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Domestic Violence/Abuse Confidentiality Request

Confidentiality Request for Victims of Domestic Violence and Other Endangered Individuals

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 * >> Required
  Last Name * >> Required
  Current Address of Record * >> Required
  City * >> Required
  State * >> Required
  Zip Code * >> Invalid Zip Code
  Date of Birth * - - (MM-DD-YYYY)>> Invalid Date
  Social Security/ID No. >> Invalid SSN

Alternative Contact Information (Please select one):>> Please select atleast one Checkbox

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:>> Please select the Checkbox
  In Care of    >> Required
  Alternative Address >> Required
  City >> Required
  State >> Required
  Zip Code >> Invalid Zip Code
  Alternative Phone >> Must contain numbers (XXX-XXX-XXXX)
  Alternative Email >> Invalid Email address
 
I do not wish to change my address at this time. However, I am requesting that my information be treated with enhanced security measures.

Protective Order>> Please select atleast one Checkbox

I have a court issued order of protection. Please e-mail to AskCompliance@metlife.com or fax to Compliance at 908-552-2874.
 
I do not have a court issued order of protection.

Product Information

Please select the MetLife products under which you are covered: >> Please select at least one Product
  Life Insurance (Separated by commas if there are multiple)
  Total Control Account
  Annuity
  Disability Income
  Group Disability
  Long-Term Care
  Dental
  Vision
  Auto & Home
  Critical Illness
  Accident
  Brokerage
 
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.
 

Primary Insured Person

For group coverage, including Group Life, Dental, and Vision, please provide:
  Primary Insured's Name >> Required
  Social Security/ID No. >> Required
  Date of Birth - - (MM-DD-YYYY)>> Invalid Date
Relationship to Primary Insured

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 >> Required
Parent or Guardian's Name >> Required
Relationship to Child >> Required
Contact Phone >> Must contain numbers (XXX-XXX-XXXX)
Contact Email >> Invalid Email address
 
For Guardians, please send guardianship documentation as soon as possible to MetLife’s Compliance Department at AskCompliance@metlife.com or fax to 908-552-2874.
 
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 >> Required
Relationship to Covered Individual >> Required
Contact Phone >> 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 or fax to 908-552-2874. NOTE: No protection will be implemented until MetLife has received and reviewed the Power of Attorney documentation.

Notes:

  1. 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.
  2. 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.
  3. Online Service Accounts: If you do business online, we recommend that you change your password and all other security settings.
  4. If you need to revoke this request, please call 1-800-MET-LIFE (1-800-638-5433).
  5. MetLife may take up to three business days to implement this request.
  Submitted by: >> Required

MetLife respects your Privacy


 
 
 
 
 

When I enter a phone number in the space provided above, I consent to receive phone calls to the phone number I provided, including calls to my wireless phone. I consent to have these calls generated using an automated technology from the MetLife family of companies, or vendors on MetLife's behalf, and that voicemails may be pre-recorded messages. My consent is not required to make a purchase.

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