Get MetLife A8200NW 2009-2024

/Day/Yr. COVERAGE REQUEST DATA I have received and read a copy of my employer s current announcement of the group plan. I want to be covered under the group plan for the benefits for which I am or may become eligible requested below. I request the following coverage Employee Coverage Basic Life/Accidental Death Dismemberment AD D or Core Coverage Requested Enhanced Optional Life or Buy up Coverage Requested Not to exceed 5x Basic Annual Earnings Dental Dental Dual Option Select one option Low Plan High Plan Voluntary Dental Dependent Spouse Coverage Note Dependent coverage is provided under the same plan the employee has chosen. Enhanced Dependent Spouse Life or Buy-Up Coverage Requested Not to exceed 50 of Employee amount Dental/Dental Dual Option/Voluntary Dental Dependent Child Coverage Note Dependent coverage is provided under the same plan the employee has chosen. I wish to DECLINE any coverage not checked above for which I may be eligible. For Life coverage I understand that I will be required to submit evidence of my and/or my dependents good health satisfactory to MetLife if I request this coverage after my initial period for enrollment has expired. For Dental and/or Dependent Dental coverage a waiting period may be required before I can enroll. Reason for declining employee and/or dependent coverage i.e. benefits elsewhere cost other GEF02-1 ADM Please Retain A Copy Of The Fully-Completed Form For Your Records And Return The Original To Your Employer Continued on Following Page A8200NW 06/06 If applying for Dependent coverage Spouse and Child complete section below Number of dependents including spouse Name of Spouse Last First MI Name s of Child ren Last First MI Sex M/F Select Is child a full-time student Yes For employees electing Enhanced Optional Life or Buy-Up and Enhanced Dependent Life or Buy-Up Insurance please answer the following question Have you been Hospitalized as defined below during the 90 days Employee Spouse Child ren preceding the date of this enrollment form No If the answer to the Hospitalization question is Yes a Statement of Health form is required for each person answering Yes. ENROLLMENT FORM FOR GROUP INSURANCE SECTION TO BE COMPLETED BY EMPLOYEE Name of Employee Last First Metropolitan Life Insurance Company New York NY Small Market Administration P. O. Box 14593 Lexington KY 40512-4593 Fax 1-888-505-7446 PLEASE PRINT Middle Social Security No* Date of Birth Mo. /Day/Yr. Male Female mm/dd/yy Employee s Address Street City Employee s E-mail Address Work Status New Hire Rehire Full-Time Part-Time State Employee s Occupation Marital Status Zip Code Single Widowed Married Divorced Class Dept Code Employee s Work Location Coverage Effective Date Mo. /Day/Yr. Active Retired Disabled On Layoff/Leave of Absence Original COBRA Effective Date Mo. /Day/Yr. Reason for Enrollment Phone No* include area code Customer Number Division Employer s Street Address Date of Hire Mo. /Day/Yr. Hours Worked Per Week Hourly Paid Annual Monthly Salary New Coverage New Hire First Time Eligible Late Enrollee Statement of Health Required Change in Coverage Amount Requested Change in Enrollment Other Than Coverage Amount Family Status Change not applicable to new enrollments Date Mo.