ࡱ> %) !"#$ nbjbjo>o> ZW T Tb- ::dZZZ Zn -r.r.r.ttt$s%Ht"qqtt::r.r.Bhhht:r.r.hthh5{6`r.` -`ufL0dmv m``8m tthttttt tttttttmttttttttt :  INSTRUCTIONSFOR THE STATEMENT OF HEALTH FORM AND THE AUTHORIZATION FORM THAT FOLLOW THIS SECTIONINSTRUCTIONS TO THE RECORDKEEPER (The Recordkeeper may be the Group Customer, a Third Party Administrator or MetLife.) Fill in the Group Customer Information and Insurance Information on the Statement of Health form. Give the forms to the Employee. INSTRUCTIONS TO THE EMPLOYEE (The Employee is the Proposed Insured and is the person for whom insurance is being requested.) Based on the enrollment form you submitted, a Statement of Health form is required to complete the request for group insurance coverage for you, the Proposed Insured. Fill in your name and Social Security # on the Statement of Health form. Your Name and your Social Security # must appear on the form.If the Insurance Information Section is not completed, obtain the information before finalizing the form. Contact your Employer/Benefits Administrator if the Life Insurance amounts were not provided or to confirm the Life Insurance amounts. Complete the Statement of Health form and sign where indicated by an arrow. Sign the Authorization form where indicated by an arrow. After completion, make a copy of both completed forms for your records and FAX, MAIL or EMAIL the original forms to the address at the right. Emailed forms must be printed and signed before they are scanned and submitted. For questions, call MetLife at 1-800-638-6420, prompt 1 (Statement of Health Unit) or email us at  HYPERLINK "mailto:eoi@metlife.com" eoi@metlife.com.Metropolitan Life Insurance Company Statement of Health Unit P.O. Box 14069 Lexington, KY 40512-4069 FAX: 1-859-225-7909 To Submit Completed Forms Email:  HYPERLINK "mailto:SOHSubmissions@MetLife.com" SOHSubmissions@metlife.com For Questions Email:  HYPERLINK "mailto:eoi@metlife.com" eoi@metlife.comNote: Additional medical information may be required after MetLifes initial review of a completed Statement of Health form. The additional information requested may be a physical examination, paramedical exam, or an Attending Physician Report. Correspondence will be sent within ten days by MetLife or our approved vendor. Incomplete forms will be returned to you for completion. Some services in connection with your Statement of Health form may be performed by our affiliate, MetLife Global Operations Support Center Private Limited. This service arrangement in no way alters Metropolitan Life Insurance Company's obligations to you. Services will not be performed by our affiliate if prohibited by state or local law or by mutual agreement with the Group Customer.STATEMENT OF HEALTH FORM Metropolitan Life Insurance Company, New York, NYGROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper)Name of Group Customer/Employer/Association  FORMTEXT Board of Regents-University of GeorgiaGroup Customer #  FORMTEXT 307601Reporting Location #  FORMTEXT 154672Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      INSURANCE INFORMATION (To be Completed by the Recordkeeper)Enrollment year  FORMTEXT      Disability Income Insurance  FORMCHECKBOX  Short Term Benefits  FORMCHECKBOX  Long Term BenefitsEMPLOYEE INFORMATION (To be Completed by the Employee)Name of Employee (First, Middle, Last)  FORMTEXT      Social Security # of Employee  FORMTEXT      YOUR INFORMATION (To be Completed by the Employee)Name (First, Middle, Last)  FORMTEXT      Relationship to Employee  FORMCHECKBOX  Self FORMCHECKBOX  Male  FORMCHECKBOX  FemaleStreet Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Date of Birth (MM/DD/YYYY)  FORMTEXT      Daytime Phone #  FORMTEXT      Home Phone #  FORMTEXT      Email Address  FORMTEXT       HEALTH INFORMATIONSECTION 1Please complete all questions below. Omitted information will cause delays. In this section, you and your refers to the person for whom insurance is being requested. Health Information is required for the Proposed Insured only. For questions 5 through 11u, for yes answers, please provide full details in Section 2.Your name  FORMTEXT       Employee s Name  FORMTEXT       Employee s Social Security/Identification #  FORMTEXT       Your height  FORMTEXT     feet  FORMTEXT     inches Your weight  FORMTEXT      poundsYesNoAre you now on a diet prescribed by a physician or other health care provider? If  yes indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX Are you now pregnant? If  yes, what is your due date (month/day/year)?  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX If  yes , provide Physician s name  FORMTEXT       Telephone: (  FORMTEXT     )  FORMTEXT       FORMTEXT      Are you now, or have you in the past 2 years, used tobacco in any form? FORMCHECKBOX  FORMCHECKBOX In the past 5 years, have you received medical treatment or counseling by a physician or other health care provider for, or been advised by a physician or other health care provider to discontinue, the use of alcohol or prescribed or non-prescribed drugs? FORMCHECKBOX  FORMCHECKBOX In the past 5 years, have you been convicted of driving while intoxicated or under the influence of alcohol and/or any drug? If yes, specify date(s) of conviction(s) (month/day/year)  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX Have you had any application for life, accidental death and dismemberment or disability insurance  FORMCHECKBOX  declined  FORMCHECKBOX  postponed  FORMCHECKBOX  withdrawn  FORMCHECKBOX  rated  FORMCHECKBOX  modified or  FORMCHECKBOX  issued other than as applied for? Indicate reason  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX Are you now receiving or applying for any disability benefits, including workers compensation? FORMCHECKBOX  FORMCHECKBOX Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days? FORMCHECKBOX  FORMCHECKBOX Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.Have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC) or the Human Immunodeficiency Virus (HIV) infection? FORMCHECKBOX  FORMCHECKBOX Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider for:cardiac or cardiovascular disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX stroke or circulatory disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX high blood pressure? FORMCHECKBOX  FORMCHECKBOX cancer, Hodgkin's disease, lymphoma or tumors? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX anemia, leukemia or other blood disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX diabetes? Your age at diagnosis?  FORMTEXT        FORMCHECKBOX  Check if insulin treated FORMCHECKBOX  FORMCHECKBOX asthma, COPD, emphysema or other lung disease? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX ulcers, stomach, hepatitis or other liver disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX colitis, Crohn s, diverticulitis or other intestinal disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX memory loss? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX epilepsy, paralysis, seizures, dizziness or other neurological disorder? FORMCHECKBOX  FORMCHECKBOX  Specify date of last seizure (month/year)  FORMTEXT       Indicate type  FORMTEXT       Epstein-Barr, chronic fatigue syndrome or fibromyalgia? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX multiple sclerosis, ALS or muscular dystrophy? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX lupus, scleroderma, auto immune disease or connective tissue disorder? FORMCHECKBOX  FORMCHECKBOX arthritis?  FORMCHECKBOX  osteoarthritis  FORMCHECKBOX  rheumatoid  FORMCHECKBOX  other/type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX back, neck, knee, spinal, joint or other musculoskeletal disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX carpal tunnel syndrome? FORMCHECKBOX  FORMCHECKBOX kidney, urinary tract or prostate disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX thyroid or other gland disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX mental, anxiety, depression, attempted suicide or nervous disorder? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX sleep apnea? Indicate type  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX After completing the Personal Physician and Prescription Information on the next page, please provide full details in Section 2 for  yes answers to questions 5 through 11u. Personal Physician InformationPersonal Physician s Name:  FORMTEXT       Address (Street, City, State, Zip Code):  FORMTEXT       Telephone: (  FORMTEXT     )  FORMTEXT       FORMTEXT      Date of last visit (MM/DD/YYYY):  FORMTEXT    /  FORMTEXT    /  FORMTEXT      Reason for visit:  FORMTEXT       Prescription InformationAre you currently taking any prescribed medications?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, list the medications.Medication:  FORMTEXT       Condition/Diagnosis:  FORMTEXT       Prescribing Physician s Name:  FORMTEXT       Telephone: (  FORMTEXT     )  FORMTEXT       FORMTEXT      Address (Street, City, State, Zip Code):  FORMTEXT       Medication:  FORMTEXT       Condition/Diagnosis:  FORMTEXT       Prescribing Physician s Name:  FORMTEXT       Telephone: (  FORMTEXT     )  FORMTEXT       FORMTEXT      Address (Street, City, State, Zip Code):  FORMTEXT        FORMCHECKBOX  Check here if you are attaching another sheet for any additional medications.SECTION 2Please provide full details below for each Yes answer to questions 5 through 11u in Section 1. If you need more space to provide full details, attach a separate sheet with the information and sign and date it. Delays in processing your application may occur if complete details are not provided. MetLife may contact you for additional or missing information.  FORMCHECKBOX  Check here if you are attaching another sheet.Your name  FORMTEXT       Employee s Name  FORMTEXT       Your Date of Birth  FORMTEXT    /  FORMTEXT    /  FORMTEXT      Question NumberCondition/DiagnosisPlease list any medication prescribed that you did not already identify in the Prescription Information above. FORMTEXT       FORMTEXT       FORMTEXT      Date of Diagnosis (Month/Year)Date of Last Treatment (Month/Year)Type of Treatment  FORMTEXT       FORMTEXT       FORMTEXT      Treating Health ProfessionalPhysician s Name:  FORMTEXT       Date of last visit:  FORMTEXT       Reason for visit:  FORMTEXT       Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Code Telephone: (  FORMTEXT     )  FORMTEXT     -  FORMTEXT      Question NumberCondition/DiagnosisPlease list any medication prescribed that you did not already identify in the Prescription Information above. FORMTEXT       FORMTEXT       FORMTEXT      Date of Diagnosis (Month/Year)Date of Last Treatment (Month/Year)Type of Treatment  FORMTEXT       FORMTEXT       FORMTEXT      Treating Health ProfessionalPhysician s Name:  FORMTEXT       Date of last visit:  FORMTEXT       Reason for visit:  FORMTEXT       Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Code Telephone: (  FORMTEXT     )  FORMTEXT     -  FORMTEXT       Question NumberCondition/DiagnosisPlease list any medication prescribed that you did not already identify in the Prescription Information above. FORMTEXT       FORMTEXT       FORMTEXT      Date of Diagnosis (Month/Year)Date of Last Treatment (Month/Year)Type of Treatment  FORMTEXT       FORMTEXT       FORMTEXT      Treating Health ProfessionalPhysician s Name:  FORMTEXT       Date of last visit:  FORMTEXT       Reason for visit:  FORMTEXT       Address  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street City State Zip Code Telephone: (  FORMTEXT     )  FORMTEXT     -  FORMTEXT      GEF09-1 HEA FRAUD WARNINGSBefore signing this Statement of Health 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. 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. 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, Virginia 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. Maryland: 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 Benefits): 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 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. Oregon and 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. 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. 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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. DECLARATIONS AND SIGNATURESBy signing below, I acknowledge: I have read this Statement of Health form and declare that all information I have given, including any health information, is true and complete to the best of my knowledge and belief. I understand that this information will be used by MetLife to determine my insurability. I have read the applicable Fraud Warning(s) provided in this Statement of Health form.  SHAPE \* MERGEFORMAT   FORMTEXT        FORMTEXT       Signature of Proposed Insured Print Name Date Signed (MM/DD/YYYY)If a child proposed for insurance is age 18 or over, the child must sign this Statement of Health. If the child is under age 18, a Personal Representative for the child must sign, and indicate the legal relationship between the Personal Representative and the proposed insured. A Personal Representative for the child is a person who has the right to control the child s health care, usually a parent, legal guardian, or a person appointed by a court.  SHAPE \* MERGEFORMAT   FORMTEXT        FORMTEXT       Signature of Personal Representative Print Name Date Signed (MM/DD/YYYY) Relationship of Personal Representative  Authorization This Authorization is in connection with an enrollment in group insurance and information required for underwriting and claim purposes for the proposed insured(s) ("employee", spouse, and /or any other person(s) named below). Underwriting means classification of individuals for determination of insurability and / or rates, based upon physician health reports, prescription drug history, laboratory test results, and other factors. Notwithstanding any prior restriction placed on information, records or data by a proposed insured, each proposed insured hereby authorizes: Any medical practitioner, facility or related entity; any insurer; MIB Group, Inc ( MIB ); any employer; any group policyholder, contract holder or benefit plan administrator; any pharmacy or pharmacy related service organization; any consumer reporting agency; or any government agency to give Metropolitan Life Insurance Company ( MetLife ) or any third party acting on MetLife's behalf in this regard: personal information and data about the proposed insured including employment and occupational information; medical information, records and data about the proposed insured including information, records and data about drugs prescribed, medical test results and sexually transmitted diseases; information, records and data about the proposed insured related to alcohol and drug abuse and treatment, including information and data records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2; information, records and data about the proposed insured relating to Acquired Immunodeficiency Syndrome (AIDS) or AIDS related conditions including, where permitted by applicable law, Human Immunodeficiency Virus (HIV) test results; information, records and data about the proposed insured relating to mental illness, except psychotherapy notes; and motor vehicle reports. Note to All Heath Care Providers: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information.  Genetic information as defined by GINA, includes an individual s family medical history, the results of an individual s or family member s genetic tests, the fact that an individual or an individual s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form or sooner if prescribed by law. The proposed insured may revoke this authorization at any time. To revoke the authorization, the proposed insured must write to MetLife at [P.O. Box 14069, Lexington, KY 40512-4069,] and inform MetLife that this Authorization is revoked. Any action taken before MetLife receives the proposed insured's revocation will be valid. Revocation may be the basis for denying coverage or benefits. If the proposed insured does not sign this Authorization, that person's enrollment for group insurance cannot be processed. By signing below, each proposed insured acknowledges his or her understanding that: All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to MIB. Such information may also be disclosed to and used by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insurance applied for or on existing insurance with MetLife, or disclosed as otherwise required or permitted by applicable laws. Medical information, records and data that may have been subject to federal and state laws or regulations, including federal rules issued by Health and Human Services, setting forth standards for the use, maintenance and disclosure of such information by health care providers and health plans and records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2, once disclosed to MetLife or upon redisclosure by MetLife, may no longer be covered by those laws or regulations. Information relating to HIV test results will only be disclosed as permitted by applicable law. Information obtained pursuant to this authorization about a proposed insured may be used, to the extent permitted by applicable law, to determine the insurability of other family members. A photocopy of this form is as valid as the original form. Each proposed insured has a right to receive a copy of this form. I authorize MetLife, or its reinsurers, to make a brief report of my personal health information to MIB.  SHAPE \* MERGEFORMAT   FORMTEXT       Signature of Proposed Insured Date Signed (MM/DD/YYYY)  FORMTEXT        FORMTEXT        FORMTEXT       Print Name State of Birth Country of BirthIf a child proposed for insurance is age 18 or over, the child must sign this Authorization form. If the child is under age 18, a Personal Representative for the child must sign, and indicate the legal relationship between the Personal Representative and the proposed insured. A Personal Representative for the child is a person who has the right to control the child s health care, usually a parent, legal guardian, or a person appointed by a court.  SHAPE \* MERGEFORMAT   FORMTEXT        FORMTEXT       Signature of Personal Representative Print Name Date Signed (MM/DD/YYYY) Relationship of Personal Representative       GEF02-1 ADM Please complete all sections of this form. Incomplete forms will be returned to you. Page  PAGE 1 of 5 SOH-XDP300M-NW (09/13)   GEF09-1 HEA Please complete all sections of this form. Incomplete forms will be returned to you. Page  PAGE 2 of  =  NUMPAGES 2 -1 1 SOH-XDP300M-NW (09/13)   GEF09-1 HEA Please complete all sections of this form. Incomplete forms will be returned to you. Page  PAGE 3 of  =  NUMPAGES 3 -1 2 SOH-XDP300M-NW (09/13)   GEF09-1 FW Please complete all sections of this form. Incomplete forms will be returned to you. 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