Group Term Life Insurance Beneficiary Designation

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Use this form to name the persons or entities you want to receive your life

insurance proceeds after your death.

Metropolitan Life Insurance Company

Things to Know Before You Begin

• Completing this form replaces your existing beneficiary designations. Please

provide details for each beneficiary, even if you have already given us this

information in the past.

• Gather the name(s), date(s) of birth, Social Security/Tax ID number(s) and

contact information for all of your beneficiaries.

• The beneficiaries you name on this form apply to your Group Term Life

insurance coverage insured by MetLife.

• To name additional beneficiaries, attach a separate page. Provide the

requested information including the beneficiary type (primary or contingent)

and the % proceeds for each. Sign and date these page(s), making sure the

date is the same as the date next to the signature on this form.

• Please complete and return all pages or we cannot record your choices.

If you make a mistake

anywhere on this form,

cross it out and initial it.

SECTION 1: About the Insured

First Name Middle Name Last Name

Date of Birth (mm/dd/yyyy) Social Security Number Phone Number

Address City State ZIP

Employer Name Customer Number

SECTION 2: About the Plan

The beneficiaries you name on this form apply only to the MetLife-insured plan(s) selected below:

All group term life coverage currently in effect

Basic Life/Personal Accidental Death & Dismemberment (AD&D)

Supplemental/Optional Life

Supplemental/Optional Accidental Death & Dismemberment (AD&D)

Retiree Life

To name separate beneficiaries for the Life or AD&D coverages in this section, photocopy this form and

complete a different form for each type of coverage.

SECTION 3: About the Primary Beneficiaries

These parties are your first choice to receive the insurance proceeds after your death. If a primary beneficiary

dies before you, we will divide their share(s) equally between the remaining primary beneficiaries.

• You must name at least one (1) primary beneficiary.

WA State Health Care Authority PEBB

164995

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• Please check the box and complete the form fields for each beneficiary you name. Having accurate information

for your beneficiaries ensures that we distribute the proceeds the way you want.

• Use the proceeds % field to tell us how you want us to distribute the proceeds. If you want a specific distribution,

use whole numbers (no fractions or decimals) and make sure they (and any listed on separate pages) add up

to 100%. To distribute them equally between your primary beneficiaries, leave all of the proceeds % fields blank.

About the Primary Beneficiaries (continued)

Individual

First Name Middle Name Last Name

Address

Date of Birth (mm/dd/yyyy)

City State ZIP

Gender

Social Security Number Phone Number Relationship to Insured

Write in

the % of

proceeds

assigned

to this

person

Individual

First Name Middle Name Last Name

Address

Date of Birth (mm/dd/yyyy)

City State ZIP

Gender

Social Security Number Phone Number Relationship to Insured

Write in

the % of

proceeds

assigned

to this

person

Individual

First Name Middle Name Last Name

Address

Date of Birth (mm/dd/yyyy)

City State ZIP

Gender

Social Security Number Phone Number Relationship to Insured

Write in

the % of

proceeds

assigned

to this

person

Your Estate – If you name your Estate as a primary beneficiary, you cannot name a

contingent beneficiary.

Proceeds

Testamentary Trust created in your Will – The trust under your last Will and Testament

as shall be admitted to probate.

Proceeds

Living (Inter Vivos) Trust – See further instructions on page 4.

Proceeds

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Charity/Organization – List the charity or organization name and not an employee of the

charity or organization. See further instructions on page 4.

Proceeds

Total proceeds for all primary beneficiaries (A-G plus any listed on separate pages)

must equal 100%.

100%

SECTION 4: About the Contingent Beneficiaries

Skip this section if you’re not naming a contingent beneficiary or if you named your Estate as a primary beneficiary.

Contingent beneficiaries receive the insurance proceeds only if all of the primary beneficiaries are deceased at the

time of your death. If a contingent beneficiary dies before you, we will divide their share(s) equally between the

remaining contingent beneficiaries.

• Please check the box and complete the form fields for each beneficiary you name. Having accurate information

for your beneficiaries ensures that we distribute the proceeds the way you want

• Do not list the same person or entity as both a primary and a contingent beneficiary.

•

Use the proceeds % field to tell us how you want us to distribute the proceeds. If you want a specific distribution,

use whole numbers (no fractions or decimals) and make sure they (and any listed on separate pages) add up to

100%. To distribute them equally between your contingent beneficiaries, leave all of the proceeds % fields blank.

Individual

First Name Middle Name Last Name

Address

Date of Birth (mm/dd/yyyy)

City State ZIP

Gender

Social Security Number Phone Number Relationship to Insured

Write in

the % of

proceeds

assigned

to this

person

Individual

First Name Middle Name Last Name

Address

Date of Birth (mm/dd/yyyy)

City State ZIP

Gender

Social Security Number Phone Number Relationship to Insured

Write in

the % of

proceeds

assigned

to this

person

Your Estate

Proceeds

Testamentary Trust created in your Will – The trust under your last Will and Testament

as shall be admitted to probate.

Proceeds

Living (Inter Vivos) Trust – See further instructions on page 4.

Proceeds

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Charity/Organization – List the charity or organization name and not an employee of the

charity or organization. See further instructions on page 4.

Proceeds

Total proceeds for all contingent beneficiaries (H-M plus any listed on separate pages)

must equal 100%.

100%

SECTION 5: About your Trust/Charity/Organization Beneficiaries

Skip this section if you did not name a Living Trust or Charity/Organization as one of your beneficiaries.

Otherwise, please provide the information requested below on a separate page. Make sure you include the type

of beneficiary (primary or contingent) and that you sign and date these page(s).

Please include: Additional information required for Living (Inter Vivos) Trust(s):

• Trust/Charity/Organization name • Trust date

• Address • Trust Tax ID number

• Phone Number • Trustee first, middle and last name

• Type of Beneficiary (primary or contingent)

• % of proceeds you are assigning to the

Trust/Charity/Organization

SECTION 6: Signature Required

By signing below, I hereby revoke any previous designations, and I designate the person, people, or entity

named herein as beneficiaries.

Check if you are completing and signing this form as agent for the insured under a valid Power of Attorney.

Please submit a copy of the Power of Attorney with this beneficiary form.

Please Print and Sign Below

Insured/Owner First Name Middle Name

Last Name

Insured/Owner Signature Date Form Completed (mm/dd/yyyy)

Did you remember to…

ü Provide complete information for each of your beneficiaries?

ü Make sure the total “proceeds %” for your primary beneficiaries (including those on a separate

page) equals 100%? Separately, did you remember to make sure the total “proceeds %” for your

contingent beneficiaries (including those on a separate page) equals 100%?

ü Complete, sign and date any extra pages that list beneficiary information (such as Living Trust/

Charity/Organization beneficiaries)?

ü Cross out and initial any mistakes you made? (If you crossed out any answers, your signature

is not enough. You must also initial all your corrections.)

Example:

12/20/25 12/20/15 HM `

answer corrected, initials required

Please note: we cannot record your beneficiary choices unless you complete these items.

SECTION 7: How to Submit This Form

Mail:

MetLife Recordkeeping & Enrollment Services

P.O. Box 14406

Lexington, KY 40512-4406

Be sure to keep a copy of this completed form for your records.