Domestic Violence/Abuse Confidentiality Request

If you are a victim of domestic violence or other abuse, you may request that MetLife send communications of claim-related or policy-related information to you by alternative means or at alternative locations. If so requested, we will keep confidential all claim or billing information relating specifically to you to the extent permitted by law, including your name, address, any services received, and the name and address of the provider of any services (such as your doctor or dentist). Your request will remain in effect until you revoke it in writing.

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, and I request confidentiality.

* First Name

* Last Name

* Current Address of Record

* City

* State

* Zip

Invalid Zip Code

Date of Birth

* MM

* DD

* YYYY

Invalid Date

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:

In Care of

what's this?

Alternative Address

City

State

Zip Code

Invalid Zip Code

Alternative Phone

Alternative Email

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.)

Please select atleast one Checkbox

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.

Please select atleast one Checkbox

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

YYYY

Invalid Date

Relation

Parents, Guardians, or Legal Representatives

Parent or Guardian

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 Guardian's Name

Relationship to Child

Contact Phone

Must contain numbers (XXX-XXX-XXXX)

Contact Email

Invalid Email

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

Legal Representative

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 Individual

XXX-XXX-XXXX

Must contain numbers (XXX-XXX-XXXX)

Contact Email

Invalid Email address

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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Domestic Violence/Abuse Confidentiality Request

Confidentiality Request for Victims of Domestic Violence and Other Endangered Individuals

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