Met SI


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Metropolitan Life Insurance Company, New York, NY 10166

ENROLLMENT • CHANGE FORM  

GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper)
Name of Group Customer/Employer: Sponsoring/Participating Association (if different from Policyholder) Group Customer
National Federation of Independent Contractors Association       #218356
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
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.
Term Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance

Supplemental/Optional Life 1 / AD&D 2 :

Dependent Child Life²/AD&D    

Dependent Information
If you are applying for coverage for your Child(ren) please provide the information requested below:
Name(s) of your Child(ren) (First,Middle,Last) Date of Birth (MM/DD/YYYY) Gender

¹ Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her life insurance amount. An interest and expense charge may be deducted from the accelerated payment.  Receipt of accelerated benefits may affect eligibility for public assistance. This benefit may be taxable and you are advised to seek assistance from a personal tax advisor.
² Amounts will be subject to state limits, if applicable.

Smoking Status Information
Have you smoked cigarettes, pipes or cigars or used tobacco in any form in the past 1 year?  
If you are changing smoking status:

Status is changing from:   

 

Please complete all questions below. Omitted information will cause delays. In this secion "you" and "your" refers to the person for whom insurance is being requested.

Your Height    Your Weight   
    Member
1. Have you had any application for life, accidental death and dismemberment or disability insurance declined, postponed, withdrawn, rated, modified, or issued other than applied for?
2. Are you now receiving or applying for any disability benefits, including workers' compensation?  
3. For Residents of all states except CT, please answer the following question: Have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC), or the Human Immunodeficiency Virus (HIV) infection?
For CT Residents, please answer the following question:  To the best of your knowledge and belief , have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC), or the Human Immunodeficiency Virus (HIV) infection?		  
4. Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider for:  
  a. cardiac or cardiovascular disorder?
  b. stroke or circulatory disorder?
  c. high blood pressure?
  d. cancer Hodgkin's disease, lymphoma or tumors?
  e. diabetes?

GEF09-1
HEA
(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana;
GEF09-1
HEA applies to residents of Connecticut, North Dakota and Utah)

5. In the past 5 years, have you been Hospitalized as defined below (not including well-baby delivery?

Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, or long care facility; or receipt of the following treatment wherever performed chemotherapy, radiation therapy, or dialysis.
6. In the past 5 years, have you been diagnosed, treated or given medical advice by a physician or other health care provider for a medical condition or had a surgical procedure (other than oral surgery)?

GEF09-1
HEA-SUPP
(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana;
GEF09-1
HEA-SUPP applies to residents of Connecticut, North Dakota and Utah)

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.
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 Benefits):  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
FW (The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana;
GEF09-1
FW applies to residents of Connecticut, North Dakota and Utah)

National Federation of Independent Contractors Association

 

LMI-EF-ST111M-NW (12/18)

 

 

 

 

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. I also understand that unless otherwise specified in the group insurance certificate, insurance due upon the death of a Dependent is payable to the Member.
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) Address (Street, City, State, Zip) 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%

 

By signing below, I acknowledge:

  1. I have read this enrollment form and declare that all information I have given, including any medical information, is true and complete to the best of my knowledge and belief. I understand that this information will be used by MetLife to determine insurability.
  2. I declare that I am able to perform the normal activities of a person of such age and sex with a like occupation or retired status on the date I am enrolling. I understand that if I am unable to perform such normal activities on the scheduled effective date of insurance, such insurance will not take effect until I am able to resume performing such activities.
  3. I understand that if I do not enroll for the maximum amount of coverage for which I am eligible, evidence of insurability satisfactory to MetLife may be required to enroll for or increase such coverage after the initial enrollment period has expired. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase.
  4. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.
  5. 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 applies to residents of Montana;
GEF09-1
DEC applies to residents of Connecticut, North Dakota and Utah)

National Federation of Independent Contractors Association
LMI-EF-ST111M-NW (12/18)

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Document name: Met SI
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May 7, 2019 3:53 pm CDTMet SI Uploaded by Scott Allison - allisons@driasi.com IP 97.116.11.184, 97.116.11.184
May 7, 2019 4:23 pm CDT Document owner team@approveme.com has handed over this document to allisons@driasi.com 2019-05-07 16:23:56 - 2600:8800:1e00:385:f522:ed38:fbc1:a6d1, 2600:8800:1e00:385:f522:ed38:fbc1:a6d1
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