Illness Insurance Claim Form - Metlife Form

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