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Service & Claims Forms

Claim Forms (PDF) - English
Cancer Claim – Individual Insurance 5057 1/99 – CA – MD
Cancer Claim – Individual Insurance – First Diagnosis/Lump Sum Only 5228 – 5228 CA
Cancer Claim ULA – Individual Insurance 5057 1/99 ULA
Claim Form for Accident Policy 6554
Claim Form – Critical Illness, Synergis 5203 – 5203 CA
Claim Form – Critical Illness, Critical Advantage 6445
Claim Form – Home Health Care 5213
Claim Form – Level Term Life/CriticaLife 5624
Claim Form – Life 5044 – 5044 CA – 5044 ULA – 5044 ING – 5044 ING CA
Claim Form – Long Term Care – NTQ 5039
Claim Form – Long Term Care – TQ 5216
Claim Form for Disability Income Insurance Policy 5169 – 5169 CA
Claim Form for Disability Income Insurance Policy – Disability Income Advantage Only 5124
Death Claim Administrative Form 5044
Hospital Income Claim Form 5043-73-73 6/94
Life of Virginia Claim Form 5111-73-73 6/94
Medicare Supplement Claim Form 5064
MetLife Application for Benefits – Individual Insurance 5173 MET – 5173 CA MET
MetLife Prescription Claim 5192 MET
NCFlex Supplemental Medical Plan Claim Form 5256
Supplemental Claimant's Statement 5052
Service/Miscellaneous Forms (PDF) - English
Absolute Assignment and Beneficiary Change 1031
Accumulated Dividends Form 6096
Acknowledgement of Nonduplication – Texas only 1307
Affidavit for Lost Policy 1435
A.M. Best's Rating Report 4361
Amendment to Application 1110
Assignment of Life Insurance 6043
Authorization For the Use and Disclosure of Protected Health Information (for Underwriting) 1390
Authorization For the Use and Disclosure of Protected Health Information (for Protective Claims) 1401
Availability of Language Assistance Notice (CA) MetLife • Kanawha
Bankdraft Authorization 6027
Charitable Giving Beneficiary Form 1629
Consent and Authorization For The Use and Disclosure of Personally Identifiable Financial Information 1312 – 1312 CA
Direct Deposit Authorization 8172
Disability Insurance Calculator 5844
Disclosure – Accelerated Benefit for Terminal Illness 1505
Disclosure for All Persons Age 65+ for Specified Diseases, such as cancer 1131
Disclosure for All Persons Age 65+ for Fixed Dollar Amounts 1132
Disclosure (NH only) 1137
Duplication of Coverage (SC) 1088
Important Notice Before You Buy Health Insurance (IA) SHIIP IA
IRA Transfer Request 6065
Life Insurance Buyer's Guide 1104
Medical Consent Release 1311
New Mexico Notice of Confidential Domestic Abuse Information Practices 1633
Non-English Fluent and Literate Applicants – Amendment of Application for Insurance 1494
Non-English Fluent and Literate Applicants – Request for Waiver of Standard Procedures 1437
Notice Concerning Policyholder Rights in an Insolvency Under The Minnesota Life and Health Insurance Guaranty Association Law BUL 91-4 MN
Notice Regarding Standards for Medi-Cal Eligibility 789.8 Notice CA
Payor Change Request 6020
Policy Receipt 8227
Policy Values to Pay Premiums 6004
Policy Service Request (Loans, CSVs) 6016 – 6016 C
Reinstatement Form – Life/Health 6032
Replacement Form – Accident and Health 8203 – State:
Replacement Form – Life 8131 – State:
Replacement Form – Long Term Care 8040 – State:
Request for the Exchange of Insurance Policies Under Section 1035 of the Internal Revenue Service Code 1338
Request for the Exchange of Insurance Policies Under 1035 of the Internal Revenue Code (for Annuities) 6128
Request for Waiver of Standard Procedures – Non-English Fluent and Literate Applicants 1437
Request to Change/Add Coverage 6106
Secondary Addressee Request 1327
Shopper's Guide to Cancer Insurance, A – WI 1062 WI
Standard Change of Beneficiary Form 6042
Statement of Additional Coverage 1358
Statement of Health and Insurability 1211
Termination of Payroll Deduction 6000
Understanding of Policy Replacement 1302
Vanishing Premium Form 6096
Voluntary Benefits Cancellation Request 1618

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