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MetLife Accident Insurance

Metropolitan Life Insurance Company, New York, NY 10166

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION (To be Completed by the Record keeper)
Name of Policyholder:	Group Customer #	Report #
National Federation of Independent Contractors Association	9218536	227534

YOUR ENROLLMENT INFORMATION (To be Completed by the Member)
Name (First, Middle, Last)	Social Security #	Gender

Address (Street, City, State, Zip Code)	Phone #	Date of Birth (MM/DD/YYYY)
,
Email Address	New Enrollment Change in Enrollment	Date of Membership (MM/DD/YYYY)

I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand that contributions are required for the benefits I select below. For Minnesota and Vermont State residents- If I am enrolling for Accident Insurance: I declare that all individuals to be insured have medical coverage in force that provides benefits for medical treatment, including hospital, surgical and medical expenses. I have received and read a copy of the Outline of Coverage or other disclosure document for the Accident Insurance. The following disclosure is required by New Mexico law: This type of plan is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the individual mandate that you have health insurance coverage. If you do not have other health insurance coverage, you may be subject to a federal tax penalty.
Accident Insurance
First select your option Then select your coverage level
Dependent Information
If you are applying for coverage for your dependents please provide the information requested below:
Name(s) of your Spouse/Domestic Partner (First,Middle,Last)	Date of Birth (MM/DD/YYYY)	Gender

Name(s) of your Child(ren) (First,Middle,Last)	Date of Birth (MM/DD/YYYY)	Gender





Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form.

Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered Domestic Partner in whom you have an insurable interest. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to your insurable interest.

GEF02-1

ADM

(The form number above applies to residents of all states except as follows: Form number GEF02-1 ADM applies to residents of Oregon;

GEF09-1 applies to residents of Louisiana and Montana;

GEF02-1

ADM applies to residents of North Dakota and Utah)

National Federation of Independent Contractors Association EF-AA ST966M-NW (05/20)

FRAUD WARNING

Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies to the extent required by applicable law.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kansas and Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.

New York (only applies to Accident and Health Insurance): 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.

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.

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.

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.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.

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

(The form number above applies to residents of all states except as follows: Form number GEF09-1 FW applies to residents of Oregon;

GEF09-1 applies to residents of Louisiana and Montana;

GEF09-1

FW applies to residents of North Dakota and Utah)

National Federation of Independent Contractors Association EF-AA ST966M-NW (05/20)

DECLARATIONS AND SIGNATURE

Your Accident certificate provides limited benefits. Read your certificate carefully.

By signing below, I acknowledge:

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.
I declare that I am not under a Medical Restriction on the date I am enrolling. I understand that if I am under a Medical Restriction on the scheduled effective date of insurance, such insurance will not take effect until I am no longer under a Medical Restriction. Medical Restriction means a person is restricted to the person’s home under a physician’s care; receiving or applying to receive disability benefits from any source; admitted for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.
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. Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.
I have read the applicable Fraud Warning(s) provided in this enrollment form.

GEF09-1

DEC

(The form number above applies to residents of all states except as follows: Form number GEF09-1 DEC applies to residents of Oregon;

GEF09-1 applies to residents of Louisiana and Montana;

GEF09-1

DEC applies to residents of North Dakota and Utah)

National Federation of Independent Contractors Association EF-AA ST966M-NW (05/20)

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June 15, 2020 2:33 pm CDT

MetLife Accident Insurance Uploaded by John Kohrs - kohrsj@driasi.com IP 136.228.217.166, 136.228.217.166