Assignment of benefits request - MetLife
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Page 1 of 1 Fs/f ASSIGN-BENEFIT (04/20) Long-Term Care Assignment of benefits request Metropolitan Life Insurance Company If you are signing for someone else, include a copy of the durable power of attorney or executorship if not previously provided. SECTION 1: Insured information First name Middle name Last name Intake ID SECTION 2: Benefit information Please select who you wish to be the recipient of the benefit payments: Insured Estate of the Insured Provider Provider name Provider Tax ID number Address City State ZIP SECTION 3: Signature(s) In order for us to process this request, please sign below and return. Signature Date (mm/dd/yyyy) SECTION 4: How to submit this form Mail: MetLife Long Term Care Claims P.O. Box 14407 Lexington, KY 40512 Fax: 866-722-1180 Email: [email protected]
Transcript of Assignment of benefits request - MetLife
Page 1 of 1 Fs/fASSIGN-BENEFIT (04/20)
Long-Term Care
Assignment of benefits request Metropolitan Life Insurance Company If you are signing for
someone else, include a copy of the durable power of attorney or executorship if not previously provided.
SECTION 1: Insured informationFirst name Middle name Last name
Intake ID
SECTION 2: Benefit informationPlease select who you wish to be the recipient of the benefit payments:
Insured
Estate of the Insured
Provider
Provider name Provider Tax ID number
Address City State ZIP
SECTION 3: Signature(s)In order for us to process this request, please sign below and return.
Signature Date (mm/dd/yyyy)
SECTION 4: How to submit this formMail: MetLife Long Term Care Claims P.O. Box 14407 Lexington, KY 40512
Fax: 866-722-1180
Email: [email protected]
