Form Gr-Tr-Bene-Emp1 - Metlife Group Term Life Insurance Beneficiary Designation - 2013
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1
2
3Group Term Life Insurance Beneficiary Designation
•
This form MUST be signed before you return it. See “SECTION IV – Signature” on page 3.
SECTION I - Insured Information
Customer Number
Employer Name/Group Policyholder Name
First Name
Middle Name
Last Name
Address – Street
City
State
ZIP Code
Date of Birth
Phone Number
SSN
(
)
SECTION II - Plan Information
I elect that the beneficiary designation shown on this form apply only to the plans insured by MetLife that I have
indicated below:
All group term life coverage
OR
Basic Life
Supplemental/Optional Life
currently in effect
Accidental Death & Dismemberment
SECTION III - Beneficiary Information
• You MUST designate at least one primary beneficiary. A person may only be listed once. Anyone listed in the primary section cannot
be listed in the contingent section.
• The sum of the Primary Beneficiary percentages MUST equal 100%. The sum of the Contingent Beneficiary percentages MUST equal
100%. Dollar amounts, fractions and decimals will not be accepted.
•
If you need more space for additional beneficiaries, attach a separate page. Include all beneficiary information, and sign/date the page.
Please complete the section that pertains to the type of beneficiary you are designating.
A. Individual Beneficiaries
PRIMARY BENEFICIARY -
Your first choice to receive your life insurance proceeds in the event of your death. If any primary
beneficiaries predecease you, that person’s share will be equally divided among any remaining primary beneficiaries.
First Name
Middle Initial
Last Name
Share:
%
Address – Street
City
State
ZIP Code
Relationship to Employee
Social Security Number
Date of Birth
Phone Number
(
)
First Name
Middle Initial
Last Name
Share:
%
Address – Street
City
State
ZIP Code
Relationship to Employee
Social Security Number
Date of Birth
Phone Number
(
)
First Name
Middle Initial
Last Name
Share:
%
Address – Street
City
State
ZIP Code
Relationship to Employee
Social Security Number
Date of Birth
Phone Number
(
)
Metropolitan Life Insurance Company
Page 1 of 3
GR-TR-BENE-EMP1 (05/13) Fs
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