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Get Metlife Election Of Portable Coverage Form 2016-2024

Ployee s Mailing Address: (Street, City, State Zip) Has coverage been assigned? Yes If yes, please specify coverage assigned No and attach a copy of assignment form. If coverage has been assigned this form must be mailed to the owner. Employee s Basic Annual Earnings: Reason for Insured s Portability Eligibility: $ Recordkeeper s Name: Print name of person at Recordkeeper completing Part A: Telephone Number: Part B TO BE COMPLETED BY THE EMPLOYEE Employee s Email Address: Soc.

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