Critical Illness Insurance Claim Form - Metlife Form (Page 3 of 8) in pdf

Type of Account (check one): £ Checking £ Savings

Be sure to confirm your account and routing numbers

with your bank to ensure prompt processing.

Bank Account Number

Bank Routing Number

Authorization & Signature

• I request MetLife to send my payments to the financial institution designated in Section 4 for deposit into my account. This

agreement will remain in effect until MetLife receives notice from me to the contrary.

• I understand that MetLife will not be liable for any failure to change or terminate this agreement until a written request is

received from me in satisfactory form and reasonable time has passed for MetLife to act upon it.

• If any overpayment is credited to my account in error, I authorize and direct my financial institution to debit my account and

to refund such overpayment to MetLife.

Alabama, Arkansas, District of Columbia, Louisiana,

Delaware, Idaho, Indiana and Oklahoma: WARNING:

Massachusetts, Minnesota, New Mexico, Ohio, Rhode

Any person who knowingly, and with intent to injure,

Island and West Virginia: Any person who knowingly

defraud or deceive any insurer, makes any claim for the

presents a false or fraudulent claim for payment of a loss

proceeds of an insurance policy containing any false,

or benefit or knowingly presents false information in an

incomplete or misleading information is guilty of a felony.

application for insurance is guilty of a crime and may be

Florida: A person who knowingly and with intent to

subject to fines and confinement in prison.

injure, defraud or deceive any insurance company files a

Alaska: A person who knowingly and with intent to

statement of claim or an application containing any false,

injure, defraud, or deceive an insurance company files

incomplete or misleading information is guilty of a felony

a claim containing false, incomplete or misleading

of the third degree.

information may be prosecuted under state law.

Kentucky: Any person who knowingly and with intent

Arizona: For your protection, Arizona law

to defraud any insurance company or other person files

a statement of claim containing any materially false

requires the following statement to appear on

information or conceals, for the purpose of misleading,

this form. Any person who knowingly presents a

information concerning any fact material thereto commits

false or fraudulent claim for payment of a loss is

a fraudulent insurance act, which is a crime.

subject to criminal and civil penalties.

Maine, Tennessee, Virginia and Washington: It is

California: For your protection, California law requires

a crime to knowingly provide false, incomplete or

the following to appear on this form: Any person who

misleading information to an insurance company for

knowingly presents a false or fraudulent claim for the

the purpose of defrauding the company. Penalties

payment of a loss is guilty of a crime and may be subject

may include imprisonment, fines or a denial of

to fines and confinement in state prison.

insurance benefits.

Colorado: It is unlawful to knowingly provide false,

Maryland: Any person who knowingly or willfully presents

incomplete or misleading facts or information to an

a false or fraudulent claim for payment of a loss or benefit

insurance company for the purpose of defrauding or

or who knowingly or willfully presents false information in

attempting to defraud the company. Penalties may include

an application for insurance is guilty of a crime and may be

imprisonment, fines, denial of insurance and civil damages.

subject to fines and confinement in prison.

Any insurance company or agent of an insurance company

New Hampshire: Any person who, with a purpose to

who knowingly provides false, incomplete or misleading

injure, defraud or deceive any insurance company, files

facts or information to a policyholder or claimant for

a statement of claim containing false, incomplete or

the purpose of defrauding or attempting to defraud

misleading information is subject to prosecution and

the policyholder or claimant with regard to a settlement

punishment for insurance fraud as provided in R.S.A.

or award payable from insurance proceeds shall be

638.20.

reported to the Colorado Division of Insurance within the

New Jersey: Any person who knowingly files a statement

Department of Regulatory Agencies.

of claim containing any false or misleading information is

subject to criminal and civil penalties.

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

Page 3 of 8

Critical Illness Insurance Claim Form - Metlife Form Page 3

Related Articles

Related forms

Related Categories