Form Gr-Ad-Bene-Emp-Csea - Metlife Accidental Death (Ad) Beneficiary Designation - 2014 Page 3
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3SECTION IV - Signature
Check if you are completing and signing this form as agent for the employee under a valid Power of Attorney.
Return a copy of the Power of Attorney with this beneficiary form. The Power of Attorney paperwork is subject to
review by MetLife.
I hereby revoke any previous designations, and I designate the person, people, or entity named in Section III as
Beneficiary(ies). I reserve the right to change or revoke this designation at any time.
Insured/Owner Name
(Please Print)
___________________________________________________________
Date
Insured/Owner Signature
(must be date form was completed)
_____________________________________________________
How to Submit This Form
To submit this form, please complete a paper copy in full, and mail it to CSEA, Inc. at the following address:
CSEA, Inc.
ATTN: Insurance Department
143 Washington Ave.
Albany, NY 12210
Once your beneficiary information has been recorded, you may obtain a copy of this form by submitting a request to the
CSEA Insurance Department.
Please note: You MUST return all pages of this form.
Metropolitan Life Insurance Company
Page 3 of 3
GR-AD-BENE-EMP-CSEA (04/14) Fs
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