BENEFICIARY DESIGNATION FOR MEMBER INSURANCE
I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked. I understand I have the right to change this designation at any time.
Check if f you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information and sign/date the page.
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Payment will be made in equal shares or all to the survivor unless otherwise indicated.
TOTAL:
100%
If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies):
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (Mo./Day/Yr.)
Relationship
Share %
Address (Street, City, State, Zip)
Phone #
Payment will be made in equal shares or all to the survivor unless otherwise indicated.
TOTAL:
100%