Enrollment Form Metropolitan Life Insurance Company for ...

1 GEF02-1 Please complete and sign page 2 SBC Enroll NW (0703) Page 1 of 4 ADM 210000000000002336(0703) Enrollment Formfor Group InsuranceMetropolitan life Insurance CompanySBC Box 14593, Lexington, KY 40512-4593 Employee Name (Last, First, Middle) Social Security Number Customer Number Division Class Your Home AddressCity State ZIP Sex (M/F) Date of Birth Marital Status Single MarriedYour Occupation Employer Name WorksiteZip Code Hire Date Hours WorkedPer Week Salary.

2 $ Annual Monthly HourlyReason forEnrollment: First Time Eligible Change in Insurance Amount Requested COBRA - Original COBRA Eff. Date # of Mos. Late Enrollee (Statement of Health form (GEF02-1 MQ) is required) Change in Enrollment Other Than Insurance AmountCoverage Requested:Employee Coverage life /AD&D (or Core): Amount $ Enhanced Optional life (or Buy-Up):Amount $ (Not to exceed 5x Salary) Short Term Disability Voluntary Short Term DisabilityAmount $ (Sold in increments of $50) Long Term Disability Dental Dental Dual Option Low Plan High PlanSpouse Coverage life Enhanced Optional life (or Buy-Up):Amount $ (Not to exceed 50% of Employee amount) Dental/Dental Dual OptionChild Coverage life Enhanced Optional life (or Buy-Up).

3 Amount $ Dental/Dental Dual OptionIf applying for Dependent Coverage (Spouse and Child), complete section below:Number of dependents (including spouse) Name (Last, First, MI)Date of BirthSex (M/F)Spouse _____ _____Child(ren) _____ _____If dependent children are full-time students in college, vocational or trade school, pleasecomplete the following:Child(ren)Name of School# of Hours_____ _____ _____ _____ _____To decline coverage, complete this section: I understand that I have beengiven the opportunity to participate in the group Insurance plan offered by myEmployer.

4 I am refusing the coverage(s) indicated at the right for which I amrequired to contribute. If I request life and/or Disability Insurance after myinitial Enrollment period, I understand that I, or my dependents (fordependent life only), will be required to submit evidence of good healthSatisfactory to MetLife. (Satisfactory to MetLife means MetLife hasdiscretionary authority to determine eligibility.) For Dental Insurance , awaiting period may be required for certain services before expenses will Optional/Buy-Up LifeShort Term DisabilityVoluntary Short Term DisabilityLong Term DisabilityDental/Dental Dual OptionEmployee Spouse Child Reason for declining employee and/or dependent coverage ( benefits elsewhere, cost, other).

5 _____For employees electing Enhanced Optional (or Buy-Up) life and Enhanced Dependent (or Buy-Up) life Insurance ,please answer the following question:Have you or your dependent(s) (if applicable) been Hospitalized (as defined below) during the last 90 days preceding the date of this enrollmentform?Employee: Yes No Spouse: Yes No Child: Yes NoIf the answer to the Hospitalization question is Yes, a Statement of Health form (GEF02-1 MQ) is required for each person answering Yes. Hospitalized means admission for inpatient care in a hospital, receipt of care in a hospice facility, intermediate care facility, or long term carefacility, receipt of the following treatments wherever performed: chemotherapy, radiation therapy, or Page 2 of 4 DECBENEFICIARY DESIGNATION FOR EMPLOYEE Insurance (Dependent Insurance is Payable to the Employee)The Employee signing below names the following person(s) as primary beneficiary(ies) for any MetLife payment upon his or her death.

6 For anyother type of beneficiary, please use a beneficiary designation form available from your employer. Unless designated otherwise, payments will bemade in equal shares or all to the survivor. The Employee understands that he or she has the right to change this designation at any Beneficiary Full Name (Last, First, Middle Initial)RelationshipDate of Birth( )Address (Street, City, State, Zip)Contingent Beneficiary Full Name (Last, First, Middle Initial)RelationshipDate of Birth( )Address (Street, City, State, Zip)

7 DECLARATION SECTIONEach person signing below declares that all the information given inthis Enrollment form is true and complete to the best of his/herknowledge and belief. Each person understands that this informationwill be used by MetLife to determine his or her the Accelerated Benefits OptionLife Insurance may include an Accelerated Benefits Option underwhich a terminally ill insured can accelerate a portion of his or her lifeinsurance amount. Receipt of accelerated benefits may affecteligibility for public assistance and an interest and expense chargemay be deducted from the accelerated Changes Requested After Initial Enrollment Period ExpiresI understand that if life or disability coverage is not elected, or if themaximum coverage is not elected.

8 Evidence of good healthsatisfactory to MetLife may be required to elect or increase suchcoverage after the initial Enrollment period has expired. Coverage willnot take effect, or it will be limited, until notice is received that MetLifehas approved the coverage or also understand that if dental coverage is not elected, a waitingperiod for certain covered services must be satisfied before coveragefor such services will take Payroll Deduction Authorization By the EmployeeI authorize my employer to deduct the required contributions from mypay for the coverage requested in this Enrollment form .

9 Thisauthorization applies to such coverage until I rescind it in Warning:If you reside in or are applying for Insurance under a policy issued inone of the following states, please read the applicable York [only applies to Accident and Health Benefits(AD&D/Disability/Dental)]: Any person who knowingly and withintent to defraud any Insurance Company or other person files anapplication for Insurance containing any materially falseinformation, or conceals for the purpose of misleading,information concerning any fact material thereto, commits afraudulent Insurance act, which is a crime, and shall also besubject to a civil penalty not to exceed five thousand dollars andthe stated value of the claim for each such.

10 Any person who knowingly and with intent to injure,defraud or deceive any insurer files a statement of claim or anapplication containing any false, incomplete or misleadinginformation is guilty of a felony of the third and Oregon: Any person who knowingly and with intentto defraud any Insurance Company or other perso