Confidential Communications Request Form Working 3715299 Final

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Please complete this form by providing as much information as you can so that we can properly identify you in our systems.

* Required Fields

Individual Requesting Confidentiality

I am a victim of domestic violence or other abuse, or a protected individual under certain state laws, and I request confidentiality.

* First Name

* Last Name

* Current Address of Record

* City

* State

* Zip

* Date of Birth (MM/DD/YYYY)

* Social Security/ID No

Alternative Contact Information (Please select one)

I request that MetLife send communications of claim-related or policy-related information to me by the following alternative means or at the following alternative locations:

I do not wish to change my contact information (address, phone number, or email) at this time. However, I am requesting that my information be treated with enhanced security measures. (Note: if alternative contact information is not provided, then claim-related and/or policy-related information will continue to be sent to your current address, phone number, and/or email address of record.)

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If you are using someone else's address, then enter his or her name here.

In Care of

Alternative Address

City

State

Zip Code

Alternate Phone

Protective Order:

I have a court-issued order of protection. Please e-mail to AskCompliance@metlife.com

I do not have a court-issued order of protection

Product Information

(Separated by commas if there are multiple)

Life Insurance

Life Insurance Policy Number

Total Control Account

Total Control Account Policy Number

Annuity

Annuity Policy Number

Disability Income

Disability Income Policy Number

Group Disability

Group Disability Policy Number

Long-Term Care

Long-Term Care Policy Number

Dental

Dental Policy Number

Vision

Vision Policy Number

Accident

Accident Policy Number

Critical Illness

Critical Illness Policy Number

Brokerage

Brokerage Policy Number

The text will appear here

Joint Brokerage Accounts: If you own a joint brokerage account, the broker-dealer is unable to keep your information secure from the other joint owner. As such, the broker-dealer will NOT change the address on its records if you have a joint brokerage account.

*The Farmers Insurance Group^®has acquired the MetLife Auto & Home business from MetLife, Inc. Therefore, the MetLife companies are no longer affiliated with MetLife Auto & Home and are no longer responsible for any of MetLife Auto & Homes’ activities. The Farmers Insurance Group will be responsible for your policy and its administration going forward. To submit a request for information protection, please provide your name, state, and policy number(s) to usw.ask.compliance@farmersinsurance.com.

Primary Insured Person

For group coverage, including Group Life, Dental, and Vision, please provide:

Primary Insured's Name

Social Security/ID No

Date of Birth (MM/DD/YYYY)

Self, Parents / Guardians, or Legal Representatives

Self

Parent or Guardian requesting confidentiality on behalf of a child

Legal Representative requesting confidentiality on behalf of a covered individual

If the covered individual is a child younger than 18 years old and the person making this request is the child’s parent or guardian, please provide the following information:

Name of child

Parent or Gaurdian's Name

Relationship To Child

Contact Phone

Contact Email

For Guardians, please send guardianship documentation as soon as possible to MetLife’s Compliance Department at AskCompliance@metlife.com

If a legal representative, such as a power of attorney, is making the request on behalf of the covered individual, please provide the following information.

Legal Representative's Name

Relationship to Covered Individiual

Phone (xxx-xxx-xxxx)

Contact Email

Please send Power of Attorney documentation as soon as possible to MetLife’s Compliance Department at AskCompliance@metlife.com

Notes:

This request for confidentiality applies only to certain MetLife-issued products. If you have insurance, investment or advisory products issued by another company, you must contact that company directly to request confidential treatment.
Joint Brokerage Accounts: If you own a joint brokerage account, the broker-dealer is unable to keep your information secure from the other joint owner. As such, the broker-dealer will NOT change the address on its records if you have a joint brokerage account.
Online Service Accounts: If you do business online, we recommend that you change your password and all other security settings.
If you need to revoke this request, please call 1-800-MET-LIFE (1-800-638-5433).
MetLife may take up to three business days to implement this request.

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MetLife respects your privacy.

For California Residents.

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