Annuities

Participant data change request

Metropolitan Life Insurance Company

SECTION 1: Participant identification

Marital status
Single Married Widowed Divorced

First name (print) Middle name Last name

Participant address

City State ZIP

Social Security number (As currently on file) Daytime phone number Account number

Date of birth (mm/dd/yyyy) (As currently on file)

SECTION 2: Change of name/address/telephone (Please Print)

Old - First name Middle name Last name

Old name (signature) Date (mm/dd/yyyy)

New - First name Middle name Last name

New name (signature) Date (mm/dd/yyyy)

New address - number and street

City State ZIP

New phone number

Please attach a copy of the driver’s license, marriage certificate, divorce decree or similar court issued
document reflecting the correction or change of name.

SECTION 3: Correction of Social Security number

Old Social Security number New Social Security number

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SECTION 4: Correction of dates
Corrected date of birth Corrected date of hire Corrected date of participation
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)

SECTION 5: Signature
Signature of participant Date (mm/dd/yyyy)

Signature of plan administrator (For ERISA only) Date (mm/dd/yyyy)

SECTION 6: How to submit this form

Mail this form to: Overnight mail only: Fax:
MetLife MetLife 877-549-5834
PO Box 10356 4700 Westown Parkway Suite 200 Please allow 24-48 hours to confirm
Des Moines, IA 50306-0356 West Des Moines, IA 50266 receipt of faxed paperwork.

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