ࡱ> Y  bjbj ziit! l l OOO$sssPs+xLW%X<aX 8::::::$ D^QOXV"3VlXX^"9]]]X^8O8]X8]]./7Ҥpe qX@$Ŭ0RYҤҤ&O,XX]XXXXX^^ZXXXXXXXXXXXXXXXXl Y :  Metropolitan Life Insurance Company, New York, NY 10166ENROLLMENT CHANGE FORM GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper)Name of Group Customer/Employer Pennsylvania State System of Higher EducationGroup Customer # 257776Report #  FORMTEXT 0258282Sub Code  FORMTEXT 0040Branch  FORMTEXT 0001Date of Hire (MM/DD/YYYY)  FORMTEXT      Coverage Effective Date (MM/DD/YYYY)  FORMTEXT      YOUR ENROLLMENT INFORMATION (To be Completed by the Employee)Name (First, Middle, Last)  FORMTEXT      Social Security #  FORMTEXT       FORMTEXT      FORMTEXT      FORMCHECKBOX  Male  FORMCHECKBOX  FemaleAddress (Street, City, State, Zip Code)  FORMTEXT      Date of Birth (MM/DD/YYYY)  FORMTEXT      Phone #  FORMTEXT      Email Address  FORMTEXT       FORMCHECKBOX  New Enrollment  FORMCHECKBOX  Change in EnrollmentI have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand that contributions are required for the benefits I select below. If you are enrolling after the initial enrollment period, you must also complete a Statement of Health form for all amounts you are requesting.Disability Income Insurance FORMCHECKBOX  Long Term Benefits  FORMCHECKBOX  Option 1 (180 Day Elimination Period)  FORMCHECKBOX  Option 2 (90 Day Elimination Period)GEF02-1 ADM (The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; GEF02-1 ADM applies to residents of North Dakota and Utah) FRAUD WARNINGSBefore signing this enrollment 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. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state 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. 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.  Metropolitan Life Insurance Company, New York, NY 10166Maryland: 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. GEF09-1 FW (The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; GEF09-1 FW applies to residents of North Dakota and Utah) DECLARATIONS AND SIGNATUREBy signing below, I acknowledge: I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief. I declare that I am actively at work on the date I am enrolling. I understand that if I do not enroll for disability coverage during the initial enrollment period, or 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 after the initial enrollment period has expired. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form. I have read the applicable Fraud Warning(s) provided in this enrollment form.  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