{"table_id": "bug8y4dmf", "import_table_id": "bqujrve7u", "success_url": "https://example.com/success", "meta_data_fid": 61, "memberRelationship": "Member", "json_fid": 59, "test_fid": 75, "form_definition_fid": 64, "related_form_fid": 71, "related_application_fid": 444, "pdf_template": "statefarm-metlife-enrollment", "pdf_date_format": "MM/DD/YYYY", "pdf_use_field_font_sizes": true, "showPdfOnSubmission": true, "form_version": "v2", "layout": "v2", "test": false, "form_id": 43, "top_banner": "mb_logo.png", "sub_banner": "metlifeLogo.png", "formBranding": "Agent Benefits Program \u2014 Exclusively for State Farm Agents", "formTitle": "Agent Benefits Program Enrollment", "submitSuccessBanner": "

Congratulations! You've completed your Agent Benefits Program enrollment application.

Please keep this confirmation for your records.

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Select the benefits that are right for you and your family. You can enroll in any combination of the plans below \u2014 choose at least one plan to continue.

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Enter your date of birth, ZIP code and requested effective date to see your rates.

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Prior State Farm plan enrollment. Term Life and Long-Term Disability coverage are available only to agents who were already enrolled in the State Farm sponsored plan. Please answer both questions so we can show you the plans you are eligible for.

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Because you were not already enrolled in the State Farm sponsored plan, the plan you answered No to is not available to you and is not shown below. You may still enroll in any of the other plans.

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The dental rates shown reflect the full cost of coverage without the employer subsidy previously provided by State Farm.

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The vision rates shown reflect the full cost of coverage without the employer subsidy previously provided by State Farm.

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"hiddenFormula", "quickbase_fid": "DentalCoverageTier", "label": "Dental Coverage Tier", "neverShowInSubmission": true, "formula": {"fn": "selected_rate_field", "args": {"ratepicker": "DentalCoverage", "rateFieldId": "40"}}, "pdf_fid": "Dental_Coverage_Tier"}, {"type": "hiddenFormula", "quickbase_fid": "VisionPlanName", "label": "Vision Plan", "neverShowInSubmission": true, "formula": {"fn": "selected_rate_field", "args": {"ratepicker": "VisionCoverage", "rateFieldId": "66"}}, "pdf_fid": "Vision_Plan"}, {"type": "hiddenFormula", "quickbase_fid": "VisionCoverageTier", "label": "Vision Coverage Tier", "neverShowInSubmission": true, "formula": {"fn": "selected_rate_field", "args": {"ratepicker": "VisionCoverage", "rateFieldId": "40"}}, "pdf_fid": "Vision_Coverage_Tier"}]}]}, {"name": "", "columns": [{"fields": [{"quickbase_fid": "ratesummary", "type": "ratesummary", "label": "Your Benefit Selections", "visible": true, "neverShowInSubmission": true}, {"type": "textbox", "quickbase_fid": "feesNoticeSummary", "label": "", "visible": true, "content": "

Important Information

A one-time, non-refundable $20.00 enrollment processing fee is due at enrollment and is not included above.

Monthly Auto-Pay (ACH) adds a $0.50 monthly draft fee.

", "cssClass": "pf-fee"}, {"type": "textbox", "quickbase_fid": "needHelp", "label": "", "visible": true, "content": "

Need Help?

Our Benefits Counselors are here to help.

Phone: (800) 282-8626
Hours: Mon\u2013Fri, 8:30a\u20135:00p ET

", "cssClass": "pf-help"}]}], "sidebar": true}, {"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "planDisclosures", "label": "", "visible": true, "content": "

Important Information

The following disclosure is required by New Mexico law: This type of plan is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the individual mandate that you have health insurance coverage. If you do not have other health insurance coverage, you may be subject to a federal tax penalty.

► If you are enrolling for the first time, you must complete a Statement of Health form for all amounts you are requesting.

Long Term Disability: The maximum monthly benefit amount (guaranteed issue) is $4,500.

Term Life: 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.

Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered Domestic Partner in whom you have an insurable interest. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to your insurable interest.

Amounts will be subject to state limits, if applicable.

See plan summary for coinsurance, copayments, deductible, exclusions, and limitations. Program not available in all states.

This enrollment form is provided for summary purposes only and is not a complete description of the plan benefits, limitations, and exclusions. Read your certificate of insurance for details on plan benefits, limitations, and exclusions.

Savings from enrolling in a dental benefits plan featuring the MetLife Preferred Dentist Program will depend on various factors, including the cost of the plan, how often participants visit a dentist, and the cost of services rendered.

Rates are subject to change and depend on geographic area. Coverage may not be available in all states. Please contact Member Benefits, your plan administrator, at 1-800-282-8626 for more information.

A class is a group of people defined in the group policy. Benefits are subject to change upon agreement between Metropolitan Life Insurance Company and the participating organization.

Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166. Like most group benefits programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. You may be financially responsible for copayments, deductibles, or any other amounts in excess of those MetLife is required to pay for covered services as described in your dental certificate and/or policy. Contact your MetLife representative or your plan administrator, Member Benefits, at 1-800-282-8626 for costs and complete details.

Vision Insurance is provided by Metropolitan Life Insurance Company (MetLife), New York, NY. Certain claim and network administration services are provided through Davis Vision. Davis Vision is not affiliated with MetLife or its affiliates. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or Member Benefits, your plan administrator, at 1-800-282-8626 for costs and complete details. Davis Vision is a registered trademark of Davis Vision.

In some cases, the plan administrator may incur costs in connection with providing oversight and administrative support for this sponsored plan. To provide and maintain this valuable membership benefit, MetLife reimburses the plan administrator for these costs.

Policy form GEF09. Policy number 282118.

MetLife and the M logo are trademarks of MetLife, Inc. L4838369[exp1027][All States][All Territories]

", "cssClass": "pf-disclosures"}]}], "cssClass": "pf-card pf-disclosures-card"}]}, {"name": "Web Enrollment & Electronic Signature Agreement", "stepLabel": "Electronic Consent", "sections": [{"name": "Electronic Consent Disclosure", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "eConsentNotice", "label": "", "visible": true, "content": "

STATEMENT ON CONSUMER CONSENT TO THE USE OF ELECTRONIC TRANSACTIONS, SIGNATURES AND RECORDS
(Consent Statement)

In this Agreement, \"we,\" \"us,\" \"our,\" and \"the company\" refer to Metropolitan Life Insurance Company and MetLife Investors USA Insurance Company. \"You\" and \"yours\" refer to the applicant for a policy offered by us.

1. Consent to do business with, and receive communications from, MetLife electronically. To the extent permitted by law, this Agreement is a \"global\" consent. You agree to:

a) Complete transactions electronically and use electronic signatures on a website we make available to you.

b) As applicable, allow us to replace paper delivery with electronic delivery of your documents and communications relating to policies you own or are applying for. Electronic delivery of the documents will be by e-mails transmitting such documents, whether as text in, attachments to, and/or hyperlinks from such e-mails to the documents stored on a MetLife website or a third party\u2019s website. You specifically agree that delivery of the link to your policy constitutes delivery of the policy and starts the free look period under your policy.

c) As applicable, receive text messages with important updates on your application and policy. You agree to allow us to send text messages to the mobile number you provide. You understand that standard message and data rates apply.

d) Make sure that neither your software nor your internet service provider inhibits or interferes with your receipt of electronic communications from us. Update your electronic mail address when it changes.

Note: You\u2019ll continue to receive paper copies of certain documents until the electronic versions become available.

2. Withdrawal of consent. You can easily withdraw your consent at any time by calling Member Benefits, the plan administrator, at 1-800-282-8626.

3. Effect of not consenting or withdrawing consent. If you choose not to consent or to withdraw your consent, you can still submit an application by signing a paper copy of the application.

4. How to obtain paper copies of the documents you sign electronically. To obtain paper copies of the documents you sign electronically, you can either print the document on your printer or call Member Benefits, the plan administrator, at 1-800-282-8626.

5. Hardware requirements. To use this service, you must have access to a computer with an Internet connection. If you would like to be able to save the documents that you receive, the computer should have a hard drive or other storage device or be connected to a printer. You must also have an email account to receive communications.

6. Software Requirements. In order to complete the electronic signature process and to download your application, you will need Adobe Acrobat Reader 3.0 (or greater).

Print or save a copy of this Consent Statement. It is also included in the completed enrollment form you can print at the end of your enrollment.

", "maxHeight": 320}, {"quickbase_fid": "eConsentCheck", "type": "checkbox", "label": "I have read the Statement on Consumer Consent to the Use of Electronic Transactions, Signatures and Records above, and I consent to conduct business electronically, to receive documents, notices and disclosures electronically, and to use electronic signatures in place of paper documents.", "required": true, "visible": true, "customRequiredMessage": "You must consent to conducting business electronically to continue with your enrollment.", "prefill": false, "agreement": {"title": "Electronic Consent (Consent Statement)", "text": "eConsentNotice"}}]}]}, {"name": "Eligibility", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "eligibilityNotice", "label": "", "visible": true, "content": "

To be eligible to apply for coverage under the Agent Benefits Program Exclusively for State Farm Agents, you must meet the following criteria:

"}, {"quickbase_fid": "eligibilityCheck", "type": "checkbox", "label": "I certify that I am a State Farm agent, or a member of a State Farm agent's staff, actively working a minimum of 17.5 hours per week. I understand that my enrollment will not be accepted and will be considered null and void if my eligibility cannot be verified by Member Benefits, the plan administrator.", "required": true, "visible": true, "customRequiredMessage": "You must confirm the eligibility requirements to proceed.", "prefill": false, "agreement": {"title": "Eligibility Certification", "text": "eligibilityNotice"}}]}]}]}, {"name": "My Information", "stepLabel": "My Information", "sections": [{"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "FirstName", "label": "First Name", "required": true, "import_fid": [9]}]}, {"fields": [{"type": "text", "quickbase_fid": "MiddleInitial", "label": "Middle Initial", "import_fid": [10]}]}, {"fields": [{"type": "text", "quickbase_fid": "LastName", "label": "Last Name", "required": true, "import_fid": [8]}]}]}, {"name": "", "columns": [{"fields": [{"type": "radio", "quickbase_fid": "Gender", "label": "Gender", "options": ["Male", "Female"], "required": true, "import_fid": [18], "pdf_fid": "Gender"}]}, {"fields": [{"type": "readonly", "quickbase_fid": "DateOfBirthDisplay", "label": "Date of Birth", "listenTo": "DateOfBirth", "displayAs": "date", "hoverOverInfo": "Date of birth is set in Step 1. To change it, go back to the Coverage page."}]}, {"fields": [{"type": "text", "quickbase_fid": "SocialSecurityNumber", "label": "Social Security Number", "customPattern": "^\\d{3}-?\\d{2}-?\\d{4}$", "customValidationMessage": "Please enter a valid 9 digit Social Security Number.", "required": true, "import_fid": [20], "prefill": false, "pdf_fid": "Member_SSN"}]}]}, {"name": "", "columns": [{"fields": [{"type": "phone", "quickbase_fid": "Phone", "label": "Phone Number", "required": true, "import_fid": [21], "pdf_fid": "Member_Phone"}]}, {"fields": [{"type": "email", "quickbase_fid": "Email", "label": "Email Address", "required": true, "import_fid": [7], "pdf_fid": "Member_Email"}]}]}, {"name": "Residential Address", "columns": [{"fields": [{"type": "text", "quickbase_fid": "StreetAddress1", "label": "Street Address 1", "required": true, "import_fid": [12]}]}, {"fields": [{"type": "text", "quickbase_fid": "StreetAddress2", "label": "Street Address 2", "import_fid": [13]}, {"type": "hiddenFormula", "quickbase_fid": "MemberFullAddress", "label": "Address (Street, City, State, Zip Code)", "neverShowInSubmission": true, "formula": {"fn": "concatenate", "args": {"fields": ["StreetAddress1", "StreetAddress2", "City", "State", "MemberZip"], "delimiter": ", ", "skipEmpty": true, "trimParts": true}}, "pdf_fid": "Member_Address"}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "City", "label": "City", "required": true, "import_fid": [14]}]}, {"fields": [{"type": "select", "quickbase_fid": "State", "label": "State", "options": ["Alabama", "Alaska", "Arizona", "Arkansas", "California", "Colorado", "Connecticut", "Delaware", "District of Columbia", "Florida", "Georgia", "Hawaii", "Idaho", "Illinois", "Indiana", "Iowa", "Kansas", "Kentucky", "Louisiana", "Maine", "Maryland", "Massachusetts", "Michigan", "Minnesota", "Mississippi", "Missouri", "Montana", "Nebraska", "Nevada", "New Hampshire", "New Jersey", "New Mexico", "New York", "North Carolina", "North Dakota", "Ohio", "Oklahoma", "Oregon", "Pennsylvania", "Rhode Island", "South Carolina", "South Dakota", "Tennessee", "Texas", "Utah", "Vermont", "Virginia", "Washington", "West Virginia", "Wisconsin", "Wyoming", "American Samoa", "Guam", "Northern Mariana Islands", "Puerto Rico", "U.S. Virgin Islands"], "required": true, "import_fid": [15]}]}, {"fields": [{"type": "readonly", "quickbase_fid": "Zip", "label": "ZIP Code", "listenTo": "MemberZip", "hoverOverInfo": "ZIP code is set in Step 1. To change it, go back to the Coverage page."}]}]}, {"name": "", "columns": [{"fields": [{"type": "checkbox", "quickbase_fid": "BillingSameAsResidential", "label": "My billing address is the same as my residential address", "required": false, "defaultValue": true}, {"type": "textbox", "quickbase_fid": "BillingAddressHeader", "label": "", "visible": false, "content": "

Billing Address

"}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BillingStreetAddress1", "label": "Street Address 1", "required": false, "visible": false, "import_fid": [437]}]}, {"fields": [{"type": "text", "quickbase_fid": "BillingStreetAddress2", "label": "Street Address 2", "visible": false, "import_fid": [438]}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BillingCity", "label": "City", "required": false, "visible": false, "import_fid": [439]}]}, {"fields": [{"type": "select", "quickbase_fid": "BillingState", "label": "State", "options": ["Alabama", "Alaska", "Arizona", "Arkansas", "California", "Colorado", "Connecticut", "Delaware", "District of Columbia", "Florida", "Georgia", "Hawaii", "Idaho", "Illinois", "Indiana", "Iowa", "Kansas", "Kentucky", "Louisiana", "Maine", "Maryland", "Massachusetts", "Michigan", "Minnesota", "Mississippi", "Missouri", "Montana", "Nebraska", "Nevada", "New Hampshire", "New Jersey", "New Mexico", "New York", "North Carolina", "North Dakota", "Ohio", "Oklahoma", "Oregon", "Pennsylvania", "Rhode Island", "South Carolina", "South Dakota", "Tennessee", "Texas", "Utah", "Vermont", "Virginia", "Washington", "West Virginia", "Wisconsin", "Wyoming", "American Samoa", "Guam", "Northern Mariana Islands", "Puerto Rico", "U.S. Virgin Islands"], "required": false, "visible": false, "import_fid": [440]}]}, {"fields": [{"type": "text", "quickbase_fid": "BillingZip", "label": "ZIP Code", "required": false, "customPattern": "^\\d{5}$", "customValidationMessage": "ZIP Code must be a 5 digit number.", "visible": false, "import_fid": [441]}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "Occupation", "label": "Occupation / Role at Agency", "required": true, "import_fid": [181]}]}, {"fields": [{"type": "text", "quickbase_fid": "Employer_Name", "label": "State Farm Agency Name", "required": true, "import_fid": [23]}]}, {"fields": [{"type": "date", "quickbase_fid": "AgentStartDate", "label": "State Farm Agent Start Date", "required": true, "noFutureDates": true, "customRequiredMessage": "Please enter the date you started with State Farm.", "hoverOverInfo": "The date you started as a State Farm agent or agency staff member. This prints as the Date of Membership on the MetLife enrollment form.", "pdf_fid": "Date_of_Membership"}]}]}, {"name": "Existing Coverage", "columns": [{"fields": [{"type": "radio", "quickbase_fid": "ReplaceExistingInsurance", "label": "By applying for this insurance coverage, do you intend to replace, discontinue or change any existing life insurance or annuity contracts currently held by you?", "options": ["Yes", "No"], "layout": "row", "maxWidth": 220, "required": true, "customRequiredMessage": "Please tell us whether this coverage will replace, discontinue or change any existing life insurance or annuity contracts.", "pdf_fid": "Replace_Existing_Insurance"}]}]}]}, {"name": "Dependent Information", "stepLabel": "Dependents", "sections": [{"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "dependentsTitle", "label": "", "visible": false, "content": "

Please provide the information below for each dependent covered by the plans you selected.

"}, {"quickbase_fid": "Spouse", "type": "modal", "label": "Spouse / Domestic Partner", "minRecords": null, "maxRecords": 1, "visible": false, "required": false, "fields": [{"quickbase_fid": "SpouseFirstName", "type": "text", "label": "First Name", "required": true, "import_fid": [228]}, {"quickbase_fid": "SpouseSecondName", "type": "text", "label": "Last Name", "required": true, "import_fid": [230]}, {"type": "hiddenFormula", "quickbase_fid": "SpouseFullName", "label": "Spouse / Domestic Partner Name", "neverShowInSubmission": true, "formula": {"fn": "concatenate", "args": {"fields": ["SpouseFirstName", "SpouseSecondName"], "delimiter": " ", "skipEmpty": true, "trimParts": true}}, "pdf_fid": "Spouse_Name", "visible": false}, {"quickbase_fid": "SpouseDOB", "type": "date", "label": "Date of Birth", "required": true, "noFutureDates": true, "import_fid": [232], "pdf_fid": "Spouse_DOB"}, {"quickbase_fid": "SpouseGender", "type": "radio", "label": "Gender", "options": ["Male", "Female"], "required": true, "import_fid": [231], "pdf_fid": "Spouse_Gender"}]}, {"type": "modal", "quickbase_fid": "Children", "label": "Children", "minRecords": null, "visible": false, "required": false, "fields": [{"type": "text", "quickbase_fid": "ChildFirstName", "label": "First Name", "required": true, "import_fid": [235, 238, 241, 244], "pdf_table_column": "First Name"}, {"type": "text", "quickbase_fid": "ChildLastName", "label": "Last Name", "required": true, "import_fid": [237, 240, 243, 246], "pdf_table_column": "Last Name"}, {"type": "hiddenFormula", "quickbase_fid": "ChildFullName", "label": "Child Name", "neverShowInSubmission": true, "formula": {"fn": "concatenate", "args": {"fields": ["ChildFirstName", "ChildLastName"], "delimiter": " ", "skipEmpty": true, "trimParts": true}}, "pdf_fid": ["Child1_Name", "Child2_Name", "Child3_Name", "Child4_Name", "Child5_Name"], "visible": false}, {"type": "date", "quickbase_fid": "ChildDOB", "label": "Date of Birth", "required": true, "noFutureDates": true, "import_fid": [247, 248, 249, 250], "pdf_fid": ["Child1_DOB", "Child2_DOB", "Child3_DOB", "Child4_DOB", "Child5_DOB"], "pdf_table_column": "Date of Birth"}, {"type": "radio", "quickbase_fid": "ChildGender", "label": "Gender", "options": ["Male", "Female"], "pdf_fid": ["Child1_Gender", "Child2_Gender", "Child3_Gender", "Child4_Gender", "Child5_Gender"], "pdf_table_column": "Gender", "required": true, "customRequiredMessage": "Please select the child's gender."}], "pdf_table": "Dependent Children"}, {"type": "textbox", "quickbase_fid": "DomesticPartnerHelperText", "label": "", "visible": false, "content": "

*Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered Domestic Partner in whom you have an insurable interest. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to your insurable interest.

", "maxHeight": 200}, {"type": "hiddenFormula", "quickbase_fid": "MoreChildrenNeeded", "label": "More than five children", "neverShowInSubmission": true, "formula": {"fn": "modalSubrecordCountGt", "args": {"modalFid": "Children", "threshold": 5}}, "pdf_fid": "More_Children"}]}]}]}, {"name": "Beneficiaries", "stepLabel": "Beneficiaries", "sections": [{"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "beneficiariesTitle", "label": "", "visible": false, "content": "

Tell us who should receive your Term Life benefit.

"}, {"type": "textbox", "quickbase_fid": "addBeneficiaryDesignationNotice", "label": "", "visible": false, "content": "

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.

Automatic Beneficiary Designation: Any amount of insurance under a Coverage for which there is no Beneficiary at your death will be payable to the first of the following: your (a) surviving spouse; (b) surviving child(ren) in equal shares; (c) surviving parents in equal shares; (d) surviving siblings in equal shares; (e) estate. You will automatically be the beneficiary for any amount of insurance on your spouse and/or children's Coverage.

Specific Beneficiary Designation: If you name more than one beneficiary, settlement will be made in equal shares to the designated beneficiaries (or beneficiary) that survive you, unless otherwise provided in the designation. If no named beneficiary survives you, settlement will be made to your estate. The beneficiary named herein will be the beneficiary for your total amount of insurance coverage issued.

", "maxHeight": 400}, {"quickbase_fid": "addBeneficiaryDesignation", "type": "select", "label": "Beneficiary Designation", "required": false, "visible": false, "import_fid": [50], "options": ["Automatic Beneficiary Designation", "Specific Beneficiary Designation"]}, {"quickbase_fid": "Beneficiaries", "type": "modal", "label": "Beneficiaries", "visible": false, "required": false, "minRecords": null, "cardLayout": true, "import_fid": [453], "fields": [{"quickbase_fid": "BeneInstitutionName", "type": "text", "label": "Name of Trust / Estate", "visible": false}, {"quickbase_fid": "BeneFirstName", "type": "text", "label": "First Name", "required": true}, {"quickbase_fid": "BeneMiddleName", "type": "text", "label": "Middle Name"}, {"quickbase_fid": "BeneLastName", "type": "text", "label": "Last Name", "required": true}, {"quickbase_fid": "BeneFullName", "type": "hiddenFormula", "label": "Full Name", "neverShowInSubmission": true, "visible": false, "formula": {"fn": "concatenate", "args": {"fields": ["BeneInstitutionName", "BeneFirstName", "BeneMiddleName", "BeneLastName"], "delimiter": " ", "skipEmpty": true, "trimParts": true}}, "pdf_fid": ["Ben1 Name", "Ben2 Name", "Ben3 Name", "Ben4 Name", "Ben5 Name", "Ben6 Name"], "pdf_table_column": "Beneficiary Name"}, {"quickbase_fid": "BeneDOB", "type": "date", "label": "Date of Birth", "required": true, "noFutureDates": true, "pdf_fid": ["Ben1 DOB", "Ben2 DOB", "Ben3 DOB", "Ben4 DOB", "Ben5 DOB", "Ben6 DOB"], "pdf_table_column": "Date of Birth"}, {"quickbase_fid": "BeneSSN", "type": "text", "label": "Beneficiary Social Security Number", "customPattern": "^\\d{3}-?\\d{2}-?\\d{4}$", "customValidationMessage": "Please enter a valid 9 digit Social Security Number.", "prefill": false, "pdf_fid": ["Ben1 SSN", "Ben2 SSN", "Ben3 SSN", "Ben4 SSN", "Ben5 SSN", "Ben6 SSN"], "pdf_table_column": "Social Security Number"}, {"quickbase_fid": "BeneAddressStreet1", "type": "text", "label": "Street Address 1"}, {"quickbase_fid": "BeneAddressStreet2", "type": "text", "label": "Street Address 2"}, {"quickbase_fid": "BeneAddressCity", "type": "text", "label": "City"}, {"type": "select", "quickbase_fid": "BeneState", "label": "State", "options": ["Alabama", "Alaska", "Arizona", "Arkansas", "California", "Colorado", "Connecticut", "Delaware", "District of Columbia", "Florida", "Georgia", "Hawaii", "Idaho", "Illinois", "Indiana", "Iowa", "Kansas", "Kentucky", "Louisiana", "Maine", "Maryland", "Massachusetts", "Michigan", "Minnesota", "Mississippi", "Missouri", "Montana", "Nebraska", "Nevada", "New Hampshire", "New Jersey", "New Mexico", "New York", "North Carolina", "North Dakota", "Ohio", "Oklahoma", "Oregon", "Pennsylvania", "Rhode Island", "South Carolina", "South Dakota", "Tennessee", "Texas", "Utah", "Vermont", "Virginia", "Washington", "West Virginia", "Wisconsin", "Wyoming", "American Samoa", "Guam", "Northern Mariana Islands", "Puerto Rico", "U.S. Virgin Islands"]}, {"type": "text", "quickbase_fid": "BeneZip", "label": "ZIP Code", "customPattern": "^\\d{5}$", "customValidationMessage": "ZIP Code must be a 5 digit number."}, {"type": "hiddenFormula", "quickbase_fid": "BeneFullAddress", "label": "Address", "neverShowInSubmission": true, "formula": {"fn": "concatenate", "args": {"fields": ["BeneAddressStreet1", "BeneAddressStreet2", "BeneAddressCity", "BeneState", "BeneZip"], "delimiter": ", ", "skipEmpty": true, "trimParts": true}}, "pdf_fid": ["Ben1 Address", "Ben2 Address", "Ben3 Address", "Ben4 Address", "Ben5 Address", "Ben6 Address"], "visible": false, "pdf_table_column": "Address"}, {"type": "phone", "quickbase_fid": "BenePhone", "label": "Phone Number", "pdf_fid": ["Ben1 Phone", "Ben2 Phone", "Ben3 Phone", "Ben4 Phone", "Ben5 Phone", "Ben6 Phone"], "pdf_table_column": "Phone Number"}, {"quickbase_fid": "BeneRelationship", "type": "select", "label": "Relationship", "required": true, "options": ["", "Spouse", "Domestic Partner", "Child", "Stepchild", "Adopted Child", "Grandchild", "Parent", "Stepparent", "Grandparent", "Sibling", "Stepsibling", "Other Relative", "Trust", "Estate", "Legal Guardian", "Power of Attorney", "Other"], "pdf_table_column": "Relationship"}, {"quickbase_fid": "beneficiaryType", "type": "select", "label": "Beneficiary Type", "required": true, "options": ["Primary", "Contingent"], "pdf_table_column": "Beneficiary Type"}, {"type": "hiddenFormula", "quickbase_fid": "BeneContingentMarker", "label": "Contingent marker", "neverShowInSubmission": true, "formula": {"fn": "map", "args": {"inputField": "beneficiaryType", "default": ""}, "map": {"Contingent": "(Contingent)"}}, "visible": false}, {"type": "hiddenFormula", "quickbase_fid": "BeneRelationshipForPDF", "label": "Relationship", "neverShowInSubmission": true, "formula": {"fn": "concatenate", "args": {"fields": ["BeneRelationship", "BeneContingentMarker"], "delimiter": " ", "skipEmpty": true, "trimParts": true}}, "pdf_fid": ["Ben1 Relationship", "Ben2 Relationship", "Ben3 Relationship", "Ben4 Relationship", "Ben5 Relationship", "Ben6 Relationship"], "visible": false}, {"quickbase_fid": "BeneShare", "type": "number", "label": "Beneficiary Percentage Share", "required": true, "pdf_fid": ["Ben1 Share", "Ben2 Share", "Ben3 Share", "Ben4 Share", "Ben5 Share", "Ben6 Share"], "pdf_table_column": "Share"}], "pdf_table": "All Beneficiaries"}, {"type": "hiddenFormula", "quickbase_fid": "MoreBeneficiariesNeeded", "label": "More than six beneficiaries", "neverShowInSubmission": true, "formula": {"fn": "modalSubrecordCountGt", "args": {"modalFid": "Beneficiaries", "threshold": 6}}, "pdf_fid": "More_Beneficiaries"}]}]}]}, {"name": "Payment & Signature", "stepLabel": "Payment & Signature", "sections": [{"name": "Select Payment Type", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "PaymentDescription", "label": "", "visible": true, "content": "

Payment Option 1: Monthly Auto Pay (ACH Bank Draft)
If you elect to pay by Monthly Auto Pay / Bank Draft (ACH), you do not need to send any premium, we will automatically draft your account on a monthly basis starting on your Coverage Effective Date. The cost for this service is an additional .50/per month which will be added to your monthly amount drafted. Your 1st monthly draft will include the one-time $20.00 processing fee*.

Payment Option 2: Direct Annual Billing (initial annual payment via credit card)
If you elect this method, you will need to make your initial payment via Credit Card for the premium required to pay your coverage through the end of the group plan year (December 31st) plus the one-time $20.00 processing fee*. Your card will not be charged thereafter and you will be invoiced on an annual basis for premiums due January 1st each group plan year. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).

"}, {"type": "radio", "quickbase_fid": "paymentMethod", "required": true, "label": "Payment Method", "import_fid": [359], "options": ["Monthly Auto-Pay (ACH)", "Direct Annual Bill - Initial Payment via Credit Card"]}, {"type": "readonly", "quickbase_fid": "coverageStartDateDisplayTwo", "label": "Coverage Start Date", "listenTo": "CoverageStartDate", "hoverOverInfo": "Coverage begins on the first of the month following enrollment, unless otherwise stated.", "displayAs": "date", "visible": true, "alwaysShowInSubmission": true}]}]}, {"name": "Payment Information", "columns": [{"fields": [{"quickbase_fid": "Payment", "type": "payment", "label": "Payment", "currency": "usd", "visible": false, "statementDescriptor": "MB* MBR BNFT INSURANCE", "paymentSummaryNotes": {"achMonthly": "Monthly ACH draft: this is the amount that will be drafted each month. Your first draft also includes the one-time processing fee.", "ccOneTime": "Credit Card one-time charge: this is the amount charged today for the remainder of the coverage year, plus the one-time processing fee.", "default": "Total monthly rates: select a payment method to see exact charges."}, "ACHFirstTimeFees": [{"amount": 0.5, "description": "ACH Draft Fee"}, {"amount": 20, "description": "One-Time Processing Fee"}], "ccOneTimeFees": [{"amount": 20, "description": "One-Time Processing Fee"}], "ccDirectBillRecurringFees": [], "ccMonthlyRecurringFees": [], "ccMonthlyFirstTimeFees": [], "requiredFields": {"zip": "Zip", "firstName": "FirstName", "lastName": "LastName", "email": "Email", "phone": "Phone", "address": "StreetAddress1", "address2": "StreetAddress2", "city": "City", "state": "State"}, "ratemultiplier": {"MonthsRemainingThisCoverageYear": "__useValue__"}}, {"type": "paymentsummary", "quickbase_fid": "PaymentSummary"}, {"type": "textbox", "quickbase_fid": "CreditAuthorizationNotice", "label": "", "visible": false, "content": "

One Time Credit Card Payment Authorization

I hereby authorize Member Benefits to make a one time debit to my credit card listed above. By agreeing, I give permission to immediately debit my account upon completion of my online enrollment. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to my account. I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the insurance coverage described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

"}, {"quickbase_fid": "CreditAuthorizationCheck", "type": "checkbox", "label": "I Agree to the One Time Credit Card Payment Authorization.", "required": false, "visible": false, "customRequiredMessage": "You must Agree to the One Time Credit Card Payment Authorization", "prefill": false, "agreement": {"title": "One Time Credit Card Payment Authorization", "text": "CreditAuthorizationNotice"}}, {"type": "text", "quickbase_fid": "BankAccountHolderName", "label": "Accountholder's Name", "visible": false, "required": false, "import_fid": [38], "prefill": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BankName", "label": "Name of Bank or Financial Institution", "visible": false, "required": false, "import_fid": [36], "prefill": false}]}, {"fields": [{"type": "select", "quickbase_fid": "BankAccountType", "label": "Account type", "options": ["Checking", "Savings"], "visible": false, "required": false, "import_fid": [37], "prefill": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BankRoutingNumber", "label": "Routing number", "visible": false, "required": false, "customPattern": "^\\d{9}$", "customValidationMessage": "Routing number must be 9 digits.", "sensitive": "achRouting", "import_fid": [39], "prefill": false}]}, {"fields": [{"type": "text", "quickbase_fid": "BankAccountNumber", "label": "Account number", "visible": false, "required": false, "customPattern": "^\\d{4,17}$", "customValidationMessage": "Account number must be 4\u201317 digits.", "sensitive": "achAccount", "import_fid": [35], "prefill": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "image", "quickbase_fid": "CheckingGuideImage", "label": "", "relativeUrl": "/static/formImages/checkImage.png", "alt": "Routing Number Account Number Help Image", "maxWidth": 400, "visible": false, "neverShowInSubmission": true}]}]}, {"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "ACHAuthorizationNotice", "label": "", "visible": false, "content": "

Monthly Auto Pay Authorization

I hereby authorize Member Benefits (MB) to initiate debit and credit entries to my Checking account and my Bank/Financial Institution to debit and/or credit the same account. I understand and agree to pay an additional .50 per month to utilize this service. MB will not be held responsible for a policy lapse or cancellation due to nonpayment if withdrawal is prepared and not honored for any reason and amount due is not paid within the payment Grace Period. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. Service fees, when applicable by law, may apply for ACH debit returns. MB and my Bank/Financial Institution may discontinue this service. This authority is to remain in full force and effective until MB has received written notice from me of its termination in such time and manner as to afford MB and my Bank/Financial Institution a reasonable opportunity to act on it.

"}, {"quickbase_fid": "ACHAuthorizationCheck", "type": "checkbox", "label": "I Agree to the Monthly Auto Pay Authorization.", "required": false, "visible": false, "customRequiredMessage": "You must Agree to the Monthly Auto Pay Authorization", "prefill": false, "agreement": {"title": "Monthly Auto Pay Authorization", "text": "ACHAuthorizationNotice"}}]}]}, {"name": "Fraud Warnings", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "FraudWarningText", "label": "", "visible": true, "maxHeight": 260, "content": "

FRAUD WARNINGS

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.

California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state 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 Insurance): 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.

Print or download the Fraud Warnings (PDF)

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Our Privacy Notice

Delaware American Life Insurance Company

MetLife Health Plans, Inc.

MetLife Legal Plans, Inc.

MetLife Legal Plans of Florida, Inc.

Metropolitan General Insurance Company

Metropolitan Life Insurance Company

Metropolitan Tower Life Insurance Company

SafeGuard Health Plans, Inc.

SafeHealth Life Insurance Company

We know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. \u201cPersonal information\u201d as used here means anything we know about you personally.

SECTION 1: Plan Sponsors and Group Insurance Contract Holders

This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, group insurance or annuity contract, as an executive benefit, or as otherwise made available at your work or through an association to which you belong. In this notice, \u201cyou\u201d refers to these individuals.

SECTION 2: Protecting Your Information

We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us.

SECTION 3: Collecting Your Information

We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life insurers, a legal plans company and a securities broker-dealer. In the future, we may also have affiliates in other businesses.

SECTION 4: How We Get Your Information

We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don\u2019t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.

We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense:

Ask for a medical exam
Ask for blood and urine tests
Ask health care providers to give us health data, including information about alcohol or drug abuse

We may also ask a consumer reporting agency for a \u201cconsumer report\u201d about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about:

Reputation
Driving record
Finances
Work and work history
Hobbies and dangerous activities

The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency.

Another source of information is MIB, LLC (\u201cMIB\u201d). It is a not-for-profit membership organization of insurance companies which operates an information exchange on behalf of its Members. We, or our reinsurers, may make a brief report to MIB. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is submitted, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901. If you question the accuracy of information in MIB\u2019s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. You may do so by writing to MIB LLC, 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734 or go to MIB website at www.mib.com.

SECTION 5: Using Your Information

We collect your personal information to help us decide if you\u2019re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:

administer your products and services
perform business research
market new products to you
comply with applicable laws
process claims and other transactions
confirm or correct your information
help us run our business

SECTION 6: Sharing Your Information With Others

We may share your personal information with others with your consent, by agreement, or as permitted or required by law. We may share your personal information without your consent if permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.

Other reasons we may share your information include:

doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas)
telling another company what we know about you if we are selling or merging any part of our business
giving information to a governmental agency so it can decide if you are eligible for public benefits
giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account)
giving your information to your health care provider
having a peer review organization evaluate your information, if you have health coverage with us
those listed in our \u201cUsing Your Information\u201d section above

SECTION 7: HIPAA

We will not share your health information with any other company \u2013 even one of our affiliates \u2013 for their own marketing purposes. The Health Insurance Portability and Accountability Act (\u201cHIPAA\u201d) protects your information if you request or purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the information that we obtain as a result of your request or purchase of insurance. Information about your rights under HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you.

You may obtain a copy of our HIPAA Privacy Notice by visiting our website at www.MetLife.com. For additional information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) 578-0299.

SECTION 8: Accessing and Correcting Your Information

You may ask us for a copy of the personal information we have about you. We will provide it as long as it is reasonably locatable and retrievable. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim or lawsuit, unless required by law.

If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.

SECTION 9: Questions

We want you to understand how we protect your privacy. If you have any questions or want more information about this notice, please contact us. A detailed notice shall be furnished to you upon request. When you write, include your name, address, and policy or account number.

Send privacy questions to:

MetLife Privacy Office
P. O. Box 489
Warwick, RI 02887-9954
privacy@metlife.com

We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of the MetLife companies listed at the top of the first page.

CPN-Initial Enr/SOH and SBR (03/23)

Print or download the MetLife Privacy Notice (PDF)

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CALIFORNIA HEALTHCARE LANGUAGE ASSISTANCE PROGRAM
NOTICE TO INSUREDS

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card, if any, or 1-800-942-0854. For more help call the CA Dept. of Insurance at 1-800-927-4357.

To receive a copy of the attached MetLife document translated into Spanish or Chinese, please mark the box by the requested language statement on the printable notice, and mail the document with this form to:

Metropolitan Life Insurance Company
PO Box 14587
Lexington, KY 40512

Please indicate to whom and where the translated document is to be sent.

Servicio de Idiomas Sin Costo. Puede obtener la ayuda de un int\u00e9rprete. Se le pueden leer documentos y enviar algunos en espa\u00f1ol. Para recibir ayuda, ll\u00e1menos al n\u00famero que aparece en su tarjeta de identificaci\u00f3n, si tiene una, o al 1-800-942-0854. Para recibir ayuda adicional llame al Departamento de Seguros de California al 1-800-927-4357.

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CA LAP STANDALONE NOTICE (09/08)

Print or download the California Language Assistance Notice (English, Spanish and Chinese) (PDF)

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Enrollment Request

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.

DECLARATIONS AND SIGNATURE

By signing below, I acknowledge:

I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.
I declare that I was actively at work for at least 17.5 hours per week during my regular work schedule preceding my date of application. I understand that if I am not actively at work on the scheduled effective date of insurance, such insurance will not take effect until I return to active work.
I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician\u2019s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized. Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.
I understand that if I do not enroll for life or disability coverage during the initial enrollment period, or 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.
I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.
I have read the applicable Fraud Warning(s) provided in this enrollment form.

Enrollment & Administration Agreement (Member Benefits, Plan Administrator)

By signing below, I acknowledge:

I hereby apply for group insurance, for which I am eligible or may become eligible. I understand that I am enrolling as a participant in a group plan. The plan provider, premium rates, and plan benefits may change.

I have read and understand the conditions and plan limitations as described in the plan materials made available through this website. I understand that any dental plan I enroll in may be subject to waiting periods for certain types of services.

I understand that my new enrollment will replace any existing coverage I may have under the Agent Benefits Program Exclusively for State Farm Agents. I understand that the plan administrator, Member Benefits (\"MB\"), may reject my enrollment submission if I do not meet all eligibility requirements and will notify me if rejected. Otherwise, my coverage will be effective on the 1st day of the month following my enrollment date and after receipt of my initial premium payment.

MB reserves the right to decline or delay enrollment if verification of eligibility or receipt of initial payment cannot be confirmed. All premium payments, coverage changes, and cancellation requests must be submitted directly to MB in writing or through the proper web form. Requests submitted directly to MetLife will not be honored.

I understand and agree that I have made my plan election and selected my covered dependents for the plan year through December 31st. My elections remain in effect until the next annual open enrollment date (January 1st). My enrollment will automatically continue unless MB receives written notice of changes before the next annual open enrollment date.

I may terminate coverage by submitting a written cancellation request to MB or by completing the MB online cancellation form at www.memberbenefits.com. Terminations become effective at 11:59 pm on the last day of the month in which my request was submitted. No partial-month or backdated terminations are permitted.

Refund requests may be granted only within the first 30 days after my coverage effective date - and only if no claims have been paid or filed. Refunds will be issued net of surcharges or processing fees and may take up to 30 days.

If I terminate or discontinue enrollment, I understand I may not re-enroll for 24 months from the date of termination.

To the best of my knowledge and belief, the information I've provided is complete and correct.

I agree to conduct business with the Plan Administrator, Member Benefits. I have read and agree to the Member Benefits Administration Terms & Agreements.

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