MetLife Small Business Center

1 6. 7. 8. & 9. 10. 11. 12. 13. 14. 15. 16. NAME OF INSURED NUMBER INSURED BIRTH MO - YR CLASS # ADJ DATE BT. CODE BENEFIT TITLE FAM IND. ADJ CODE PREMIUM VOLUME TOTAL PREMIUM LIST BILL MetLife Small Business Center PAGE 1 1. KM05 XXXXXX 0001 2. BILL DUE DATE: 04 01 08 3. BILL DATE: 03 16 08 TO: THE ABC COMPANY ATTN: JANE DOE 1 MAIN STREET KANSAS CITY, MO 64114 4. AMOUNT PAID: _____ For customer service please contact us at 1-800-ASK-4 MET (275-4638) (Prompt 2) PLEASE NOTE THE FOLLOWING: PLEASE COMPLETE A CHANGE FORM FOR ALL CHANGES WHICH CAN BE LOCATED AT ASK YOUR ACCOUNT SPECIALIST ABOUT ELECTRONIC FUNDS TRANSFER (EFT) FOR ADDITIONAL INFORMATION, SEE REVERSE SIDE OF THE LAST PAGE INSURED A PERSON 0001 AV ADD C 100,000 xxxxx0226 06-1955 LS D/LI C LV LIF C 100,000 INSURED A PERSON 0001 AV ADD C 40,000 xxxxx0395 05-1958 LS D/LI C LV LIF C 40,000 TOTAL FOR THIS BILLING PERIOD 17.

2 17. **ADJUSTMENTS** INSURED A PERSON 06-1950 AV ADD A xxxxx1910 LV LIF A MLIC BILLING FEES 18. 18. OUTSTANDING DUE AS OF 03/16/08 19. 19. **GRAND TOTAL DUE PLEASE PAY THIS AMOUNT====> 20. 20. AFTER CHANGES HAVE BEEN RECEIVED AND MADE IN OUR OFFICE, PREMIUM ADJUSTMENS WILL BE REFLECTED ON YOUR BILLING STATEMENT. 5.

3 21. **SUMMARY TOTALS** INSUREDS DEPENDENTS TITLE COUNT VOLUME PREMIUM COUNT PREMIUM AD&D 2 140,000 0 LIFE 2 140,000 2 **PLEASE NOTE** MetLife MUST RECEIVE YOUR PREMIUM WITHIN 31 DAYS OF THE BILL DUE DATE OR YOUR POLICY WILL TERMINATE ACCORDING TO ITS TERMS. 2 Administration & Claims Instructions for General Section MetLife Small Business Center 22. THIS PAGE MUST BE RETURNED WITH YOUR REMITTANCE. IF THERE ARE NO CHANGES TO REPORT, PLEASE DETACH AND RETURN THE TOP PORTION OF THIS PAGE TO: KM05 XXXXXXX 0001 Group Name BILL DUE DATE: 04 01 2008 BILL PRINT DATE: 03 16 2008 AMOUNT PAID: _____ CHECK #: _____ For customer service please contact us at: 1-800-ASK-4 MET (275-4638) (Prompt 2) To ensure timely processing of your bill, please make your check payable to: MetLife SBC PO BOX 804466 Kansas City, Missouri 64180-4466 PLEASE INCLUDE YOUR GROUP NUMBER ON YOUR CHECK All premiums are due on the first of the month for which coverage is provided.

4 MetLife must receive your premium within 31 days of the bill due date or your policy will terminate according to its terms. Please note that your bill no longer includes a change form. Please use the change form in your administrative manual under Forms. If you need to request a change form, or have any questions please contact us at: 1 800 ASK-4-MET (1 800-275-4638) Prompt 2 A change form needs to be completed for any enrollment or eligibility changes. For adding a new employee, please complete an enrollment form. The enrollment and change forms may then be faxed to: 1 888-505-7446 Or mailed to: SBC Administration PO Box 14593 Lexington, KY 40512-4593 Changes received after the 6th day of the month will not be reflected until the following cycle. 3 Administration & Claims Instructions for General Section MetLife Small Business Center Box 804466 Kansas City, Missouri 64180-4466 LIST BILL Item Explanation 1 Group Number: KM05 XXXXXX identifies your Policy number and XXX1, the 4 digit entry, identifies your division number.

5 2 Bill Due Date: This is the date your remittance is due. 3 Bill Date: This is the date our Home office produced your bill. 4 Amount Paid: This is where you enter the amount of remittance for each statement. Please pay the amount shown. (Refer to item 18.) MetLife will make any required adjustment on your next statement after changes are made. 5 Updating Information: Each month, please update for additions, terminations, and salary/volume changes in the spaces provided. 6 Name of Employee/ID Number: This is each Insured s name and the last 4 digits of the Social Security or ID number. 7 Employee Birth/MO Yr.: This is each Insured s date of birth (month and year). 8 Class #: This is the class assigned to the insured as shown in your group policy. 9 Adj.

6 Date: This is the effective date of a change or new addition resulting in premium charged or credit allowed. The adjustment dates will appear at the end of the employee listing. 10 BT Code: This is for Home Office use only. 11 Benefit Title: This is the type of coverage for each Insured. 12 Family Indicator: This is a code indicating who is covered. See the definition on the last page of your statement. 13 Adj. Code: This is the reason for a premium adjustment in the Insured s coverage. You will find any adjustment codes and dates at the end of the employee listing. See the definition on the last page of your statement. 14 Premium: This is the premium due, by line of coverage, for each Insured. 4 Administration & Claims Instructions for General Section Item Explanation 15 Volume: This is the amount of benefit for each line of coverage.

7 16 Total Premium: This is the total premium due for each Insured. 17 Total For This Billing Period: This is the accumulated total premium due for the current billing period. 18 MLIC ( MetLife Insurance Company) Billing Fees: This is the amount for administration or non-sufficient fees (if applicable). 19 Outstanding Due As Of: This is the total credit/shortage from your previous remittance. 20 Grand Total Due Please Pay This Amount: This is the amount to be remitted. Please do not change the amount of your remittance from the figure shown here. Any premium adjustments will be reflected on your next statement. 21 Summary Totals: This is the summary of the bill by each line of coverage. 22 Remittance Page: This page must be detached and sent in with payment.

8 5 Administration & Claims Instructions for General Section