"Group Term Life Insurance Beneficiary Designation Form - Metlife"

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Metropolitan Life Insurance Company
Group Term Life Insurance Beneficiary Designation
Use this form to name the persons or entities you want to receive your life
insurance proceeds after your death.
Things to know before you begin
• Completing this form replaces your existing beneficiary designations. Please
provide details for each beneficiary, even if you have already given us this
information in the past.
• Gather the name(s), date(s) of birth, Social Security/Tax ID number(s) and
contact information for all of your beneficiaries.
• The beneficiaries you name on this form apply to your Group Term Life
insurance coverage insured by MetLife.
• To name additional beneficiaries, attach a separate page. Provide the
requested information including the beneficiary type (primary or contingent)
and the % proceeds for each. Sign and date these page(s), making sure the
If you make a mistake
date is the same as the date next to the signature on this form.
anywhere on this form,
• Please complete and return all pages or we cannot record your choices.
cross it out and initial it.
SECTION 1: About the Insured
First name
Middle name
Last name
Date of birth (mm/dd/yyyy)
Social Security number
Phone number
Address
City
State
ZIP
Employer name
Customer number
Washington State Health Care Authority
164995
SECTION 2: About the Plan
The beneficiaries you name on this form apply only to the MetLife-insured plan(s) selected below:
All group term life coverage currently in effect
OR
Basic Life
Basic Accidental Death & Dismemberment (AD&D)
Optional Life
Optional Accidental Death & Dismemberment (AD&D)
Retiree Life
To name separate beneficiaries for the Life or AD&D coverages in this section, photocopy this form and complete a
different form for each type of coverage.
SECTION 3: About the Primary Beneficiaries
These parties are your first choice to receive the insurance proceeds after your death. If a primary beneficiary dies
before you, we will divide their share(s) equally between the remaining primary beneficiaries.
• You must name at least one (1) primary beneficiary.
• Please check the box and complete the form fields for each beneficiary you name. Having accurate information
for your beneficiaries ensures that we distribute the proceeds the way you want.
• Use the proceeds % field to tell us how you want us to distribute the proceeds. If you want a specific distribution,
use whole numbers (no fractions or decimals) and make sure they (and any listed on separate pages) add up to 100%.
To distribute them equally between your primary beneficiaries, leave all of the proceeds % fields blank.
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GR-TR-BENE-MET1-WA-HCA
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Metropolitan Life Insurance Company
Group Term Life Insurance Beneficiary Designation
Use this form to name the persons or entities you want to receive your life
insurance proceeds after your death.
Things to know before you begin
• Completing this form replaces your existing beneficiary designations. Please
provide details for each beneficiary, even if you have already given us this
information in the past.
• Gather the name(s), date(s) of birth, Social Security/Tax ID number(s) and
contact information for all of your beneficiaries.
• The beneficiaries you name on this form apply to your Group Term Life
insurance coverage insured by MetLife.
• To name additional beneficiaries, attach a separate page. Provide the
requested information including the beneficiary type (primary or contingent)
and the % proceeds for each. Sign and date these page(s), making sure the
If you make a mistake
date is the same as the date next to the signature on this form.
anywhere on this form,
• Please complete and return all pages or we cannot record your choices.
cross it out and initial it.
SECTION 1: About the Insured
First name
Middle name
Last name
Date of birth (mm/dd/yyyy)
Social Security number
Phone number
Address
City
State
ZIP
Employer name
Customer number
Washington State Health Care Authority
164995
SECTION 2: About the Plan
The beneficiaries you name on this form apply only to the MetLife-insured plan(s) selected below:
All group term life coverage currently in effect
OR
Basic Life
Basic Accidental Death & Dismemberment (AD&D)
Optional Life
Optional Accidental Death & Dismemberment (AD&D)
Retiree Life
To name separate beneficiaries for the Life or AD&D coverages in this section, photocopy this form and complete a
different form for each type of coverage.
SECTION 3: About the Primary Beneficiaries
These parties are your first choice to receive the insurance proceeds after your death. If a primary beneficiary dies
before you, we will divide their share(s) equally between the remaining primary beneficiaries.
• You must name at least one (1) primary beneficiary.
• Please check the box and complete the form fields for each beneficiary you name. Having accurate information
for your beneficiaries ensures that we distribute the proceeds the way you want.
• Use the proceeds % field to tell us how you want us to distribute the proceeds. If you want a specific distribution,
use whole numbers (no fractions or decimals) and make sure they (and any listed on separate pages) add up to 100%.
To distribute them equally between your primary beneficiaries, leave all of the proceeds % fields blank.
Page 1 of 4
GR-TR-BENE-MET1-WA-HCA
(02/16) Fs
About the Primary Beneficiaries (continued)
Individual
First name
Middle name
Last name
A
Address
Date of birth (mm/dd/yyyy)
Write in
the % of
proceeds
City
State
ZIP
assigned
to this
person
Gender
Social Security number
Phone number
Relationship to Insured
%
M
F
Individual
First name
Middle name
Last name
B
Address
Date of birth (mm/dd/yyyy)
Write in
the % of
proceeds
City
State
ZIP
assigned
to this
person
Gender
Social Security number
Phone number
Relationship to Insured
%
M
F
Individual
First name
Middle name
Last name
C
Address
Date of birth (mm/dd/yyyy)
Write in
the % of
proceeds
City
State
ZIP
assigned
to this
person
Social Security number
Phone number
Relationship to Insured
Gender
%
M
F
D
Your Estate –
If you name your Estate as a primary beneficiary, you cannot name a
contingent beneficiary.
Proceeds
%
E
Testamentary Trust created in your Will –
The trust under your last Will and Testament
as shall be admitted to probate.
Proceeds
%
F
Living (Inter Vivos) Trust –
See further instructions on page 4.
Proceeds
%
G
Charity/Organization –
List the charity or organization name and not an employee of the
charity or organization. See further instructions on page 4.
Proceeds
%
100%
Total proceeds for all primary beneficiaries (A-G plus any listed on separate pages) must equal 100%.
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GR-TR-BENE-MET1-WA-HCA
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SECTION 4: About the Contingent Beneficiaries
Skip this section if you’re not naming a contingent beneficiary or if you named your Estate as a primary beneficiary.
Contingent beneficiaries receive the insurance proceeds only if all of the primary beneficiaries are deceased at the
time of your death. If a contingent beneficiary dies before you, we will divide their share(s) equally between the
remaining contingent beneficiaries.
• Please check the box and complete the form fields for each beneficiary you name. Having accurate information
for your beneficiaries ensures that we distribute the proceeds the way you want.
• Do not list the same person or entity as both a primary and a contingent beneficiary.
• Use the proceeds % field to tell us how you want us to distribute the proceeds. If you want a specific distribution,
use whole numbers (no fractions or decimals) and make sure they (and any listed on separate pages) add up to 100%.
To distribute them equally between your contingent beneficiaries, leave all of the proceeds % fields blank.
Individual
First name
Middle name
Last name
H
Date of birth (mm/dd/yyyy)
Address
Write in
the % of
proceeds
City
State
ZIP
assigned
to this
person
Social Security number
Phone number
Relationship to Insured
Gender
%
M
F
Individual
First name
Middle name
Last name
I
Address
Date of birth (mm/dd/yyyy)
Write in
the % of
proceeds
City
State
ZIP
assigned
to this
person
Gender
Social Security number
Phone number
Relationship to Insured
%
M
F
J
Your Estate
Proceeds
%
K
Testamentary Trust created in your Will –
The trust under your last Will and Testament
as shall be admitted to probate.
Proceeds
%
L
Living (Inter Vivos) Trust –
See further instructions on page 4.
Proceeds
%
M
Charity/Organization –
List the charity or organization name and not an employee of the
charity or organization. See further instructions on page 4.
Proceeds
%
100%
Total proceeds for all contingent beneficiaries (H-M plus any listed on separate pages) must equal
100%.
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GR-TR-BENE-MET1-WA-HCA
(02/16) Fs
SECTION 5: About your Trust/Charity/Organization Beneficiaries
Skip this section if you did not name a Living Trust or Charity/Organization as one of your beneficiaries.
Otherwise, please provide the information requested below on a separate page. Make sure you include the
type of beneficiary (primary or contingent) and that you sign and date these page(s).
Please include:
Additional information required for Living (Inter Vivos) Trust(s):
• Trust/Charity/Organization name
• Trust date
• Address
• Trust Tax ID number
• Phone number
• Trustee first, middle and last name
• Type of Beneficiary (primary or contingent)
• % of proceeds you are assigning to the
Trust/Charity/Organization
SECTION 6: Signature required
By signing below, I hereby revoke any previous designations, and I designate the person, people, or entity
named herein as beneficiaries.
Check if you are completing and signing this form as agent for the insured under a valid Power of Attorney.
Please submit a copy of the Power of Attorney with this beneficiary form.
Please print and sign below
Insured/Owner first name
Middle name
Last name
Insured/Owner signature
Date form completed (mm/dd/yyyy)
Did you remember to…
ü
Provide complete information for each of your beneficiaries?
ü
Make sure the total “proceeds %” for your primary beneficiaries (including those on a separate
page) equals 100%? Separately, did you remember to make sure the total “proceeds %” for your
contingent beneficiaries (including those on a separate page) equals 100%?
ü
Complete, sign and date any extra pages that list beneficiary information (such as Living Trust/
Charity/Organization beneficiaries)?
ü
Cross out and initial any mistakes you made? (If you crossed out any answers, your signature is not
enough. You must also initial all your corrections.)
HM `
answer corrected, initials required
12/20/25 12/20/15
Example:
Please note: we cannot record your beneficiary choices unless you complete these items.
SECTION 7: How to submit this form
Mail:
MetLife Recordkeeping & Enrollment Services
P.O. Box 14406
Lexington, KY 40512-4406
Be sure to keep a copy of this completed form for your records.
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