Fillable Enrollment - Change Form - Metlife Form printable pdf download

Metropolitan Life Insurance Company, New York, NY

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION

(To be Completed by the Recordkeeper)

Name of Group Customer/Employer

Group Customer #

Division

Class

Dept Code

Pinnacle PEO Corporation

5343663

Date of Hire

Coverage Effective Date

Original COBRA Effective Date if applicable

COBRA Termination Date if applicable

YOUR ENROLLMENT INFORMATION

(To be Completed by the Employee in blue or black ink)

Name (First, Middle, Last)

Social Security #

Male

Single

–

Female

Married

Address (Street, City, State, Zip Code)

Date of Birth

Job Title:

Basic Annual Earnings:

Hours Worked Per Week:

Employee

Salaried

Retiree

Hourly

New Enrollment

Change in Enrollment

COBRA Continuation

If due to a Qualifying Event, enter date

I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts

of insurance I request must comply with and are limited by the plan design described in my enrollment materials.

► If you are enrolling during the initial enrollment period, you must complete this Hospitalization question for Supplemental/Optional Life,

Supplemental/Optional Dependent Spouse/Domestic Partner Life and Supplemental/Optional Dependent Child Life. If you answered "yes" to the

Hospitalization question, a Statement of Health form must also be completed for the person to whom the "yes" applies.

Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days?

Employee

Spouse/Domestic Partner

Child(ren)

Yes

Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care

facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

► If you are enrolling after the initial enrollment period, you must complete a Statement of Health form for all amounts you are requesting.

Term Life and Accidental Death & Dismemberment (AD&D) Insurance

Basic Life

and AD&D (Core)

Term Life Insurance

Supplemental/Optional Life

(Buy up)

Enter amount requested $

Supplemental/Optional Dependent Spouse/Domestic Partner Life

(Buy up)

1,2

Enter amount requested $

Supplemental/Optional Dependent Child Life

(Buy up)

Enter amount requested $

Accidental Death & Dismemberment (AD&D) Insurance

Supplemental/Optional AD&D (Buy up)

Enter amount requested $

Supplemental/Optional Dependent Spouse/Domestic Partner AD&D (Buy up)

Enter amount requested $

Supplemental/Optional Dependent Child AD&D (Buy up)

Enter amount requested $

Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her life insurance amount.

An interest and expense charge may be deducted from the accelerated payment. Receipt of accelerated benefits may affect eligibility for public assistance.

Amounts will be subject to state limits, if applicable.

GEF02-1

ADM

SUBMISSION INSTRUCTIONS

After completion, make a copy for your records and return the original to

MetLife Administration, P.O. Box 14593, Lexington, KY 40512-4593

Fax MetLife at 1-888-505-7446

EF-UN-ST4479S-NW (11/12)

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