Fill - Free fillable Form 35370: ENROLLMENT CHANGE FORM MEMBER ENROLLMENT INFORMATION PDF form

GEF02-1

ADM

(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; and

GEF02-1

ADMapplies to residents of North Dakota and Utah)

SUBMISSION INSTRUCTIONS

After completion, sign and date the form on the last page where indicated. Make a copy for your records and return to:

Mercer Consumer, P.O. Box 9186, Des Moines, IA, 50306-9186.

Please note that coverage may not be available in all states. See your plan administrator for additional information.

NYSUT

Page 1 of 4 LMI-EF-NY (03/18)

Metr

opol

an L

ife Insurance Company, New York, NY 10166

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION

Name of Policyholder:

NYSUT Member Benefits Trust

Group Customer #

35370

Source Code (Office Use Only):

NYSUT DB 53017/53018/1002/54128-S

NYSUT PRD 53019/53020/1002/54128

UFT DB 53023/53024/1002/54128-S

UFT PRD 53025/53026/1002/54128

MEMBER ENROLLMENT INFORMATION (To be Completed by the Member)

Name (First, Middle, Last) Date of Birth (MM/DD/YYYY) Social Security # Male

Female

ddress

(

Street, Cit

, State, Zip Code

)

Phone

# Email Address

Basic Annual Earnings: Job Title Hours Worked Per Week

Employer:

New Enrollment

Change in Enrollment

I have read m

enrollment materials and I request covera

e for the benefits for which I am or ma

become eli

ible. I understand that if I’m

enrolling in Long Term Disability Insurance I am also enrolled in Voluntary AD&D Insurance. I understand that contributions are required for

the benefits I select below.

If you enroll for certain Contributory Insurance, a portion of your contributions for such insurance will be allocated to fund the premium for certain

Noncontributory Insurance under the Policyholder’s Group Insurance Program.

Long Term Disability Income Insurance

Select your monthly benefit:

Enter a multiple of $50 (minimum amount is $500) $

The maximum monthly benefit amount age 65 and under is $5,000, not to exceed 60% of your Basic Annual Earnings.

Indicate your waiting period:

60 days 90 days 120 days 150 days 180 days

Select Benefit Period:

12 months 60 months Long-Term

Accidental Death & Dismemberment (AD&D) Insurance

Voluntary AD&D -$25,000

GEF09-1

HEA-SUPP

(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; and

GEF09-1

HEA-SUPP applies to residents of North Dakota and Utah)

NYSUT

Page 2 of 4 LMI-EF-NY (03/18)

Metropolitan L

ife Insurance Company, New York, NY 10166

HEALTH INFORMATION (To be Completed by the Member)

Please complete all questions below. Omitted information will cause delays. In this section, “you” and “your” refers to the person for whom

insurance is being requested.

Your Name Your Social Security/Identification #

Your height feet inches Your weight pounds

Yes No

1. Are you now pregnant?

2. In the past 5 years, have you received medical treatment or counseling by a physician or other health care provider for, o

r been

advised by a physician or other health care provider to discontinue, the use of alcohol or prescribed or non-prescribed drugs?

3. Are you now receiving or applying for any disability benefits, including workers’ compensation?

4. Have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficien

cy Syndrome

(AIDS) or AIDS Related Complex (ARC)?

5. Have you ever been diagnosed, treated or given medical advice by a physician or

other health care provider for:

a. cardiac or cardiovascular disorder?

b. stroke or circulator

disorder?

c. hi

h blood

ressure?

d. cancer, Hodgkin's disease, lymphoma or tumors?

e. diabetes?

f. asthma, COPD, emphysema or other lung disease?

g. ulcers, stomach, hepatitis or other liver disorder?

h. colitis, Crohn’s, diverticulitis or other intestinal disorder?

i. epilepsy, paralysis, seizures, dizziness or other neurological disorder?

j. Epstein-Barr, chronic fatigue syndrome or fibromyalgia?

k. multiple sclerosis, ALS or muscular dystrophy?

l. back, neck, knee, spinal, joint or other musculoskeletal disorder?

m. mental, anxiety, depression, attempted suicide or nervous disorder?

6. Are you currently taking an

other prescribed medications?

GEF09-1

HEA

(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; and

GEF09-1

HEA applies to residents of North Dakota and Utah)

7. In the past 3 years, have you been Hospitalized as defined below (not including well-baby delivery)?

Hospitalized means admission for inpatient care in a hospital; receipt of ca

re in a hospice facility, intermediate care facility, or long

term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

8. In the past 2 years, have you used tobacco or nicotine in any form?

If you answered “Yes” to any of the above questions, you must also complete a Statement of Health form. Mercer Consumer will mail you the

Statement of Health form upon receipt and review of this enrollment form.

GEF09-1

(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; and

GEF09-1

FW applies to residents of North Dakota and Utah)

NYSUT

Page 3 of 4 LMI-EF-NY (03/18)

Metropolitan L

ife Insurance Company, New York, NY 10166

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.

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.

Kentucky: 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 Benefits): 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.

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.

Metr

opol

an L

ife Insurance Company, New York, NY 10166

BENEFICIARY DESIGNATION

I desi

nate the followin

person

(

)

as primar

beneficiar

ies

)

for an

amount pa

able upon m

death for the MetLife insurance covera

e 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.

Check if you need more space for additional beneficiaries including contingent beneficiary information, attach a separate page. Include all beneficiary

information, and sign/date the page. If you are adding contingent beneficiaries, please indicate which beneficiaries are to be considered contingent.

Full Name

(

First, Middle, Last

)

Social Securit

Date of Birth

(

Mo./Da

/Yr.

)

Relationship

Share %

Add

ress

(St

ree

City

)

one

Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100%

DECLARATIONS AND SIGNATURE

By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given, including any medical information, is true and complete to the best of my

knowledge and belief. I understand that this information will be used by MetLife to determine insurability.

2. I declare that I am actively at work on the date I am enrolling. I understand that if I am not actively at work on the scheduled effective date of insurance,

such insurance will not take effe

ct until I return to active work.

3. I understand that 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.

4. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if

I so choose.

5. I have read the applicable Fraud Warning(s) prov

ided in this enrollment form.

New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company o

r 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.

Signature of Member Print Name Date Signed (MM/DD/YYYY)

GEF09-1

DEC

(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; and

GEF09-1

DEC applies to residents of North Dakota and Utah)

NYSUT

Page 4 of 4 LMI-EF-NY (12/17)

Sign

Here

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NYSUT -35370

AUTH-XDP110M-NW (03/18)

AUTHORIZATION

This Authorization is in connection with an enrollment in group insurance and information required for underwriting and claim purposes for the

proposed insured(s)("employee", spouse, and any other person(s) named below). Underwriting means classification of individuals for

determination of insurability and / or rates, based upon physician health reports, prescription drug history, laboratory test results, and other

factors. Notwithstanding any prior restriction placed on information, records or data by a proposed insured, each proposed insured hereby

authorizes:

 Any medical practitioner, facility or related entity; any insurer; MIB, Group Inc. ("MIB"); any employer; any group policyholde

r, contract holder or benefit

plan administrator; any pharmacy or pharmacy related service organization; any consumer reporting agency; or any government agency to give

Metropolitan Life Insurance Company (“MetLife”) or any third party acting on MetLife's behalf in this regard:

 personal information and data about the proposed insured including employment and occupational information;

medical information, records and data about the proposed insured including information, records and data about drugs prescribed, medical test

results and sexually transmitted diseases;

 information, records and data about the proposed insured related to alcohol and drug abuse and treatment, including information and data records

and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2;

 information, records and data about the proposed insured relating to Acquired Immunodeficiency Syndrome (AIDS) or AIDS related conditions

including, where permitted by applicable law, Human Immunodeficiency Virus (HIV) test results;

 information, records and data about the proposed insured relating to mental illness, except psycho

therapy notes; and

 motor vehicle reports.

Note to All Health Care Providers: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA

Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To

comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. 'Genetic

information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an

individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's

family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form or sooner if prescribed by law. The

proposed insured may revoke this authorization at any time. To revoke the authorization, the proposed insured must write to MetLife at P.O. Box 14069,

Lexington, KY 40512-4069, and inform MetLife that this Authorization is revoked. Any action taken before MetLife receives the proposed insured's

revocation will be valid. Revocation may be the basis for denying coverage or benefits. If the proposed insured does not sign this Authorization, that

person's enrollment for group insurance cannot be processed.

By signing below, each proposed insured acknowledges his or her understanding that:

 All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to MIB.

Such information may also

be disclosed to and used by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insurance

applied for or on existing insurance with MetLife,

your employer for a plan administration purpose

or disclosed as otherwise required or permitted by

applicable laws.

 Medical information, records and data that may have been subject to federal and state laws or regulations, including

federal rules issued by Health and

Human Services, setting forth standards for the use, maintenance

and disclosure of such information by health care providers and health plans and

records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2, once disclosed to MetLife or upon redisclosur

e by

MetLife, may no longer be covered by those laws or regulations.

 Information relating to HIV test results will only be disclosed as permitted by applicable law.

 Information obtained pursuant to this authorization about a proposed insured may be used, to the extent permitted by applicable law, to determine t

insurability of other family members.

 A photocopy of this form is as valid as the original form. Each proposed insured

(or his/her authorized representative)

has a right to receive a copy of

this form.



I authorize MetLife, or its reinsurers, to make a brief report of my personal health information to MIB.

Signature of Member Date Signed (MM/DD/YYYY)

Print Name State of Birth

Countr

of Birth

Sign

Here

click to sign

signature

click to edit

Premium Mode / Payment Option Section:

Select one mode of payment:

Payroll Deduction (Please complete the Payroll Deduction Authorization)

Direct Bill Quarterly

Direct Bill Semi-Annually

Direct Bill Annually

Pre-Authorization Check Plan: I would like the Plan Administrator to deduct from my checking account the monthly premium for

my NYSUT Member Benefits-endorsed Disability Insurance Plan. I have attached a voided personal check for the checking account

from which I want these further deductions made. I understand that by signing up for the Pre-Authorized Check Plan, I will no longer

receive a notice of premium due for my insurance premiums, and that this process will continue until I notify the Plan Administrator

in writing to terminate the deduction.

The MetLife Disability Plan is a NYSUT Member

Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement

of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs

and, where appropriate, to enhance them. The Insurer pools the premiums of Member Benefits participants who are insured for the purposes of determining

premium rates and accounting. Coverage outside of this plan may have rates and terms that are not the same as those obtainable through Member

Benefits. The Insurer or Member Benefits may hold premium reserves that may be used to offset rate increases and/or fund such other expenses related to

the plan as determined appropriate by Member Benefits. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you

experience a problem with any endorsed program.

Return with application

(Please Print):

Last Name___________________________ First________________ Middle Initial_____

Address__________________________________________ NYSUT ID #____________

Home Phone # _____________________Member’s SS #_________________________

I hereby authorize my employer to deduct from each of my salary checks the deductions necessary for the purpose of

NYSUT Member Benefits.

Depending on the NYSUT Member Benefits program(s) which I am currently enrolled in and that

deductions are taken for, monies will be forwarded to the appropriate NYSUT Member Benefits entity.

For insurance plans, I

understand that this authorization may be revoked at any time by written notice to the Plan Administrator. For plans with

annual fees, I understand that I must provide written notice to the Plan Administrator to cancel automatic renewal and

that I must satisfy the annual fee.

Signature of Employee_____________________________________________________ Date_____________________

NYSUT MEMBER BENEFITS PAYROLL DEDUCTION AUTHORIZATION

UUP

PSC/CUNY*

All other NYSUT Locals

The amount of deductions will

be determined by NYSUT Member

Benefits based on the programs chosen,

and may be adjusted to ensure that

premiums are paid in full.

*This authorization card cannot be

used to authorize deductions for

PSC-CUNY Welfare Fund Benefits.

Please check your union

membership affiliation:

UFT

Mail this completed form with your invoice to the address on the invoice. Please call 800-626-8101 with any questions.

1.5K, 5-16 I-05

NYSUT Member Benefits Trust NYSUT Member Benefits Corporation NYSUT Member Benefits CMM Insurance Trust

click to sign

signature

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CPN–Group–Initial Enr/SOH and SBR-2016 CPN-SBR

1 Fs

Our Privacy Notice

We know that you buy our products and services because you trust us. This notice explains how we protect your privacy

and treat your personal information. It applies to current and former customers. “Personal information” as used here

means anything we know about you personally.

Plan Sponsors and Group Insurance Contract Holders

This privacy notice is for individuals who apply for or obtain our products

and services under an employee benefit plan,

group insurance or annuity contract, or as an executive benefit. In this notice, “you” refers to these individuals.

Protecting Your Information

We take important steps to protect your personal information. We treat it as confidential. We tell our

employees to take

care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also

protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access.

We comply with all laws that apply to us.

Collecting Your Information

We typically collect your name, address, age, and other relevan

t inf

ormation. We may also collect information about any

business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also

include a legal plans company and a securities broker-dealer. In the future, we may also have affiliates in other

businesses.

How We Get Your Information

We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct

and co

mplete. These sour

ces may include consumer reporting agencies, employers, other financial institutions, adult

relatives, and others. These sources may give us reports or share what they know with others. We don’t control the

accuracy of information outside sources give us. If you want to make any changes to information we receive from others

about you, you must contact those sources.

Wemayaskformedicalinformation.TheAuthorizationthatyousignwhenyourequestinsurancepermitsthesesources

tell us about you. We may also, at our expense:

 Ask for a medi

cal exam Ask for blood and urine tests

 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 rep

ort” about you (or anyone else to be insured).

Consumer reports may tell us about a lot of things, including information about:



Reputation

 Driving record 

Finances

 Work and work histor

 Hobbies and dangerous activities

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 no

n-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 that

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., 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734, by

calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting MIB at www.mib.com.

Using Your Information

We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to

verify identities to help deter

fraud, money laundering, or other crimes. How we use this information depends on what

products and services you have or want from us. It also depends on what laws apply to those products and services. For

example, we may also use your information to:



administer your products and services



process claims and other transactions



perform business research



confirm or correct your information

 market new products to you





help us run our business

 comply wi

h applicable laws

CPN–Group–Initial Enr/SOH and SBR-2016 CPN-SBR

2 Fs

Sharing Your Information With Others

We may share your personal information with others with your consent, by agree

ment, or as permitted or required by law.

We may share your personal information without your consent if permitted or required by law. For example, we may share

your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated

business partners through joint marketing agreements. In those situations, we share your information to jointly offer you

products and services or have others offer you products and services we endorse or sponsor. Before sharing your

information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and

give you an opportunity to opt out.

Other reasons we may share your information include:

 doing what a court, law enforcement, or government agency requires us to do (for example, complying with

warrants or subpoenas)

 telling another company what we know about you if we are selling or merging any part of our business

 giving information to a governmental agency so it can decide if you are eligible for public benefits

 giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on

your account)

 giving your information to your health care provider

 having a peer review organization evaluate your information, if you have health coverage with us

 those listed in our “Using Your Information” section above

HIPAA

We will not share your health information with any other company – even one of our affiliates – for their own marketing

purposes. The Health Insurance Portability and Accountability Act (“HIPAA”) protects your information if you request or

purchase dental, vision, long-term care and/or medical insurance from us. HIPAA limits our ability to use and disclose the

information that we obtain as a result of your request or purchase of insurance. Information about your rights under

HIPAA will be provided to you with any dental, vision, long-term care or medical coverage issued to you.

You may obtain a copy of our HIPAA Privacy Notice by visiting our

website at www.MetLife.com. For additional

information about your rights under HIPAA; or to have a HIPAA Privacy Notice mailed to you, contact us at

HIPAAprivacyAmericasUS@metlife.com, or call us at telephone number (212) 578-0299.

Accessing and Correcting Your Information

You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is

reasonably retrievable an

d within our control. You must make your request in writing listing the account or policy numbers

with the information you want to access. For legal reasons, we may not show you privileged information relating to a claim

or lawsuit, unless required by law.

If you tell us that what we know about you

is incorrect, we will review it. If we agree, we will update our records. Otherwise,

you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to

anyone outside MetLife.

Questions

We want you to understand how we protect your p

rivacy. If you have any questions or want more information about this

notice, please contact us. When you write, include your name, address, and policy or account number.

Send privacy questions to:

MetLife Privacy Office

P. O. Box 489

Warwick, RI 02887-9954

privacy@metlife.com

We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this

privacy notice to you on behalf of these MetLife companies:

Metropolitan Life Insurance Company MetLife Health Plans, Inc.

Metro

politan Tower Life Insurance Company General American Life Insurance Company

SafeGuard Health Plans, Inc. SafeHealth Life Insurance Company

Delaware American Life Insurance Company

MIB Pre Notice 04/2015

Metropolitan Life Insurance Company, New York, NY

MIB PRE NOTICE

Information regarding your insurability will be treated as confidential. Metropolitan Life

Insurance Company (“MetLife”) or its reinsurers may, however, make a brief report thereon to

MIB, Inc., a not-for-profit membership organization of insurance companies, which operates

an information exchange on behalf of its Members. If you apply to another MIB Member

company for life or health insurance coverage, or a claim for benefits is submitted to such a

company. MIB, upon request, will supply such company with the information in its file.

Upon receipt of the request from you MIB will arrange disclosure of any information it may

have in your file. Please contact MIB at 866-692-6901. If you question the accuracy of

information in MIB’s file, you may contact MIB and seek a correction in accordance with the

procedures set forth in the federal Fair Credit Reporting Act. The address of MIB’s

information office is 50 Braintree Hill Park, Suite 400 Braintree, MA 02184-8734.

MetLife, or its reinsurers, may also release information in its file to other insurance companies

to whom you may apply for life or health insurance, or to whom a claim for benefits may be

submitted. Information for consumers about MIB may be obtained on its website at

www.mib.com.

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Form 35370: ENROLLMENT CHANGE FORM MEMBER ENROLLMENT INFORMATION

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