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Group Insurance Form

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Election of Portable Coverage Form For Group Life Insurance Coverage

Important Information About MetLife’s Portability Option

You’re in a time of transition, and MetLife welcomes the opportunity to provide you with an affordable option to continue the Group Life Insurance coverage that you had with your former plan.

Here are some highlights of your Portability option...

• You can take coverage with you. You may continue the same or lesser amount of life insurance coverage you had on yourself at the time of your coverage termination through your former plan.

• Full protection for you. When you elect portable coverage, you will have these valuable features: MetLife’s Total Control Account (TCA) and Accelerated Benefits Option (ABO) for you.

It’s easy to elect Portable coverage:

1. Complete the attached Election Form within 31 days from the date your benefits are terminated or 45 days from the date this notice is given, if notice is given more than 15 days but less than 90 days after the date benefits were terminated.

2. Select the portable coverage amount for you (see attached Election Form Part B).

3. Designate your beneficiary(ies) and provide the required signatures.

4. Send your completed Election Form to: MetLife Recordkeeping Center, P. O. Box 14401, Lexington, KY 40512-4401.

5. Upon receipt of your completed Election Form, MetLife will send your initial monthly bill directly to your home address.

If you have any questions, require assistance in completing your Election Form, or wish to find out the cost of your portable coverage, you may phone our MetLife Recordkeeping Center toll-free at 1-888-252-3607, between the hours of 8:00 a.m. and 8:00 p.m. (EST).

Election of Portable Coverage Form

Instructions to the Recordkeeper:

(The Recordkeeper is either the Employer, TPA or MetLife.)

1. Immediately upon the Insured’s termination of employment, complete Part A below and make two copies of this form.

2. Provide the Eligible Insured with the original or mail it to their last known address.

3. Mail a copy of this form to MetLife Recordkeeping Center, P.O. Box 14401, Lexington, KY 40512-4401.

4. Maintain a copy for your records.

Part A — To Be Completed By The Recordkeeper

Has Coverage Been Assigned? Yes No

If yes, please specify coverage assigned and attach a copy of assignment form.

Was the insured actively at work on the date of separation? Yes No

Employer To Verify Insurance Amount(s) In Effect At Termination Date:

MetLife Insured Coverage Amounts in Effect

Insured:

• Supplemental/Optional Life

MetLife provides coverage under a Group Insurance policy issued to the Chase Manhattan Bank, N.A., as Trustee. Portable term coverage terminates when your premium payments cease or on January 1 of the year in which you attain age 80. Portable term insurance does not provide payment for death caused by suicide within the first two years from the effective date of coverage.

Part B — To Be Completed By The Insured

Insured Application Period: The Insured must apply for portable coverage within 31 days from the date benefits were terminated or 45 days from the date this notice is given, if notice is given more than 15 days but less than 90 days after the date benefits were terminated.

You may continue coverage at the same amount you had at the time of coverage termination or at a lesser amount.

Portable Insurance Amount(s) Requested (Please Round Coverage to the nearest thousand)

Insured: Supplemental/Optional Life

Same Amount

Decreased Amount

No Coverage

NOTE: All coverage amounts are subject to applicable state laws.

Designation Of Beneficiary For Insured Life Benefits

I designate as my Primary Beneficiary: My Designation of Beneficiary is on a separate form which is signed, dated and attached.

Full Name (Last, First, Middle Initial)
Relationship
Date of Birth (Mo./Day/Yr.)
Address (Street, City, State, Zip)
Share %

TOTAL: 100%

If the Primary Beneficiary(ies) die before me, I designate as Contingent Beneficiary(ies):

Full Name (Last, First, Middle Initial)
Relationship
Date of Birth (Mo./Day/Yr.)
Address (Street, City, State, Zip)
Share %

TOTAL: 100%

Unless designated otherwise, payment will be made in equal shares or all to the survivor. I reserve the right to change this designation at any time.

Signature of Insured

Date Signed (Mo./Day/Yr.)

Rate Sheet

Schedule of Monthly Portable Group Life Insurance Term Rates For Insured

Rates (cost per $1,000 of coverage per month) are based on the Insured’s age as of December 31st of the current calendar year. Rates are subject to change.

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What the Group Insurance Form Is and when it applies

A Group Insurance Form collects enrollment and eligibility information for employer-sponsored or association-based insurance plans. It documents member identity, coverage choices, dependents, beneficiary designation, premium allocation, and employer contributions. Organizations use the form to enroll employees or members into medical, dental, vision, life, or disability plans and to trigger plan administration workflows such as carrier enrollment, payroll deductions, and eligibility verification.

Why accurate Group Insurance Forms matter

A correctly completed Group Insurance Form minimizes coverage gaps, ensures accurate premium calculation, and supports timely carrier enrollment. It reduces underwriting delays and downstream corrections that can affect benefits, payroll, and regulatory compliance.

Why accurate Group Insurance Forms matter

Who completes and reviews this form

Responsibility for accuracy typically rests with the employer or plan sponsor; keep copies in HR records and provide members with copies of their enrollment confirmation.

  • HR or benefits administrators — prepare enrollment packages, verify eligibility, and forward to carriers for processing.
  • Employees and members — provide personal data, dependent details, beneficiary choices, and signature consent for deductions.
  • Benefits brokers or consultants — collect forms from clients, confirm plan selections, and submit bundled enrollments to carriers.

Core sections to include in a professional Group Insurance Form

A thorough form groups information into distinct sections so carriers and payroll teams can process enrollments quickly and accurately.

Member Details

Full legal name, date of birth, Social Security Number or TIN, contact information, and employee ID to match carrier enrollment records and payroll systems.

Coverage Selection

Plan name, tier (employee only, family, spouse), effective date, coverage level, and any optional riders or supplemental benefits elected by the member.

Dependent Information

Dependents’ full names, relationships, dates of birth, and SSNs or TINs when required to establish dependent eligibility and premium charges.

Beneficiary Designation

Primary and contingent beneficiaries for life, accidental death, or other coverages, including percentages and contact details for payout administration.

Payroll and Premium

Premium cost breakdown, employer contribution amounts, payroll deduction authorization, and billing frequency to align with payroll and accounting.

Authorizations & Signatures

Consent to electronic records, privacy acknowledgements, HIPAA authorization language where applicable, and signature block for employee and employer representatives.

Required data elements on the form

Full name: Legal name
Date of birth: MM/DD/YYYY
SSN / TIN: Nine-digit ID
Coverage choice: Plan and tier
Effective date: MM/DD/YYYY
Signature: Handwritten or e-sign

Step-by-step: completing and submitting a Group Insurance Form

Follow these sequential steps to fill the form, validate data, and route it to carrier and payroll systems.

  • 01
    Collect required documents: Gather IDs and dependent evidence before starting.
  • 02
    Enter member details: Complete legal name, DOB, TIN, and contact information.
  • 03
    Choose coverage: Select plan, tier, and optional riders accurately.
  • 04
    Sign and route: Obtain signatures, then send to carrier and payroll.

Configuring an online enrollment workflow

Set up a digital form and routing rules so enrollments flow directly to carriers and payroll without manual rekeying.

Field Configuration
Required fields Mark member name, DOB, TIN, and signature required
Conditional fields Show dependent section only when dependents selected
Routing Auto-send completed form to carrier and HR inbox
Notifications Email confirmations to employee and benefits admin

Where to send the completed form

After signing, route the form to the plan administrator, carrier enrollment team, and payroll to complete coverage setup.

  • Plan Administrator: Receives final copy for records and audit
  • Carrier Enrollment: Carrier enters member into coverage database
  • Payroll: Implements premiums and deductions on next cycle
  • Employee Copy: Member keeps a signed copy for personal records

Digital signing and submission requirements

Confirm the chosen platform meets HIPAA and payroll data security requirements and that recipients can import the delivered file types into their systems.

  • Authentication: Email or SMS code verification
  • File formats: PDF, DOCX, or structured XML accepted
  • Integrations: Connects to HRIS and carrier portals

Common timelines and deadlines to track

Plan sponsors must meet enrollment windows, effective date rules, and timely carrier submission to avoid coverage gaps.

Open enrollment window:

Typically annually; varies by plan terms

New hire enrollment:

Often 30–60 days from hire date

Carrier submission:

Submit enrollments per carrier SLA to ensure effective dates

COBRA notice period:

Employers must follow COBRA timing when applicable

Payroll cutoff:

Provide deductions before payroll processing deadlines

Key processing milestones for an enrollment lifecycle

Sequential milestones ensure data flows from member to payroll and carrier without interruption.

01

Form Completion

Member completes and signs the enrollment form.

02

HR Verification

HR confirms eligibility and supporting documents.

03

Carrier Transmission

HR or broker submits enrollment to carrier.

04

Premium Setup

Payroll schedules deductions to match effective date.

Common mistakes that delay processing

  • Missing or incorrect TINs that prevent carrier enrollment or trigger backup withholding.
  • Incorrect effective dates that result in coverage lapses or retroactive billing adjustments.
  • Unclear dependent documentation such as missing birth certificates or marriage certificates causing dependent rejection.
  • Unsigned forms or missing electronic consent to records that invalidate the submission.

Risks and potential consequences of incorrect forms

Coverage denial: Claims may be denied
Premium errors: Incorrect payroll deductions
Regulatory exposure: HIPAA or COBRA violations
Tax implications: Incorrect W-2/benefit reporting
Enrollment delays: Late effective dates
Reputational risk: Member dissatisfaction

Real-world examples of platform-enabled enrollment workflows

Organizations use eSignature platforms to collect and route Group Insurance Forms without paper-based delays.

Optica Ventures LLC — Brian Fitzgibbons

Optica automated enrollments using online forms and digital routing to reduce errors.

  • The interface was simple for staff and customers.
  • As a result they accelerated enrollment turnaround, reduced re-keying errors, and improved member satisfaction while maintaining required audit trails for compliance.

Fertility Centers of Illinois — John Butler

A healthcare provider implemented digital forms for benefits enrollment across locations.

  • The team praised secure signing and responsive support.
  • They achieved consistent data capture, HIPAA-compliant workflows with a BAA, and easier record retrieval for audits and patient inquiries.

Who may legally sign the Group Insurance Form

Plan Administrator

An authorized HR or benefits officer may sign employer attestation sections, certify premium contributions, and submit group enrollments on the sponsor's behalf.

Enrolling Member

The employee or plan member signs to consent to coverage, payroll deductions, and any electronic records or authorizations required by the carrier.

Tips for accurate and efficient form completion

Small practices reduce rework and support faster carrier processing when consistently applied across enrollments.

Pre-fill known data
Populate member name, employee ID, and company details automatically from HRIS to reduce manual entry errors and speed member completion.
Use conditional logic
Show dependent or beneficiary sections only when applicable to keep the form concise and prevent missing information in required paths.
Capture proof at upload
Request scanned dependent documents during enrollment to avoid follow-up; accept JPG or PDF attachments sized per carrier requirements.
Maintain an audit trail
Record timestamps, IP addresses, and signer authentication methods for each signed form to support compliance and dispute resolution.

Downloading, saving, and sharing completed forms

Export in commonly accepted formats and distribute to all stakeholders to complete the enrollment lifecycle.

Export formats

Save completed forms as PDF/A for long-term retention and as DOCX when edits are required by carriers.

Record copies

Provide signed copies to members, HR, and carriers; store master copies in a secure document repository.

Secure sharing

Transmit via secure SFTP, encrypted email, or direct carrier portal upload to protect personal data in transit.

Version control

Keep a dated, versioned copy for each enrollment cycle to reconcile future claims or audits.

eSignature pricing and feature snapshot for Group Insurance Forms

Compare starting prices and core features relevant to high-volume enrollment workflows; signNow appears first for direct product reference.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions about Group Insurance Forms and eSigning

Answers to common questions about electronic signing, signatures' legal validity, HIPAA considerations, and platform capabilities.


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