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MetLife Member Enrollment Form

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Enrollment Form for Group Insurance

Metropolitan Life Insurance Company

SBC Administration

P.O. Box 14593, Lexington, KY 40512-4593

MetLife

Employee Name (Last, First, Middle)

Social Security Number

Customer Number

Division

Class

Your Home Address

City

State

ZIP

Sex (M/F)

Date of Birth

Marital Status

Your Occupation

Employer Name

Hire Date

Hours Worked Per Week

Salary

Reason for Enrollment:

Beneficiary Designation for Employee Life Insurance: I hereby name the following person(s) as beneficiary for any MetLife benefit payment upon my death.

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

(Dependent Life Insurance benefits are payable to the employee.)

Primary Beneficiary

Relationship

Date of Birth

Contingent Beneficiary

Relationship

Date of Birth

Coverage Requested:

Employee Coverage

Dependent Spouse Coverage

Dependent Child Coverage

If applying for Dependent Coverage (Spouse and Child), complete section below:

Number of dependents (including spouse)

Name (Last, First, MI)
Date of Birth
Sex (M/F)

If dependent children are full-time students in college, vocational or trade school, please complete the following:

Child(ren)
Name of School
# of Hours

For employees electing Enhanced Optional Life and Enhanced Dependent Life Insurance, please answer the following question:

Have you or your dependent(s) (if applicable) been Hospitalized (as defined below) during the last 90 days preceding the date of this enrollment form?

Employee:

Spouse:

Child:

Hospitalized means admission for inpatient care in a hospital, receipt of care in a hospice facility, intermediate care facility, or long term care facility, receipt of the following treatments wherever performed: chemotherapy, radiation therapy, or dialysis.

To decline coverage, complete this section:

I understand that I have been given the opportunity to participate in the group insurance plan offered by my Employer. I am refusing the coverage(s) indicated at the right for which I am required to contribute. If I request Life and/or Disability Insurance after my initial enrollment period, I understand that I, or my dependents (for dependent life only), will be required to submit evidence of good health Satisfactory to MetLife. (Satisfactory to MetLife means MetLife has discretionary authority to determine eligibility.) For Dental Insurance, a waiting period may be required for certain services before expenses will be payable.

Life/AD&D
Enhanced Optional Life/Buy-Up Life
Dental
Employee   Spouse   Child

Reason for declining employee and/or dependent coverage (i.e. benefits elsewhere, cost, other):

DECLARATION SECTION -- TO BE COMPLETED BY THE EMPLOYEE

The Employee signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge and belief. The Employee understands that this information will be used by MetLife to determine insurability.

For the Accelerated Benefits Option

I understand that my Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her Life Insurance amount. I also understand that receipt of accelerated benefits may affect eligibility for public assistance and that an interest and expense charge may be deducted from the accelerated payment.

Fraud Warning:

If you are applying for insurance under a policy issued in one of the following states, or if you reside in one of the following states, note the following applicable warning:

New York [only applies to Accident and Heath Insurance (AD&D/Disability/Dental)]: 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, 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.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kansas and Massachusetts: 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, and may subject such person to criminal and civil penalties.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Oklahoma: 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.

Oregon: 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 may be guilty of insurance fraud, and may be subject to criminal and civil penalties.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement may have violated state law.

All other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a 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.

For Payroll Deduction Authorization by the Employee

I authorize my Employer to deduct the required contributions from my pay for the insurance requested in this enrollment form. This authorization applies to such insurance until I rescind it in writing.

I affirm the beneficiary designation shown on page 1 of this form.

Employee Signature (The employee must sign in all cases.)

Date (Month/Day/Year)

Michigan Residents ONLY – Sign Below if Employee is enrolling for Dependent insurance on Page 1

Proposed Dependent age 18 or older

Date (Month/Day/Year)

Proposed Dependent age 18 or older

Date (Month/Day/Year)

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What the MetLife Member Enrollment Form Is

The MetLife Member Enrollment Form is the standardized document used to enroll an individual in MetLife benefits or insurance plans, record plan selections, tally employee and employer contributions, and designate beneficiaries. It collects personal identifiers, contact and payroll information, selected coverage levels, dependent information, and any required authorizations for payroll deduction or premium payment. Employers, brokers, and plan administrators may accept a paper-signed form or an electronically signed submission that meets U.S. e-signature law and privacy rules when health information is involved.

Why Accurate Enrollment Matters

A complete, correctly executed MetLife Member Enrollment Form ensures timely coverage, accurate premium withholding, and clear beneficiary designation; it also creates a legal record for claims and audits while reducing processing errors and administrative delays.

Why Accurate Enrollment Matters

Who Typically Completes or Manages This Form

Common participants include the enrolling individual, employer HR staff, and the insurance carrier or broker handling plan setup.

  • Enrolling employees who select plans, list dependents, and name beneficiaries for life or voluntary benefits; they must supply accurate personal and payroll data.
  • Human resources or benefits administrators who verify eligibility, set payroll deductions, and forward completed forms to MetLife for processing and recordkeeping.
  • Brokers or benefits consultants who assist employees, reconcile employer/employee elections, and submit batches to MetLife on behalf of the sponsor.

Clear role separation reduces errors: employees supply personal choices; HR validates payroll and eligibility; the carrier finalizes enrollment and issues confirmation.

Core Sections Found on a Professional Enrollment Form

A complete MetLife Member Enrollment Form follows a predictable layout so carriers and payroll systems can process elections reliably.

Personal Information

Full legal name, date of birth, Social Security number or TIN, and contact details; used to match records and verify identity before coverage is effective.

Employer Details

Employer name, group number, hire date, work location, and payroll ID fields so the carrier and payroll provider can record employer contributions and eligibility status.

Plan Selections

Options for base and voluntary coverage, coverage tiers (employee-only, family), benefit codes, and premium election lines that feed payroll deductions.

Beneficiary Designation

Primary and contingent beneficiary names, relationships, and allocation percentages; precise names and SSNs reduce probate and claims disputes.

Privacy & Authorization

Consent boxes for release of protected health information when required, payroll deduction authorization, and acknowledgement of plan terms or waiting periods.

Signature and Date

Signature block for the enrollee (and employer/HR attestation where required) with a dated signature to establish the effective election and acceptance.

Step-by-Step: Completing the Enrollment

Follow this sequence to prepare and submit a complete MetLife Member Enrollment Form with minimal rework.

  • 01
    Gather documents: Collect SSN/TIN, dependents' data, and employer group info before starting.
  • 02
    Select coverage: Choose plan codes and coverage tiers consistent with employer offerings.
  • 03
    Review authorizations: Confirm payroll deduction consent and any HIPAA or privacy checkboxes are correctly marked.
  • 04
    Sign and submit: Sign in ink or use compliant e-signature, then deliver to HR or upload to carrier portal.

Configuring an Online Enrollment Workflow

Recommended settings for a digital enrollment template to minimize errors and ensure enforceability.

Field Configuration
Authentication Method Email link with optional SMS code for higher assurance
Field Validation Require TIN format, DOB MM/DD/YYYY, and numeric premium amounts
Conditional Fields Show dependent fields only when family coverage selected
Notification Routing Auto-send completed copy to employee, HR, and carrier

Where Completed Forms Are Sent

Completed enrollments follow a short routing process to ensure payroll and carrier records remain synchronized.

  • Employer HR: HR verifies eligibility, initials employer attestations and forwards to carrier or broker.
  • MetLife Processing: Carrier intake team records elections and issues enrollment confirmation to employee and employer.
  • Broker/Agent: Brokers may batch submissions and reconcile missing data with HR or the enrollee.
  • Record Retention: Finalized forms are kept by employer and carrier per retention rules.

Digital Signing and Submission Considerations

Electronic submission of enrollment forms is common but must meet identity, consent, and retention standards under U.S. law.

  • Supported Formats: PDF and DOCX are widely accepted and preserve form layout.
  • Integrations: Connectors with payroll and HR systems reduce manual entry.
  • Authentication: Email link, SMS code, or stronger KBA available for higher assurance.

Key Deadlines and Effective Dates to Watch

Enrollment timing affects when coverage starts and which payroll deductions apply; account for employer cutoffs and carrier processing windows.

Open Enrollment Window:

Occurs annually per employer policy; missing it normally defers coverage to next period.

New Hire Enrollment:

Often limited to 30–60 days after hire; check employer policy for exact window.

Coverage Effective Date:

Specified on the form; often first of month after employer payroll processing.

Payroll Deduction Cutoff:

Submit prior to payroll run to apply deductions the following pay period.

Carrier Processing Time:

Allow at least 5–15 business days for carrier verification and confirmation.

Common Preparation Errors to Avoid

  • Leaving beneficiary allocations blank or using imprecise language, which can complicate claims and estate proceedings.
  • Entering an incorrect Social Security number or TIN, which can trigger backup withholding or rejected enrollments.
  • Failing to sign or date the form properly, including missing employer attestations where required.
  • Uploading poor-quality scans or incorrect plan codes that prevent automated imports into payroll or carrier systems.

Risks and Consequences of Incorrect Enrollment

Backup Withholding: 24% withholding if TIN missing or incorrect
Coverage Denial: Late or incomplete forms may delay or void coverage
HIPAA Exposure: Unauthorized disclosure can trigger HIPAA penalties
Payroll Errors: Incorrect deductions lead to reconciliation burdens
Beneficiary Disputes: Ambiguous designations complicate claims
Administrative Fines: Potential fines for repeated compliance failures

eSignature Vendor Comparison Relevant to Enrollment Forms

Basic pricing and feature contrasts for common e-signature vendors; signNow appears first for vendor parity and cost context.

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 by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

FAQs: Troubleshooting Common Enrollment Questions

Answers to frequent questions about e-signing, changing elections, and required attachments for the MetLife Member Enrollment Form.


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