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Appointment Form Only
Metropolitan Life Insurance Company
This form cannot act as an
authorization to assign commissions.
Steps to obtain an appointment:
Complete the personal information sheet entirely:
The Personal Information Sheet is used to obtain information necessary to establish an appointment with
Metropolitan Life Insurance Company ("MLIC") and/or its affiliate Safeguard DHMO. The application on page
2 must be completed in its entirety as applicable. If you are requesting an appointment for only the producer,
then only the producer fields need to be completed. If the request for appointment includes the agency, all
fields need to be completed.
Page 3 must be executed by appropriate parties.
Page 4, the Disclosure/Authorization form, must be executed by the appointment applicant.
Pages 5 and 6, the HIPAA Business Associate Agreement, must be executed by appointment applicant who
will be involved in the sale of Dental or Long-Term Care products.
Page 7, must be completed if the request includes the agency.
The applicant must be licensed in the state for which the appointment is being requested.
This application will serve as an appointment request for your resident state. Non-resident state appointments
will be processed on as needed basis, which will be determined by MetLife.
Puerto Rico
For all other states, the appointment request must be made no later than MetLife's receipt of the
customer application.
vice Delivery Center
Attn: Corporate Licensing &
500 Schoolhouse Road
Johnstown, PA 15904
Email only:
PAI (03/21)
When do you request an appointment?
For the states listed below (pre-appointment),
a producer must be licensed and appointed with the applicable
insurer of the product(s) in which the customer application is being ex
ecuted for MLIC and/or SafeGuard Health
Plans, Inc. prior to the customer application being executed.
Pre-Appointment States:
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Appointment Form Only
Metropolitan Life Insurance Company
Things to know before you begin
This application will serve as an appointment request for your
resident state.
Non-resident state appointments will be processed on as needed
basis, which will be determined by MetLife.
Please type or print
You are requesting an appointment with Metropolitan Life Insurance Company (“MLIC”) and/or its
affiliates. Please check the appropriate coverage(s) for which you are requesting an appointment:
MLIC Group Life/Health/Disability/MetLife Dental
SECTION 1: Producer
Producer - First name
Middle name Last name
Date of birth (mm/dd/yyyy)
Social security number E-mail address
Business street address Required City State ZIP
Resident street address City State ZIP
SECTION 2: Agency
Principal officer - First name
Middle name
Last name
Social security number
License number
Agency name
Agency tax I.D. number
Business phone
Business fax
Business street address Required
Business P.O. box if applicable
P.O. box City
Business phone Business fax
Please check which is applicable:
Safeguard DHMO (available only in CA, FL and TX)
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Individual (Printed name)
Signature of Individual
Date (mm/dd/yyyy)
Name of agency company officer (Printed name)
Signature of Agency Company Officer
Date (mm/dd/yyyy)
Producer resident state license number
Agency resident state license number
SECTION 3: Licensing**
Producer non-resident state and state license number(s) (Only required if business is pending in a non-
resident state.)
Agency non-resident state and state license number(s) (Only required if business is pending in a non-
resident state.)
SECTION 4: Acknowledgement and authorization
I hereby certify that I have read and understand the items on this appointment form and that my answers are true
and complete to the best of my knowledge. I have been advised that Metropolitan Life Insurance Company and/
or its affiliates (collectively “MetLife”) may conduct investigations in connection with my request to represent
MetLife in the solicitation of certain products. I authorize an inquiry to be made of all sources deemed appropriate
by MetLife for the purpose of obtaining information concerning my business practices and ethics, background,
credit history, and financial status, including, but not limited to, my record, if any, on file with the FINRA Central
Records Depository. Any information that MetLife may obtain about me will be treated as confidential and may
be shared with the appointing general agent, if necessary. I release the broker/dealer and/or its agents and any
person or entity, which provide information pursuant to this authorization, from any and all liabilities, claims or
lawsuits in any matter related to the i formation obtained from any and all of the above referenced sources used.
I understand that no right to commission or other compensation shall arise or exist until I have been appointed
and all due diligence successfully approved. If I am approved, I shall accept as full compensation for all services
to be performed by me, the compensation provided in the applicable commission and compensation schedule
as issued, substituted or changed. As an appointed producer, I shall observe and be bound by the rules of
FAIR CREDIT REPORTING ACT - As part of its regular procedures, MetLife may obtain an investigative
consumer report. It may deal with character, reputation, personal traits and life style. It may involve personal
interviews with friends, neighbors and associates. I understand I have the right to make, within a reasonable
amount of time, a written request for details on the name and address of the agency making the report. I further
understand that depending on the state law, subjects of an investigative consumer report may have the right to:
1) request that they be interviewed in connection with the making of the report; and 2) receive a copy of the
report, upon request. My signature below constitutes my agreement and authorization to above. I understand
that if any of the material information I provided is found to be incorrect or incomplete, MetLife may at its
discretion not appoint and/or contract with me or terminate my appointment and/or contract.
I agree to conduct my business in accordance with applicable laws and standards set forth by MetLife.
First name
Middle name
Last name
First name
Middle name
Last name
*For P&C appointments, please contact MAH Contracting (800) 638-3012/
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PAI (03/21)
Date (mm/dd/yyyy)
SSN of applicant
Signature of Applicant
Last name
Printed name of applicant - First name Middle name
MetLife Institutional U.S. Business
Sales and Broker Compensation Services
By this document, Metropolitan Life Insurance Company on behalf of itself and its affiliates (collectively
“MetLife”) discloses to you that a consumer report or an investigative consumer report containing information
as to your character, general reputation, personal characteristics and mode of living, is part of the process of
our consideration of your application to become licensed or appointed to sell insurance and/or other products or
to become registered with the Financial Industry Regulatory Authority. A consumer report or an investigative
consumer report may be secured as part of a pre-appointment background investigation and at any time during
your appointment with MetLife. Should an investigative consumer report be requested, you will have the right to
demand a complete and accurate disclosure of the nature and scope of the investigation requested and a
written summary of your rights under the Fair Credit Reporting Act.
Acknowledgment and authorization
I acknowledge receipt of the above disclosure by MetLife, that a consumer report or an investigative consumer
report may be obtained by it as part of the process of its consideration of my application to become licensed or
appointed to sell insurance and/or other products or to become registered with the Financial Industry Regulatory
Authority. A consumer report or an investigative consumer report may be secured as part of its pre-appointment
background investigation, and at any time during my appointment with MetLife. I authorize the procurement of
such consumer reports by MetLife for the purposes disclosed to me.
I hereby authorize MetLife to query my record, if any, on file with the Financial Industry Regulatory Authority.
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HIPAA Business Associate Agreement
This Agreement is made between METROPOLITAN LIFE INSURANCE COMPANY and its affiliates
(“MetLife”), and the party identified below as the producer (“Producer”).
WHEREAS, MetLife and Producer have one or more agreements in place (collectively, the “Contract”)
whereby Producer agreed to provide certain services for MetLife which may involve the use and/or disclosure of
Customer Information and Protected Health Information (“PHI”) as defined below, and whereby Producer may
have access to certain information about individuals who have applied for or are covered by an insurance
product underwritten by MetLife; and
WHEREAS, MetLife and Producer desire to protect the confidentiality of any Customer Information or PHI
disclosed to Producer pursuant to the Contract and to satisfy requirements of the Health Insurance Portability
and Accountability Act of 1996 (“HIPAA”) and as amended by the Health Information Technology for Economic
and Clinical Health Act ("HITECH Act"),
NOW, THEREFORE, MetLife and Producer hereby agree as follows:
Capitalized terms not defined herein that are defined in the Contract shall have the meanings ascribed to
them in the Contract.
Producer agrees to treat all information about individuals who enroll, apply for or purchase MetLife’s products
or services that Producer may have or may obtain in connection with its obligations under the Contract
(“Customer Information”) as confidential. Customer Information may include, but is not limited to, an
individual’s name, address, social security number, and any financial or health information relating to the
individual. Producer may use Customer Information only for the purpose of fulfilling its obligations under the
Contract and Producer may not disclose Customer Information to anyone other than the individual to whom
the information relates, except as required for Producer to fulfill its obligations under the Contract or as
otherwise directed by MetLife, or except as expressly required by law. Producer must also ensure that
Customer Information is kept in a secure manner.
PHI is defined as individually identifiable information that is transmitted or maintained in any medium and
relates to: the past, present or future physical or mental health or condition of an individual; the provision of
health care to an individual; or past, present, or future payment for the provision of health care to the
individual. MetLife and Producer understand that this definition of PHI includes demographic information
about the individual, including names; geographic subdivisions smaller than a state (including but not
limited to street addresses and ZIP codes); all elements of dates (except year) for dates directly related to an
individual, including but not limited to birth date; telephone numbers; fax numbers; electronic mail (E-mail)
addresses; Social Security numbers;Medical record numbers; health plan beneficiary numbers; account
numbers; certificate/license numbers; vehicle identifiers and serial numbers, including license plate numbers;
device identifiers and serial numbers;Web Universal Resource Locators (URLs); Internet Protocol (IP)
address numbers; biometric identifiers, including finger and voice prints; full face photographic images and
any comparable images; and any other unique identifying number, characteristic, or code.
In order to further protect the confidentiality of any PHI disclosed to or used by Producer pursuant to the
Contract and to satisfy requirements of HIPAA, MetLife and Producer agree to the following with respect to
any PHI received or created by Producer in providing services pursuant to the Contract, including PHI
received or created prior to the effective date of the Contract (“MetLife PHI”): (a) the obligations regarding
MetLife PHI contained in this Agreement shall be in addition to any other obligations contained in the
Contract that apply to MetLife PHI; (b) Producer may not use or disclose MetLife PHI except to provide
services pursuant to the Contract; (c) Producer shall use appropriate safeguards to prevent use or disclosure
of MetLife PHI; (d) MetLife and Producer represent and warrant that their security procedures are adequate
to protect and maintain the confidentiality of MetLife PHI; (e) Producer shall promptly report to MetLife any
use or disclosure of MetLife PHI not permitted by this Agreement of which it becomes aware; (f) Producer
shall ensure that any Agents, including any sub-contractors or Producer affiliates, that Producer may use in
accordance with the Contract and to whom Producer provides MetLife PHI or who uses MetLife PHI has
been approved by MetLife in writing and agrees to the same restrictions and conditions that apply to
Producer with respect to MetLife PHI pursuant to this Agreement; (g) within thirty (30) days of MetLife’s
request, Producer shall provide to MetLife any MetLife PHI or information relating to MetLife PHI as deemed
necessary by MetLife to comply with its obligations under HIPAA to provide individuals with access to,
amendment of, and an accounting of disclosures of their MetLife PHI, and Producer agrees to incorporate
any amendments of the MetLife PHI as requested by MetLife; (h) Producer agrees to make its internal
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PAI (03/21)
Printed Name
Jamie Madden
Signature of Vice President (Metropolitan Life Insurance Company)
Date (mm/dd/yyyy)
SSN of Producer
TIN of Agency
Signature of Producer
Date (mm/dd/yyyy)
practices, books, and records relating to its use or disclosure of MetLife PHI available to the Secretary of the
United States Department of Health and Human Services at his/her request to determine MetLife’s
compliance; (i) Producer agrees that upon termination of the Contract it will, if feasible, return or destroy all
MetLife PHI it maintains in any form and retain no copies, and if such return or destruction is not feasible,
Producer agrees to extend the protections of this Agreement to the MetLife PHI beyond the termination of the
Contract and for as long as Producer has MetLife PHI, and further agrees that any further use or disclosure
of the MetLife PHI will be solely for the purposes that make return or destruction infeasible; (j) Producer
agrees that it will not disclose MetLife PHI, other than enrollment information, to an employer or plan
sponsor, unless the employer or plan sponsor has taken the steps required by HIPAA to permit disclosure to
the employer or plan sponsor; (k) Producer may use or disclose MetLife PHI to the extent that such use or
disclosure is required by law and the use or disclosure complies with and is limited to the relevant
requirements of such law, and only to the extent that such use or disclosure complies with any applicable
HIPAA requirements relating to uses and disclosures required by law; and (l) Producer shall (1) implement
administrative, physical, and technical safeguards that reasonably and appropriately protect the
confidentiality, integrity, and availability of any electronic MetLife PHI that Producer creates, receives,
maintains, or transmits on behalf of MetLife; (2) ensure that any agent of Producer, including any
subcontractor or Producer affiliate to whom Producer provides electronic MetLife PHI, agrees to implement
reasonable and appropriate safeguards to protect electronic MetLife PHI; and (3) report to MetLife any
security incident related to electronic MetLife PHI of which Producer becomes aware.
Producer agrees and acknowledges that it is directly subject to HIPAA as amended by the HITECH Act,
including its provisions relating to security and privacy of PHI as well as its enforcement and penalty
provisions. Producer agrees that it will: (a) comply with all applicable security and privacy provisions of
HIPAA as amended by the HITECH Act and as it may be amended from time to time; (b) not act in any way
to interfere with or hinder MetLife's ability to comply with HIPAA as amended by the HITECH Act and as it
may be amended from time to time; and (c) notify MetLife within five (5) business days of discovering a
“breach” as that term is defined in Section 13400 of the HITECH Act at the following e-mail address:
In the event Producer learns of a pattern of activity or practice of MetLife that constitutes a material breach or
violation of its obligations relating to PHI under the Agreement, Producer will take reasonable steps to cure
the breach or end the violation. If such steps are unsuccessful, Producer will terminate the Agreement, if
feasible, or, if termination is not feasible, report the problem to the Secretary of the Department of Health and
Human Services (“HHS”).
If Producer conducts in whole or part electronic transactions on behalf of MetLife for which HHS has
established standards, Producer will comply, and will require any subcontractor, vendor, or agent it involves
with the conduct of electronic transactions to comply, with each applicable requirement of the Electronic
Transactions Rule at 45 C.F.R. Part 162.
Producer - First Name (Printed) Middle Name Last Name
Agency - Name (Printed)
Vector One Operations, LLC dba Vector One (collectively with its affil iates, "Vector One") manages the secured web portal interactive, LLC("DebitCheck"). ThisDebitCheckAgent/AgencyAuthorization Formis byandamong
theundersigned("you","me","I"or"my"),VectorOne,and theCompany(asdefinedbelow) andisusedbyDebitChecksubscriberswho
desiretobe grantedauthorizationfromyo
uforthesubmissionand/or receipt ofyourpersonalinformationtotheDebitCheck serviceas
e"Company")isaDebitChecksubscriber.Accordingly,aspartofthecontractingandappointment processordetermination
cescreeningsasdeterminedin the
Company's sole discretion following the engagement of any employment, appoint ment, contract, tenure, or other relationship with the
AccesstoDebitCheckInformat ion:Youcanobtainyourc ommissionrelateddebitbalanceinformationbycontactingtheVector OneAgent
may obtain commission related debit balance information through DebitCheck as state law allows. I understand that my information,
related debit balance screening. I further understand that in the event of termination or expiration of my employment, appointment,
rvicewhichmaybe accessedbyDebitChecksubscribersuntil
(A) ________Authori zetheCompanytouseMyInformationforpurposesofconductingacommissionrelateddebitbalance
screening, and periodic commission related debit balance screenings as determined in the Company’s sole discretion following the
(B) ________AuthorizetheCompanytoconsiderthe resultsofthecommissionrelateddebitbalancescreeninginorderto
(C) ________AuthorizeanddirectVectorOnetoreceiveandprocess MyInformationasnecessarytointentionallydisclose
(D) ________ Authorize the Company to submit My Information to the DebitCheck service in the event of termination or
(E) ________AuthorizeanddirectVectorOnetoreceiveandprocessMyInformationandintentionallydisclosetoanyDebit
Signature: Date:
Agency Name: _______________________________________________________________________________________
Agency TIN: ______________________________________
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PAI (03/21)