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MetLife Group Term Life Insurance Quote

Here is Your Term Life Insurance Quote. The quote listed below is based on the following data:



Add optional Accidental Death (AD&D) coverage
Adding this benefit doubles your death benefit if you die as a result of an accident.


Covers all eligible dependent children.

{ YOUR MONTHLY COST }

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Total Monthly Cost includes $2.00/monthly ABN association dues required to enroll in the QuickTerm Life insurance program. Payments may be made via Monthly Auto Pay (ACH) or Direct Annual Payment. If Direct Annual Payment Mode is selected, you will be required to make your initial payment by credit card. Premiums are guaranteed not to change before 12/31/22 and are subject to change thereafter.

CLICK NEXT BUTTON TO APPLY FOR SELECTED COVERAGE >>

Web Enrollment & Electronic Signature Agreement

STATEMENT ON CONSUMER CONSENT TO THE USE OF ELECTRONIC TRANSACTIONS, SIGNATURES AND RECORDS (Consent Statement)

In this Agreement, "we," "us," "our," and "the company" refer to Metropolitan Life Insurance Company and MetLife Investors USA Insurance Company. "You" and "yours" refer to the applicant for a policy offered by us.

1. Consent to do business with, and receive communications from, MetLife electronically. To the extent permitted by law, this Agreement is a "global" consent. You agree to:

a) Complete transactions electronically and use electronic signatures on a website we make available to you.

b) As applicable, allow us to replace paper delivery with electronic delivery of your documents and communications relating to policies you own or are applying for. Electronic delivery of the documents will be by e-mails transmitting such documents, whether as text in, attachments to, and/or hyperlinks from such e-mails to the documents stored on a MetLife website or a third party’s website. You specifically agree that delivery of the link to your policy constitutes delivery of the policy and starts the free look period under your policy.

c) As applicable, receive text messages with important updates on your application and policy. You agree to allow us to send text messages to the mobile number you provide. You understand that standard message and data rates apply.

d) Make sure that neither your software nor your internet service provider inhibits or interferes with your receipt of electronic communications from us. Update your electronic mail address when it changes.

Note: You’ll continue to receive paper copies of certain documents until the electronic versions become available.

2. Withdrawal of consent. You can easily withdraw your consent at any time by calling 1-800-966-7125.

3. Effect of not consenting or withdrawing consent. If you choose not to consent or to withdraw your consent, you can still submit an application by signing a paper copy of the application.

4. How to obtain paper copies of the documents you sign electronically. To obtain paper copies of the documents you sign electronically, you can either print the document on your printer or call us at 1-800-966-7125.

5. Hardware requirements. To use this service, you must have access to a computer with an Internet connection. If you would like to be able to save the documents that you receive, the computer should have a hard drive or other storage device or be connected to a printer. You must also have an email account to receive communications.

6. Software Requirements. In order to complete the electronic signature process and to download your application, you will need Adobe Acrobat Reader 3.0 (or greater).

Member Benefits Consumer Disclosure Regarding Conducting business electronically, Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of Member Benefits "sending party", plan administrator, whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.

Paper Copies

You are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the electronic signature system. Member Benefits may also email you a PDF copy of all agreements you sign using the service. If you wish to receive paper copies in lieu of electronic documents you may close this web browser and request paper copies from Member Benefits by following the procedures outlined below.

Use of the Service requires a standards-compliant web-browser which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requires additional software such as Adobe Reader or similar.

Withdrawal of Consent

You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify Member Benefits that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.

Scope of Consent

You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with Member Benefits. You may at any point withdraw your consent by following the procedures described below.

Requesting paper copies, withdrawing consent, and updating contact information

You will have the ability to download and print any documents you complete through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically, please contact Member Benefits by telephone (800) 282-8626, or by sending an email to (support@memberbenefits.com) with the following subjects:

“Requesting Paper Copies” Please provide your name, email, telephone number, postal address and document title.

“Withdraw Consent” Please provide your name, email, date, telephone number, postal address.

“Update Contact Information” Please provide your name, email, telephone number and postal address.

(Please include valid email to conduct business electronically. WE DO NOT SPAM. Your enrollment confirmation and coverage documents will be emailed to this address.)

About You

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Name*
Address*
No dashes

About Your Family

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you, as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependent tax exemption. Dependent tax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard dependents such as a grandchild, a niece or a nephew.



Please add information about your dependents to be covered.

Child/Dependent Name
Date of Birth
Gender


Child/Dependent Name
Gender
Date of Birth


Child/Dependent Name
Gender
Date of Birth


Child/Dependent Name
Gender
Date of Birth


Please list Name, Gender, Date of birth

HEALTH INFORMATION

This online application utilizes an SSL Certificate to ensure secure transmission of your information. 

If you answer “yes” to any of the above questions, a Statement of Health form must also be completed for the person to whom the “yes” applies.

Feet / Inches
Pounds


1. Have you had any application for life, accidental death and dismemberment or disability insurance declined, postponed, withdrawn, rated, modified, or issued other than as applied for?*


2. Are you now receiving or applying for any disability benefits, including workers’ compensation?*


3. Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days?*
Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.


4. For residents of all states except CT, please answer the following question: Have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC) or the Human Immunodeficiency Virus (HIV) infection?*
For CT residents, please answer the following question: To the best of your knowledge and belief, have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC) or the Human Immunodeficiency Virus (HIV) infection?

HEALTH INFORMATION (cont.)

If you answer “yes” to any of the above questions, a Statement of Health form must also be completed for the person to whom the “yes” applies.

5. Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider for:



a. cardiac or cardiovascular disorder?*
b. stroke or circulatory disorder?*
c. high blood pressure?*
d. cancer, Hodgkin's disease, lymphoma or tumors?*
e. diabetes?*
f. asthma, COPD, emphysema or other lung disease?*

LIFE INSURANCE - Name Your Beneficiary

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Name your Primary Beneficiary. You may name 1 primary beneficiary using this online form. To designate more than 1 beneficiary and/or to designate contingent beneficiaries, Download and Submit Beneficiary Designation/Change Form to make additional designations.

Primary Beneficiary Name
Must equal 100% amongst all primary beneficiaries
Date of Birth
Address

Payment Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Payment Option 1 - Monthly Auto Pay
If you elect to pay by Monthly Bank Draft (ACH), you do not need to send any premium. Upon approval of your enrollment form, we will automatically draft your account on a monthly basis. 


Payment Option 2 - Direct Annual Billing

If you elect this method, if you are approved for coverage, you will receive your policy documents and an initial invoice for the required payment up through the end of the plan year (Dec. 31st). Thereafter, you will be invoiced on a calendar annual basis, with premiums due January 1st each group plan year.



IMPORTANT: DO NOT USE DEPOSIT TICKET NUMBERS as these numbers are often different than your checking ABA and Account number's. Routing and Account number must be from an authorized Checking account. An actual check is the best source to acquire the proper routing information.


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Agreement/Signature

FRAUD WARNINGS, DECLARATIONS AND SIGNATURE(S), AUTHORIZATION

FRAUD WARNINGS

Before signing this Statement of Health form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies to the extent required by applicable law.

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

Kansas and Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

Kentucky: 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.

Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.

New York (only applies to Accident and Health Insurance): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 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.

Oklahoma: WARNING: 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.

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

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

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


DECLARATIONS AND SIGNATURE(S)

Member:
By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given, including any health information, is true and complete to the best of my knowledge and belief. I understand that this information will be used by MetLife to determine insurability.

2. I declare that I am able to perform the normal activities of a person of such age and sex with a like occupation or retired status on the date I am enrolling. I understand that if I am unable to perform such normal activities on the scheduled effective date of insurance, such insurance will not take effect until I am able to resume performing such activities.

3. If I do not enroll for the maximum amount of coverage for which I am eligible, evidence of insurability satisfactory to MetLife may be required to enroll for or increase such coverage. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase.

4. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.

5. I have read the applicable Fraud Warning(s) provided in this enrollment form.

Spouse/Domestic Partner (If applicable): By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given, including any health information, is true and complete to the best of my knowledge and belief. I understand that this information will be used by MetLife to determine insurability.

2. I have read the applicable Fraud Warning(s) provided in this enrollment form.


AUTHORIZATION

This Authorization is in connection with an enrollment in group insurance and information required for underwriting and claim purposes for the proposed insured(s)("employee", spouse, and any other person(s) named below). Underwriting means classification of individuals for determination of insurability and / or rates, based upon physician health reports, prescription drug history, laboratory test results, and other factors. Notwithstanding any prior restriction placed on information, records or data by a proposed insured, each proposed insured hereby authorizes:

· Any medical practitioner, facility or related entity; any insurer; MIB, Group Inc. ("MIB"); any employer; any group policyholder, contract holder or benefit plan administrator; any pharmacy or pharmacy related service organization; any consumer reporting agency; or any government agency to give Metropolitan Life Insurance Company (“MetLife”) or any third party acting on MetLife's behalf in this regard: personal information and data about the proposed insured including employment and occupational information; medical information, records and data about the proposed insured including information, records and data about drugs prescribed, medical test results and sexually transmitted diseases; information, records and data about the proposed insured related to alcohol and drug abuse and treatment, including information and data records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2; information, records and data about the proposed insured relating to Acquired Immunodeficiency Syndrome (AIDS) or AIDS related conditions including, where permitted by applicable law, Human Immunodeficiency Virus (HIV) test results; information, records and data about the proposed insured relating to mental illness, except psychotherapy notes; and motor vehicle reports.

Note to All Health Care Providers: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. 'Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form or sooner if prescribed by law. The proposed insured may revoke this authorization at any time. To revoke the authorization, the proposed insured must write to MetLife at P.O. Box 14069, Lexington, KY 40512-4069, and inform MetLife that this Authorization is revoked. Any action taken before MetLife receives the proposed insured's revocation will be valid. Revocation may be the basis for denying coverage or benefits. If the proposed insured does not sign this Authorization, that person's enrollment for group insurance cannot be processed.

By signing below, each proposed insured acknowledges his or her understanding that:

· All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to MIB. Such information may also be disclosed to and used by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insurance applied for or on existing insurance with MetLife, or disclosed as otherwise required or permitted by applicable laws.

· While this authorization is in force, we may use the information we receive under this authorization to improve our underwriting and claims processes generally.

· Medical information, records and data that may have been subject to federal and state laws or regulations, including federal rules issued by Health and Human Services, setting forth standards for the use, maintenance and disclosure of such information by health care providers and health plans and records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2, once disclosed to MetLife or upon redisclosure by MetLife, may no longer be covered by those laws or regulations.

· Information relating to HIV test results will only be disclosed as permitted by applicable law.

· Information obtained pursuant to this authorization about a proposed insured may be used, to the extent permitted by applicable law, to determine the insurability of other family members.

· A photocopy of this form is as valid as the original form. Each proposed insured (or his/her authorized representative) has a right to receive a copy of this form.

· I authorize MetLife, or its reinsurers, to make a brief report of my personal health information to MIB.


ABN MEMBERSHIP AGREEMENT
I hereby apply for membership in the American Association of Business Networking (ABN). Upon completion of this enrollment form and payment of initial dues ($2.00 monthly), I understand that: (a) I will be entitled to ABN’s benefits; (b) these benefits may change from time to time; (c) my membership will become effective on the day this enrollment form is dated and signed; (d) I am eligible to apply for association group insurance; and (e) I authorize the release of my name and address listed on the Application for Insurance to ABN.


MONTHLY AUTO-PAY AGREEMENT (only if selected)
I hereby authorize Member Benefits (MB) to initiate debit and credit entries to my Checking account and my Bank/Financial Institution to debit and/or credit the same account. MB will not be held responsible for a policy lapse or cancellation due to nonpayment if withdrawal is prepared and not honored for any reason and amount due is not paid within the payment Grace Period. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. Service fees, when applicable by law, may apply for ACH debit returns. MB and my Bank/Financial Institution may discontinue this service. This authority is to remain in full force and effective until MB has received written notice from me of its termination in such time and manner as to afford MB and my Bank/Financial Institution a reasonable opportunity to act on it.

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