Fillable Form 164995: ENROLLMENT CHANGE FORM (Washington)

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Form 164995: ENROLLMENT CHANGE FORM (Washington)

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The Form 164995: ENROLLMENT CHANGE FORM (Washington) form is 4 pages long and contains:

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  • 30 check-boxes
  • 62 other fields

Country of origin: US
File type: PDF

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GEF02-1-WAHCA
ADM
SUBMISSION INSTRUCTIONS
After completion, make a copy for your records and return the original to
MetLife Recordkeeping Center, P.O. Box 14406, Lexington, KY 40512-4406.
Fax (859) 825-6719 Email: Southfield_RES@metlife.com.
WA State Health Care Authority PEBB
Page 1 of 4 EF-RES101M-NW (08/20)
Metropolitan Life Insurance Company, New York, NY 10166
ENROLLMENT • CHANGE FORM
GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper)
Name of Group Customer/Employer
WA State Health Care Authority PEBB
Group Customer #
164995
Report #
Sub Code
Branch
YOUR ENROLLMENT INFORMATION (To be Completed by the Employee)
Name (First, Middle, Last) Social Security #
– –
Male
Female
Address (Street, City, State, ZIP Code) Date of Birth (MM/DD/YYYY)
Phone # Email Address New Enrollment Change in Enrollment
If due to a Qualifying Event, enter event date (MM/DD/YYYY)
I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I u nderstand that no
contributions are required for Basic Life and Basic AD&D. I understand that contributions are required for the benefits I select below.
► If you are enrolling during the initial enrollment period, you must complete a Statement of Health form:
• If you are enrolling for more than $500,000 of Supplemental Life Insurance
• If you are enrolling for more than $100,000 of Dependent Spouse/State-Registered Domestic Partner Life Insurance
► If you are enrolling after the initial enrollment period, you must also complete a Statement of Health form for all amounts you are requesting.
Term Life Insurance
Basic Life
1
Supplemental Life
1
Enter a multiple of $10,000 up to a maximum of $1,000,000. $
Dependent Spouse/State-Registered Domestic Partner
2
Life
1,3
Enter a multiple of $5,000 up to a maximum of $500,000, not to exceed 50% of your life benefits. $
Dependent Child Life
3
Enter a multiple of $5,000 up to a maximum of $20,000. $
Accidental Death & Dismemberment (AD&D) Insurance
Basic AD&D
Supplemental AD&D
Enter a multiple of $10,000 up to a maximum of $250,000. $
Dependent Spouse/State-Registered Domestic Partner
2
AD&D
Enter a multiple of $10,000 up to a maximum of $250,000. $
Dependent Child AD&D
Enter a multiple of $5,000 up to a maximum of $25,000. $
1
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.
An interest and expense charge may be deducted from the accelerated payment. Receipt of accelerated benefits may affect eligibility for public assistance.
This benefit may be taxable and you are advised to seek assistance from a personal tax advisor.
2
State-Registered Domestic Partner means two adults who meet the requirements for a valid state-registered domestic partnership, and enter into a state-
registered domestic partnership, in the State of Washington; or a legal union, other than marriage, of two persons that was validly formed in a jurisdiction
other than the State of Washington and that is substantially equivalent to a domestic partnership in the State of Washington.
3
Amounts will be subject to state limits, if applicable.
GEF09-1-WAHCA
FW
WA State Health Care Authority PEBB
Page 2 of 4 EF-RES101M-NW (08/20)
Metropolitan Life Insurance Company, New York, NY 10166
Tobacco Use Status Information
Have you smoked cigarettes, pipes or cigars or used tobacco in any form in the past 2 months?
Yes No
Spouse/State-Registered
Domestic Partner
Yes No
If you are changing tobacco use status
Status is changing from: Tobacco User to Non-Tobacco User
Non-Tobacco User to Tobacco User
Change is for: Employee
Spouse/State-Registered Domestic Partner
Dependent Information
If you are applying for coverage for your Spouse/State-Registered Domestic Partner and/or Child(ren), please provide the information
requested below:
Name of your Spouse/State-Registered Domestic Partner (First, Middle, Last) Date of Birth (MM/DD/YYYY)
Male Female
Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY)
Male Female
Male Female
Male Female
Male Female
Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form.
GEF02-1-WAHCA
ADM
FRAUD WARNINGS
Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are
applying for coverage was issued.
Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, 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.
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 to the extent required by applicable law.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kansas and Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense
and may be subject to penalties under state law.
Kentu cky: 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.
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 Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.
New York (only applies to Accident and Health Insurance): 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.
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.
GEF09-1-WAHCA
DEC
WA State Health Care Authority PEBB
Page 3 of 4 EF-RES101M-NW (08/20)
Metropolitan Life Insurance Company, New York, NY 10166
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.
Vermont: Any person who knowingly presents a false statement in an application 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 the 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.
GEF09-1-WAHCA
FW
BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE
I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this
enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked.
I understand I have the right to change this designation at any time. I also understand that unless otherwise specified in the group insurance certificate,
insurance due upon the death of a Dependent is payable to the Employee.
Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page.
Full Name (First, Middle, Last)
Social Security #
Date of Birth (MM/DD/YY)
Relationship
Share %
Address (Street, City, State, ZIP Code)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth MM/DD/YY)
Relationship
Share %
Address (Street, City, State, ZIP Code)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (MM/DD/YY)
Relationship
Share %
Address (Street, City, State, ZIP Code)
Phone #
Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL:
100%
If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies):
Full Name (First, Middle, Last)
Social Security #
Date of Birth (MM/DD/YY)
Relationship
Share %
Address (Street, City, State, ZIP Code)
Phone #
Full Name (First, Middle, Last)
Social Security #
Date of Birth (MM/DD/YY)
Relationship
Share %
Address (Street, City, State, ZIP Code)
Phone #
Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL:
100%
GEF09-1-WAHCA
DEC
WA State Health Care Authority PEBB
Page 4 of 4 EF-RES101M-NW (08/20)
Metropolitan Life Insurance Company, New York, NY 10166
DECLARATIONS AND SIGNATURE
By signing below, I acknowledge:
1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.
2. I declare that I am actively at work on the date I am enrolling and, if I am enrolling for any contributory life insurance, that I was actively at work for at least
20 hours during the 7 calendar days preceding my date of enrollment. I understand that if I am not actively at work on the scheduled effective date of
insurance, such insurance will not take effect until I return to active work.
3. I understand that, 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.
4. I understand that if I do not enroll for life coverage during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I
am eligible, evidence of insurability satisfactory to MetLife may be required to enroll for 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.
5. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind
it in writing.
6. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.
7. I have read the applicable Fraud Warning(s) provided in this enrollment form.
Signature of Employee Print Name Date Signed (MM/DD/YYYY)
Sig n
Her e
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Form 164995: ENROLLMENT CHANGE FORM (Washington)

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Completed 19 February 2022

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