ENROLLMENT FORM FOR HOOD COLLEGE

Metropolitan Life Insurance Company, New York, NY
ENROLLMENT FORM FOR HOOD COLLEGE
SECTION TO BE COMPLETED BY EMPLOYER
Name of Employer (Please Print)
HOOD COLLEGE
Employer’s Street Address
City
401 Rosemont Avenue
Frederick
Date of Hire (Mo./Day/Yr.) Employee Base Annual
Salary (BAS)
$
Group Report No.
114240
State
MD
Employee’s Occupation:
Work Status:
Hours Worked Per Week:
New Hire
Rehire
Reason for Enrollment:
Active
Retired
Disabled
On Layoff/Leave of Absence
Sub Division
Branch
0001
0001
Zip Code
Employee Work Location
21701
Coverage Effective Date (Mo./Day/Yr.):
Hourly Paid
Salaried
Full-Time
Part-Time
New Coverage
New Hire First Time Eligible
Late Enrollee (Statement of Health Required)
Change in Coverage Amount Requested
Change in Enrollment Other Than Coverage Amount
Family Status Change (not applicable to new enrollments) Date (Mo./Day/Yr.)
SECTION TO BE COMPLETED BY EMPLOYEE
Name (print)
First
Middle
Address Street
Last
City
Social Security No.
State
E-mail Address
Zip Code
Date of Birth (Mo./Day/Yr.)
Male
Female
Marital
Single
Married
Status:
Widowed
Divorced
Phone No. (include area code)
COVERAGE REQUEST DATA:
I have received and read a copy of my employer’s current announcement of the group plan. I want to be covered under the group plan for the benefits
which I am or may become eligible, requested below.
I request the following coverage:
Employee Coverage
Basic Life (Employer Paid – 1x your Base Annual Salary up to a maximum of $125,000)
Accidental Death & Dismemberment (AD&D) (Employer Paid – 1x your Base Annual Salary up to a maximum of $125,000)
Optional Life (You may elect coverage from 1x to 5x your Base Annual Salary up to a maximum of the lesser of 5x your Base Annual Salary or
$600,000, combined with Basic Life Insurance. Note: (A Statement of Health form is required for coverage amounts exceeding 3x your Base Annual
Salary or $300,000, combined with Basic Life Insurance)
Select one coverage option:
1x
2x
3x
4x
5x Base Annual Salary
Long Term Disability (LTD) (Employer Paid – You are eligible for this coverage the first day of the 6 months after your Date of Hire)
Dependent Spouse Coverage
Dependent Spouse Life* (You may elect coverage in $10,000 increments up to a maximum of $100,000. Note: (Coverage amounts exceeding $10,000 require
a Statement of Health form. Employee MUST be enrolled in Optional Life to elect this coverage) Coverage Requested: $
Dependent Child Coverage
Dependent Child Life* (You may elect coverage in $5,000 increments up to a maximum of $25,000. Note: (Coverage amounts exceeding $10,000 require a
Statement of Health form. Employee MUST be enrolled in Optional Life to elect this coverage) Coverage Requested: $
*Amounts will be subject to state limits, if applicable (MD: Dependent Life amounts may not exceet the employee benefit amount.)
If applying for Dependent coverage (Spouse and Child), complete
section below:
Number of dependents (including spouse)
Name (Last, First, MI)
Date of Birth Sex (M/F)
If dependent children are full-time students in college, vocational or trade
school, please complete the following:
Child(ren)
Name of School
Spouse:
Child(ren):
GEF02-1
ADM
Please Retain A Copy Of The Fully-Completed Form For Your
Records And Return The Original To Your Employer
(Continued on Following Page)
1
Hood College (06/04)
Have you been Hospitalized (as defined below) during the 90 days
Employee
Spouse
Child(ren)
preceding the date of this enrollment form?
Yes
No
Yes
No
Yes
No
If the answer to the Hospitalization question is “Yes,” a Statement of Health form is required for each person answering “Yes.”
Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility; intermediate care facility, or long term care facility,
or receipt of the following treatments wherever performed: chemotherapy, radiation therapy, or dialysis.
GEF02-1
ADM
DECLARATION SECTION
Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge and
belief. Each person understands that this information will be used by MetLife to determine his or her insurability.
The employee declares that he or she is actively at work on the date of this enrollment form. For any contributory life insurance only, the employee
has been actively at work for at least 20 hours during the 7 calendar days preceding that date. If Hospitalized during the 90-day period preceding the
date of this enrollment form, such insurance will not take effect until MetLife receives evidence of good health satisfactory to MetLife.
On the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s 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.
For the Accelerated Benefits Option
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. Receipt of accelerated benefits may affect eligibility for public assistance and that an interest and expense charge may be deducted from the
accelerated payment.
For Changes Requested After Initial Enrollment Period Expires
I understand that if life or disability coverage is not elected, or if the maximum coverage is not elected, evidence of good health satisfactory to MetLife
may be required to elect 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.
For Payroll Deduction Authorization By the Employee
I authorize my employer to deduct the required contributions from my pay for the coverage requested in this enrollment form. This authorization
applies to such coverage until I rescind it in writing.
Fraud Warning:
If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.
New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: 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, 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.
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.
Massachusetts: 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, and may subject such person to criminal and civil penalties.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
Oklahoma: 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.
Kansas and Oregon: 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 may be guilty of insurance fraud, and may be subject to criminal and civil penalties.
Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application
containing a false or deceptive statement may have violated state law.
In any other case, read the following warning.
GEF02-1a
DEC
Metropolitan Life Insurance Company, New York, NY
2
MD
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 any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
GEF02-1a
DEC
Metropolitan Life Insurance Company, New York, NY
3
MD
BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE (Dependent Insurance is Payable to the Employee)
The Employee signing below names the following person(s) as primary beneficiary(ies) for any MetLife payment upon his or her death. For any other
type of beneficiary, please use a beneficiary designation form available from your employer. Unless designated otherwise, payments will be made in
equal shares or all to the survivor. The Employee understands that he or she has the right to change this designation at any time.
Primary Beneficiary Full Name (Last, First, Middle Initial)
Relationship
Date of Birth
Address (Street, City, State, Zip)
(Mo./Day/Yr.)
Signature(s): The employee must sign in all cases. Each person signing below acknowledges that they have read and understand the statements
and declarations made in this enrollment form.
Employee Signature
Print Name
Date (Mo./Day/Yr.)
Proposed Insured(s) if other than employee and at least 18 years of age:
Other Signature
Print Name
Date (Mo./Day/Yr.)
Other Signature
Print Name
Date (Mo./Day/Yr.)
GEF02-1a
DEC
Metropolitan Life Insurance Company, New York, NY
4
MD
PRIVACY NOTICE
If you submit a request for insurance (enrollment form, and if applicable, Statement of Health form) we will evaluate it. We will
review the information you give to us and we may confirm it or add to it in the ways explained below.
This Privacy Notice is given to you on behalf of each of these companies:
Metropolitan Life Insurance Company
Paragon Life Insurance Company
Please read this Privacy Notice carefully. It describes how we learn about you and how we treat that information. (If anyone else is
proposed for insurance, what we say here also applies to information about them.)
Why We Need Information: We need to know about you (and anyone else to be insured) so that we can provide the insurance and other
products and services you’ve asked for. We may also need it to administer your business with us, evaluate claims, process transactions
and run our business. And we need information from you and others to help us verify identities in order to prevent money laundering and
terrorism.
What we need to know includes address, age and other basic information. But we may need more information, including finances,
employment, health, hobbies or business conducted with us, with other MetLife companies (our “affiliates”) or with other companies.
How We Get Information: What we know about you (and anyone else to be insured) we get mostly from you. But we may also have to
find out more from other sources in order to make sure that what we know is correct and complete. Those sources may include adult
relatives, employers, consumer reporting agencies, health care providers and others. Some of our sources may give us reports and may
disclose what they know to others. We may ask for medical information about you from these sources. The Authorization that you sign
when you request insurance permits these sources to tell us about you. So we may, for instance:
•
•
Ask for a medical exam
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 “consumer report” about you (or anyone else to be insured). Consumer reports may
tell us about a lot of things, including information about your finances, employment, hobbies, mode of living, work history, and driving
record.
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 Group, Inc. (“MIB”). It is a non-profit association of life insurance companies. We and our
reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or
claim benefits from another member company, MIB will give that company any information it has about you. If you contact MIB, it will tell
you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc.,
P.O. Box 105, Essex Station, Boston, MA 02112, by calling MIB at (617) 426-3660, or by contacting MIB at www.mib.com.
How We Protect What We Know: We treat what we know about you confidentially. Our employees are told to take care in handling your
information. They may get information about you only when there is a good reason to do so. We take steps to make our computer data
bases secure and to safeguard the information we have.
CPN-ENROLL
How We Use and Disclose What We Know About You: We may use what we know about you to help us serve you better. We may use
it, and disclose it to our affiliates and others, for any purpose allowed by law. For instance, we may use your information, and disclose it to
others, in order to:
•
Help us evaluate your request for a product or service
•
Help us run our business
•
Help us process claims and other transactions
•
Process information for us
•
Confirm or correct what we know about you
•
Perform research for us
•
Help us prevent fraud and other crimes
•
Audit our business
•
Help us comply with the law
Other reasons we may disclose what we know about you include:
•
•
•
•
•
•
•
Doing what a court or government agency requires us to do; for example, complying with a search warrant or subpoena
Telling another company what we know about you, if we are or may be selling all or any part of our business or merging with another
company
Giving information to the government so that it can decide whether you may get benefits that it will have to pay for
Telling a group customer about its members’ claims or cooperating in a group customer’s audit of our service
Telling your health care provider about a medical problem that you have but may not be aware of
Giving your information to a peer review organization if you have health insurance with us
Giving your information to someone who has a legal interest in your insurance, such as someone who lent you money and holds a lien
on your policy
Generally, we will disclose only the information we consider reasonably necessary to disclose.
We may use what we know about you in order to offer you our other products and services. We may disclose this information (other than
consumer reports and health information) to our affiliates so that they can offer their products and services, or ours, to you. Unless
applicable law requires otherwise, we don’t have to let you prevent these disclosures. Our affiliates include life, car and home insurers,
securities firms, broker-dealers, a bank, a legal plans company and financial advisors. In the future, we may have affiliates in other
businesses.
We may also provide information to others outside of the MetLife companies, such as marketing companies, to help us offer our products
and services to you. If we have joint marketing agreements with other financial services companies, we may give them information about
you so that they can offer their products and services to you. Except for joint marketing arrangements, we do not make any other
disclosures of your information to other companies who want to sell their products or services to you. For example, we will not sell your
name to a catalog company. And we will not disclose any consumer report or health information to other companies so that they can
offer their products and services, or ours, to you.
You Can See and Correct Your Information: Generally, we will let you review what we know about you if you ask us in writing. (Because
of its legal sensitivity, we will not show you anything that we learned in connection with a claim or lawsuit.) Also, if the law allows us to do
so, we may decide to disclose what we know about your health only through your health care provider. If you tell us that what we know
about you is incorrect, we will review it. If we agree with you, we will correct our records. If we do not agree with you, you may tell us in
writing, and we will include your statement in any future disclosure of Information.
You Can Get Other Material from Us: This is a general description of our information practices. We treat your information in accordance
with applicable laws. You may have other rights under the law. If you want to know more about our privacy policy, please contact us at
our website, www.metlife.com, or write to us at MetLife, c/o MetLife Privacy Office, P.O. Box 2006 Aurora, Illinois 60507-2006.
2
CPN-ENROLL