Statement of Claim for Disability Benefits

Statement of Claim for Disability Benefits INSTRUCTIONS FOR FILING THIS CLAIM This claim package is provided to present your claim for disability under your individual disability insurance policy. Please follow the instructions below in completing this claim package. Your individual disability insurance policy requires that you give MetLife prompt notification of claim. Failure to notify us promptly may delay or limit our ability to determine benefit eligibility, and in some instances, cause us to deny your claim. Please complete and return this claim package as soon as possible after the start of a disability. Please be sure to completely answer all questions. Incomplete or illegible answers may result in a delay in the handling of your claim. This claim package has five sections: A. CLAIMANT S STATEMENT You must complete this section. Please be sure to sign and date the bottom of this section. B. DESCRIPTION OF OCCUPATION/ACTIVITIES You must complete this section. Please state your occupational duties at the time your disability began. C. ATTENDING PHYSICIAN S STATEMENT The physician who is PRIMARILY responsible for your care should complete this section. D. EMPLOYER S STATEMENT Your employer should complete this section. If self-employed, you should complete this section. E. AUTHORIZATION Please read, sign and date the authorization. If you have any problems or questions about the completion of this claim package, please contact us for assistance: (800) 929-1492 Any person who, knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim with materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may be guilty of committing a fraudulent insurance act. Please see pages 2 and 3 for special notice required by state law. You should send the fully completed claim package to: Metropolitan Life Insurance Company Disability Income Claims P.O. Box 30429 Tampa, FL 33630-3429

STATE SPECIFIC FRAUD WARNINGS: If a policy was issued in one of the following states, or if you reside in one of the following states, one of the following state warnings may apply to you: Alaska: A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of loss is subject to criminal and civil penalties. Arkansas, Louisiana, Rhode Island, 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 a false or fraudulent 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 life 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 respect to a settlement or award from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies to the extent required by applicable law. Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Kentucky: Any person who knowingly and with the intent to defraud any insurance company or other person files a 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. Maine: 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. Page

STATE SPECIFIC FRAUD WARNINGS: Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: A person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey: Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. New Mexico: 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 civil fines and criminal penalties. New York: 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. Ohio: A person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statement is guilty of insurance fraud. 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. Oregon: A person who knowingly and with intent to defraud an insurance company, files a claim containing false, incomplete or misleading information material to such claim, may be guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning a fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, or assist or abet 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. Tennessee, Virginia, 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 include imprisonment, fines and denial of insurance benefits. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Page

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Initial Claim for Disability Benefits Metropolitan Life Insurance Company P.O. Box 30429 IF YOU HAVE QUESTIONS Tampa, FL 33630-3429 CALL (800) 929-1492 A. CLAIMANT S STATEMENT Name (Last, First, MI) Policy #: Address (If PO Box, also show street address) Social Security #: City State Zip Date of Birth Height Weight Home Phone (include area code) Date Last Worked: Is your disability due to: q Injury/Accident q Sickness q Pregnancy? If due to Injury/Accident, please provide date, time and details (when, where, how). If due to Sickness, please provide nature and details of sickness. Have you ever had a similar injury or sickness? q Yes q No If Yes, please provide dates: Is this condition work related? q Yes q No If condition is due to pregnancy, what is your expected delivery date? Please provide the name of your Medical Coverage Provider: Their Address: Policy #: Phone #: Please identify the primary insured (self, spouse, other): What type of delivery is expected? Please provide the date of first treatment for this condition: Have you been hospitalized for this condition? q Yes q No If Yes, please provide dates from to Name & Address of Hospital: Please list all physicians who have TREATED you within the last 5 years (Attach extra sheet, if necessary) Name: Street Address: City, State, Zip: Name: Street Address: City, State, Zip: Phone #: Phone #: Treatment Dates: Treatment Dates: PLEASE LIST ALL HOSPITAL CONFINEMENTS WITHIN THE LAST 5 YEARS (Attach extra sheet, if necessary) Hospital: Street Address: City, State, Zip: Hospital: Street Address: City, State, Zip: Phone #: Phone #: Treatment Dates: Treatment Dates: Page

A. CLAIMANT S STATEMENT (CONTINUED) I was unable to work due to injury or sickness: I first returned to my place of business or work since becoming disabled I returned to work in a limited capacity From: (mo/day/year) On: (mo/day/year) From: (mo/day/year) Have you applied for or are you receiving income from any other sources? q Yes q No If Yes, please check any and all benefits that you are eligible to receive or are receiving: To: (mo/day/year) To: (mo/day/year) Applied Receiving Date Applied For Amount Received Effective Date Yes No Yes No Weekly Monthly Social Security q q q q / / / / Workers Compensation q q q q / / / / State Disability Insurance q q q q / / / / Retirement or Pension q q q q / / / / Short Term Disability q q q q / / / / Salary Continuation q q q q / / / / Dept. of Veterans Affairs q q q q / / / / Unemployment q q q q / / / / Union q q q q / / / / Other q q q q / / / / Describe all disability coverage in force, and all disability coverage applied for in the past 12 months. Indicate if it is (A) Individual, (B) Social Security Substitute, (C) Association, (D) Group, (E) Salary Continuation, (F) Overhead Expense, or (G) Buy-out. If none, so state by writing none. Company or source, and policy number Type (A, B, C, etc.) Monthly Amount Elimination Period Benefit Period Please provide your educational background: High School (Name & Location) Dates Attended: Graduate? Year College/Trade School (Name & Location) q Yes q No Major/Degree Graduate School (Name & Location) q Yes q No q Yes q No Please provide your employment background: Previous Employer (Name & Location) Length of Employment Position Held Next Previous Employer (Name & Location) Do you currently have or have you ever had any professional certifications, licenses, or affiliations: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM WITH MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO MAY BE GUILTY OF COMMITTING A FRAUDULENT INSURANCE ACT. PLEASE SEE PAGES 2 AND 3 FOR STATE SPECIFIC FRAUD WARNINGS. THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IT MAY BE A CRIME TO FILL OUT THIS FORM WITH FACTS I KNOW ARE FALSE OR LEAVE OUT FACTS I KNOW ARE IMPORTANT. CLAIMANT S SIGNATURE Date Page

B. DESCRIPTION OF OCCUPATION/ACTIVITIES (If Retired or Unemployed, please provide the details of your daily tasks prior to the start of your disability as requested in the appropriate section). Your Name: Employer Name: If self-employed, please provide type of business as filed for Federal Income Tax Purposes: q regular corporation q sub S corporation q partnership q sole proprietor What is your ownership interest? % Your Occupation: Employer Address: Street City State Zip Code ( ) Telephone ( ) Fax Number of hours worked in a normal week: Usual hours worked From: am/pm Shift? Years with current employer: Gross monthly income prior to disability: To: am/pm IN AN 8 HOUR WORKDAY, YOUR OCCUPATION REQUIRES: Number of Hours Per Work Shift Number of Hours Per Work Shift 0 1-2 3-4 5-6 7-8 0 1-2 3-4 5-6 7-8 1. Sitting 14. Grasping 2. Standing A. Simple/Light 3. Walking 1. Right hand only 4. Bending over 2. Left hand only 5. Twisting 3. Both hands 6. Climbing B. Firm/Strong 7. Reaching above shoulder level 1. Right hand only 8. Crouching/Stooping 2. Left hand only 9. Kneeling 3. Both hands 10. Balancing 15. Fine finger dexterity 11. Pushing or pulling A. Right hand only 12. Repetitive use of foot control B. Left hand only A. Right foot only C. Both hands B. Left foot only 16. Use of head and neck in: C. Both feet A. Static position 13. Repetitive use of hands B. Twisting A. Right hand only C. Looking up B. Left hand only D. Looking down C. Both hands Never 0% of Time Occasionally 1-33% of Time Frequently 34-66% of Time Continually 67-100% of Time 17. Lifting or carrying A. Up to 10 lbs. B. 11 20 lbs. C. 21 50 lbs. D. 51 100 lbs. E. 100 + lbs. 18. In the course of performing the job, you are required to: Yes No Yes No A. Drive cars, trucks, forklifts and/or D. Be exposed to dust, gas or fumes q q other equipment q q If Yes; are respirators required q q B. Be around moving equipment E. Be exposed to marked changes in and/or machinery q q temperature or humidity q q C. Walk on uneven ground q q F. Work overtime on a routine basis q q Page

B. DESCRIPTION OF OCCUPATION/ACTIVITIES (CONTINUED) Where do you work? q Mostly indoors q Mostly outdoors q Equally indoors and outdoors Have your occupational duties or employment status changed in any way in the 12 months immediately preceding your disability? q Yes q No If Yes, how? DESCRIBE OCCUPATIONAL DUTIES OR IF RETIRED/UNEMPLOYED, DESCRIBE DAILY TASKS PRIOR TO DISABILITY: Activity Hours spent weekly Equipment used in task Frequency of use WHICH OF THE DUTIES/ACTIVITIES ABOVE ARE YOU NOW UNABLE TO PERFORM AND WHY? Activity Explanation PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU FEEL WOULD ASSIST US IN EVALUATING YOUR CLAIM. ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR A STATEMENT OF CLAIM WITH MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO MAY BE GUILTY OF COMMITTING A FRAUDULENT INSURANCE ACT. PLEASE SEE PAGES 2 AND 3 FOR STATE SPECIFIC FRAUD WARNINGS. THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IT MAY BE A CRIME TO FILL OUT THIS FORM WITH FACTS I KNOW ARE FALSE OR LEAVE OUT FACTS I KNOW ARE IMPORTANT. CLAIMANT S SIGNATURE Date Page 8

C. ATTENDING PHYSICIAN S STATEMENT Name of Patient Social Security Number Employer Date of Birth Who referred this patient to you? Address: Phone: Symptoms result from: q Injury/Accident q Sickness q Pregnancy Date symptoms first appeared or injury/accident happened: Is condition work related? q Yes q No Initial date of treatment: Dates of additional treatment: Has the patient ever had a same or similar condition? q Yes q No If Yes, please provide details: Please provide the name, address, and phone number for each provider the patient is being treated by: Name Address Phone Number ( ) ( ) Has the patient ever been hospitalized? q Yes q No If Yes, please provide dates confined: through Name and address of the facility: Diagnosis: ICD9 Code: Subjective Symptoms: Objective findings to include copies/results of any x-rays, lab tests, EKGs, MRIs, scans and office notes: Please describe any surgery performed or scheduled. Please include CPT4 code, procedure, and date. Does the patient have any chronic or recurring conditions not described above? q Yes q No If Yes, please provide details including diagnosis and treatment information: Disability Income Claims P.O. Box 30429 Tampa, Florida 33630-3429 Page 9

C. ATTENDING PHYSICIAN S STATEMENT (CONTINUED) Please describe the specific physical and/or mental limitations and restrictions the patient is experiencing: Please describe the treatment plan for this patient. Please list the medications prescribed, including name and dosage. Do you recommend that the patient become involved in any of the following? Please check as many as apply. q Physical Therapy q Pain Management Program q Vocational Rehabilitation q Occupational Therapy q Work Hardening Program q Psychological Counseling q Cardiac Rehabilitation q Job Modification q Other Has this been discussed with the patient? q Yes q No Please provide the name and address of any facility to which this patient has been referred: Please provide any additional information you feel would assist us in evaluating this patient s claim for disability benefits. I hereby certify that the above information is true and accurate to the best of my knowledge. Physician Name: Degree: Specialty: Street address: City: State: Zip Code: Telephone # ( ) Fax # ( ) Tax ID #: Contact person if additional information is necessary: Signature: Date: (Required) ** Please be sure that you sign this form as stamped signatures are not acceptable.** Page 10

D. EMPLOYER S STATEMENT -- Please attach written job description to this form -- Employee s Name: Social Security Number: Company Name: Contact Person: Company address and phone number: Premium Contributions q Pre-Tax Basic Earnings (exclusive of overtime, bonus, etc.) Employee s Date of Hire Employer % q Post-Tax $ q Hourly q Weekly q Monthly Employee % Employee s status as of first day absent q Active q Vacation If other than Active, please explain. q LOA q Laid Off q Terminated q Retired Has employee had previous absences from work due to disability? q Yes q No If Yes, provide dates and medical conditions. Does your company provide group disability coverage? q Yes q No q STD q LTD Provider Name Policy # Provider Address Telephone # Date Coverage Effective: Is condition work related? q Yes q No Is employee receiving Workers Compensation benefits? q Yes q No Workers Compensation Carrier s name, address and phone number: Case Number: Policy Number: Name of employee s immediate supervisor: Title of employee s occupation: Does the employee s job remain open? Can employee s job be modified? q Yes q No Date last worked: Full-time? If Yes, describe how. Avg. hours worked per week Part-time? Has return to work been discussed with employee? q Yes q No If Yes, date: Employer Representative s Signature: Date Print Name (Last, First, Middle Initial) Title Telephone/Extension Number Disability Income Claims P.O. Box 30429 Tampa, Florida 33630-3429 Page 11

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Metropolitan Life Insurance Company P.O. Box 30429 Tampa, FL 33630-3429 E. AUTHORIZATION Name of Insured: DOB: (Please Print) Policy Number(s): For purposes of determining eligibility for disability benefits and evaluating claim(s), I authorize: Any medical/treating practitioner or facility, any insurer, any employer, any pharmacist or pharmacy, any government agency (including the Social Security Administration), any benefit plan administrator or other third party administrator, any insurance support organization, consumer reporting agency or MIB Group Inc. (MIB) to give Metropolitan Life Insurance Company ( MetLife ) an employee or representative of MetLife or any third party (including a consumer reporting agency preparing a consumer report) acting on MetLife s behalf, any and all information about the health, medical care, physical condition and disability of the Insured named above, including: The entire medical record for the Insured including medical information, records and data about the Insured, including information, records and data about prescribed treatment, physical therapy, medicines and drugs and about sexually transmitted diseases: Information relating to Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions about the Insured, including Human Immuno-deficiency Virus (HIV) test results; Information, records and data about the Insured relating to alcohol or drug use, including that which may be protected by Federal Regulations 42 CFR part 2; and Information, records and data about the Insured relating to mental illness (other than psychotherapy notes). MetLife to request and obtain consumer, investigative consumer or motor vehicle reports about the Insured. Any employer, business associate, financial institution, consumer reporting agency, insurer, group policyholder or contract holder, government agency (including the Social Security Administration) to give MetLife, an employee or representative of MetLife or any third party (including a consumer reporting agency preparing a consumer report) acting on MetLife s behalf, any information or data that it may have about the employment, occupation, avocations, driving record, finances, character, reputation and aviation activities of the Insured. I understand that: All or part of the information, records and data that MetLife receives pursuant to this Authorization may be disclosed to MIB. All or part of the information may also be disclosed to and used by any reinsurer, employee, affiliate, Health Claims Index or independent contractor who performs a business service for MetLife regarding the claim(s) for benefits, which concerns insurance coverage regarding the Insured, or as otherwise required or permitted by applicable laws. Medical information, records and data that may have been subject to federal and state laws or regulations (including 42 CFR part 2 and federal regulations issued by Health and Human Services setting forth standards for the use, maintenance and disclosure of such information by health care providers and health plans), once disclosed to MetLife, may no longer be covered by those laws or regulations. Information relating to HIV test results will only be disclosed as permitted by applicable law. I am not required by law to sign this Authorization, but if I do not, the Company will not be able to evaluate my claim for individual disability income benefits. In addition, health care provider(s) or health care plan(s) asked to release information pursuant to this Authorization cannot condition treatment or payment for treatment or other benefits on my signing it. This Authorization will end 24 months from the date on this form or sooner if prescribed by law. I may revoke this Authorization at any time by writing to MetLife at the address above and advising that I have revoked this Authorization. Any action taken before MetLife has received my revocation will be valid. I have a right to receive a copy of this form. A photocopy of this form is as valid as the original form. Signature: Date: Print Name: If other than the Insured, please describe your legal authority to authorize the release of this information: (e.g., Conservator or Guardian of the person or estate of the Insured, person named under a Durable Power of Attorney, surviving spouse or other next-of-kin, etc.) Page 13

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