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	Medical Authorization/Disclosure of Information


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Dental (purchased through employer)

	Title	What is this for?	Mailing Instructions
	Dental Claim Form	We recommend that you bring a claim form with you when you visit your dentist for an appointment.	MetLife Dental Claims PO Box 981282 El Paso, TX 79998-1282


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Disability (purchased through employer)

	Title	What is this for?	Mailing Instructions
	Medical Authorization/Disclosure of Information	Use the form to inform your physician(s) that MetLife will be administering your disability claim and give authorization to release your medical information to MetLife.	Metropolitan Life Insurance Company Attn: MetLife Disability Claims PO Box 14590 Lexington, KY 40511-4590 Fax #: 1-800-230-9531

	Attending Physician Statement	This form is used to gather medical information necessary for the ongoing management of disability claims. Have your physician complete this form when your case manager requests new/updated medical information.	Metropolitan Life Insurance Company Attn: MetLife Disability Claims PO Box 14590 Lexington, KY 40511-4590 Fax #: 1-800-230-9531

	Health Care Provider Certification-FMLA	This form is used to gather medical information neccessary for the ongoing management of Family and Medical Leave Act (FMLA) Claims. Have your physician complete this form after you file your claim.	Metropolitan Life Insurance Company Attn: MetLife Disability Claims P.O. Box 14590 Lexington, KY 40511-4590 Fax #: 1-800-230-9531

	Electronic Funds Transfer (EFT) Authorization Form	Complete, sign and mail/fax this form to MetLife to authorize electronic funds transfers of your disability insurance payments directly to your bank. Please verify that your employer's plan offers electronic funds transfer for disability income benefit payments before submitting this form to MetLife.	Metropolitan Life Insurance Company Attn: MetLife Disability Claims P.O. Box 14590 Lexington, KY 40511-4590 Fax #: 1-800-230-9531
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Annuity (purchased individually)

	Title	What is this for?	Mailing Instructions
	Change of Beneficiary	To correct, change or designate your beneficiaries.	MetLife PO Box 10342 Des Moines, IA 50306 - 0342 Fax #: 1-908-552-3402

	Change or Name a New Owner or Joint Owner	To correct, change or name a new owner or joint owner. You cannot change an owner if your account is an IRA account.	MetLife PO Box 10342 Des Moines, IA 50306 - 0342 Fax #: 1-908-552-3402

	Change Owner's Name on Record	To correct, change or name a new owner or joint owner. You cannot change an owner if your account is an IRA account.	MetLife PO Box 10342 Des Moines, IA 50306 - 0342 Fax #: 1-908-552-3402

	Request a Nursing Care Provision Withdrawal	Use if your account is eligible for this benefit.	MetLife PO Box 10342 Des Moines, IA 50306 - 0342 Fax #: 1-908-552-3402


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Annuity (purchased through employer)

	Title	What is this for?	Mailing Instructions
	Change of Beneficiary	To correct, change or designate your beneficiaries.	MetLife PO Box 10356 Des Moines, IA 50306 - 0356 Fax #: 1-908-552-3403

	Make Corrections to Group Participant Information	For use by an Adminstrator to change Group Participant information (i.e., name changes, deletions, corrects, etc.)	MetLife PO Box 10356 Des Moines, IA 50306 - 0356 Fax #: 1-908-552-3403


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Life Insurance (purchased individually)

	Title	What is this for?	Mailing Instructions
	Electronic Payment (EP) Account Agreement	Pay your premiums and make other transactions with our convenient Electronic Payment (EP) Account Agreement. Use this form to authorize electronic fund transfers from your checking, savings or share draft account to pay premiums due on your personal life insurance policies. The form contains detailed instructions on how to use this convenient service.	MetLife PO Box 30440 Tampa, FL 33630-3440 Fax #: 1-908-552-2442

	Change of Beneficiary Form	Change the beneficiary of your policy with this easy to use form.	MetLife Attn: Beneficiary and Assignment Unit PO Box 313 Warwick, RI 02887-0313


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Auto & Home

	Title	What is this for?	Mailing Instructions
	ExpressIT SM Authorization and Agreement(Form MPL-1098-000)	Save time and money with the ExpressIT automatic payment plan. With ExpressIT, premium payments are automatically withdrawn from your checking account each month by electronic funds transfer (EFT). You can select one of the four predetermined deduction dates that best meets your budgeting needs. To find out more about this payment option, contact your agent or a customer service representative.	If your policy is serviced by an independent agent: Freeport Service Center Attention: Correspondence Unit PO Box 441 Freeport, IL 61032-0441 Fax #: 1-888-540-9915 All Others: Dayton Service Center Attention: Correspondence Unit PO Box 48020 Dayton, OH 45475-0020 Fax #: 1-866-743-4891

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Medical Authorization/Disclosure of Information

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