Fillable Enrollment - Change Form - Metlife Form (Page 3 of 4) in pdf

Oklahoma: WARNING: 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.

Oregon and Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject

to penalties under state law.

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets

in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and

if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or

imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5)

years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or 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.

GEF09-1

BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE

Note: Dependent insurance is payable to the Employee.

If you have previously designated a beneficiary under this Group Customer’s plan, such beneficiary designation will remain in effect. Any MetLife payment

upon your death will be paid in accordance with the records of the recordkeeper for such insurance unless you designate a beneficiary below.

I designate the following person(s) as primary beneficiary(ies) for any MetLife payment upon my death.

I understand I have the right to change this designation at any time.

Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page.

Full Name (First, Middle, Last)

Social Security #

Date of Birth

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Payment will be made in equal shares or all to the survivor unless otherwise indicated.

TOTAL:

100%

If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies):

Full Name (First, Middle, Last)

Social Security #

Date of Birth

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Payment will be made in equal shares or all to the survivor unless otherwise indicated.

TOTAL:

100%

GEF09-1

DEC

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

Page 3 of 4

Enrollment - Change Form - Metlife Form Page 3

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