Fillable CII Health Screen Benefit CLAIM FORM Met Life

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CII Health Screen Benefit CLAIM FORM Met Life

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The CII Health Screen Benefit CLAIM FORM Met Life form is 3 pages long and contains:

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  • 40 other fields

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HSB-CII-INGENIUM-GENERIC-NW (01/21)
Page 1 of 3
Fs/f
Critical Illness Insurance
Health Screening Benefit Claim Form
Please complete this form in its entirety
Metropolitan Life Insurance Company
Return completed form
by fax or mail.
SECTION 1: Certificateholder Information
Certificateholder - First Name Middle Name Last Name
Certificate Number
Street Address City State ZIP Code
Date of Birth (mm/dd/yyyy)
Gender
Male Female
Social Security Number
Cell Phone Number Daytime Phone Number Evening Phone Number
Email Address (Optional)
Employer Name
SECTION 2: Patient Information (If certificateholder is the patient, no need to complete the below)
First Name Middle Name Last Name
Daytime Phone Number Evening Phone Number Relationship to Insured
SECTION 3: Medical Information
If a covered person undergoes a covered Health Screening test while such covered person is insured under
this Policy, the following information must be provided to Us regarding the covered test performed.
Physician's Name
Address City State ZIP Code
Phone Number
Name of Testing Facility (If different from physician office)
Address City State ZIP Code
Phone Number
HSB-CII-INGENIUM-GENERIC-NW (01/21)
Page 2 of 3
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Date of Health Screening Test (Required) (mm/dd/yyyy) Test Type (Required)
Date of Health Screening Test (Required) (mm/dd/yyyy) Test Type (Required)
SECTION 4: Fraud Warning
Before signing this claim form, please read the warning for the state where you reside and for the state where
the insurance policy under which you are claiming a benefit was issued.
Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, 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.
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 a loss is subject to
criminal and civil penalties.
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 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.
Delaware, Idaho, Indiana and 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.
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.
Kentucky: Any person who knowingly and with 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, 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 Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a
statement of claim containing any 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 any false or misleading
information is subject to criminal and civil penalties.
Oregon: Any person who knowingly presents a materially false statement of claim may be guilty of a criminal
offense and may be subject to penalties under state law.
HSB-CII-INGENIUM-GENERIC-NW (01/21)
Page 3 of 3
Fs/f
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.
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.
Vermont: Any person who knowingly presents a false statement of claim 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 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.
SECTION 5: Certification and Signature
By signing below, I acknowledge:
• All information I have given is true and complete to the best of my knowledge and belief.
• I have read the applicable Fraud Warning(s) provided in this form. New York Residents: 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
claim for each such violation.
Under penalties of perjury, I certify that:
1.
That the number shown on this form is my correct Taxpayer Identification / Social Security Number; and
2. That I am not subject to IRS required backup withholding as a result of failure to report all interest or
dividend income; and
3. I am a U.S. citizen, or a U.S. resident for tax purposes.
Please note: If item 2 or 3 above is not true, cross out the applicable item(s). The IRS does not
require your consent to any provision of this document other than the certification to avoid backup withholding
.
Name of Claimant (Please print)
First Name Middle Name Last Name
Signature of Claimant or Authorized Representative
Social Security Number
Date (mm/dd/yyyy)
If signed by Authorized representative, describe your authority and provide documentation
(e.g., guardian, conservator, power of attorney, etc.)
SECTION 6: How to Submit This Form
Mail:
Critical Illness Insurance Service
P.O. Box 6120
Scranton, PA 18505-9972
Toll Free Phone:
1-800-GET-MET8
Fax:
1-866-268-2621
Email:
CItampa@metlife.com
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CII Health Screen Benefit CLAIM FORM Met Life

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Completed 1 March 2022

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