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

Enrollment - Change Form - Metlife Form Page 4

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DECLARATIONS AND SIGNATURE

By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.

2. I declare that I am actively at work on the date I am enrolling and, if I am enrolling for any contributory life insurance, that I was actively at work for at least

20 hours during the 7 calendar days preceding my date of enrollment. I understand that if I am not actively at work on the scheduled effective date of

insurance, such insurance will not take effect until I return to active work. If you were Hospitalized during the 90-day period preceding your date of

enrollment, such insurance will not take effect until MetLife receives evidence of insurability satisfactory to MetLife.

3. I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a

physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such

date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or

Hospitalized.

4. I understand that if I do not enroll for life coverage during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I

am eligible, evidence of insurability satisfactory to MetLife may be required to enroll for or increase such coverage after the initial enrollment period has

expired. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase. I also understand

that if I do not enroll for dental coverage during the initial enrollment period, a waiting period may be required before I can enroll for such coverage after

the initial enrollment period has expired.

5. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind

it in writing.

6. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form.

7. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.

8. I have read the applicable Fraud Warning(s) provided in this enrollment form.

Sign

Here

Signature of Employee

Print Name

Date Signed

GEF09-1

DEC

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