Cs-Gl-Form-A-Dtp-Ers - Life Insurance Claim Form Page 6
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9Insured Employee - First Name
Middle Name
Last Name
C. Total Control Account (TCA)
Our standard payment method is in the form of a Total Control Account. A personalized draftbook and a kit that includes information
about your TCA will be sent to you if an Account is established. Your TCA will be guaranteed by MetLife and your TCA will be accessible to
you when you need it. A check will be issued to you if required by state law, regulation or direction.
D. Estate Resolution Service (ERS)
Because your loved one participated in MetLife’s group supplemental life insurance program, you are entitled, at no cost, to take
advantage of the Estate Resolution Services. For more information regarding Estate Resolution Services and how to access the service
please read the enclosed document titled MetLife Estate Resolution Services
SM
– Assistance in Probating the Insured Estate.
E. Delivering the Promise (DTP)
If a MetLife DTP Specialist assisted you with this claim, you may elect to have your check mailed to the Specialist, who will deliver it to
you. If you wish to have the proceeds mailed to your DTP Specialist, please check the appropriate box below. If no box is checked, the
proceeds will be delivered directly to you.
District Agency Index (DAI)
Deliver to DTP Specialist
Deliver to Beneficiary
Middle Initial
Last
DTP Specialist Name - First
DTP Specialist Address
City
State
Zip
F. Certifications and Signature
By signing below, I acknowledge:
1. All information I have given is true and complete to the best of my knowledge and belief.
2. That any contributions owed by the insured will be deducted from the insurance proceeds paid to me.
3. MetLife has the right to recover any amounts that it determines to be an overpayment. An overpayment occurs if MetLife determines
that: (a) the total amount paid by MetLife on your claim is more than the total amount of benefits due to you under the benefit plan/
insurance certificate; or (b) MetLife made payment to you when the payment should have been made to someone else. In case of an
overpayment, I agree to repay MetLife the specifically overpaid funds. I further understand that if an overpayment is not repaid, MetLife
reserves the right to rely on any means to recover the overpayment, including institution of litigation.
4. I have read the applicable Fraud Warning(s) provided in this form. New York Residents: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of
the claim for each such violation.
Under penalty of perjury, I certify:
1. That the number shown on this form is my correct taxpayer identification number; and
2. That I am not subject to IRS required backup withholding as a result of failure to report all interest or dividend
income; and
3. I am a U.S. citizen, or a U.S. resident for tax purposes.
Please note: If item 2 or 3 above is not true, cross out the applicable item(s).
The IRS does not require your consent to any provision of this document other than the certification to avoid backup withholding
Please sign below. Include first and last name. If you are receiving a Total Control Account, this signature will be placed on file with your
Account. If Beneficiary is a minor, the legal guardian or adult submitting this form must sign, not the minor.
Date Signed
Claimant Signature
u
CS-GL-FORM-A-DTP-ERS
2 of 2
(04/13) Fs
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