1 x annual salary
2 x annual salary
3 x annual salary
4 x annual salary
5 x annual salary
Group Term Life Insurance Application
LE
4. Your Group Term Life Insurance Beneficiary Designation
Signature of Faculty or Staff Member Date Signed
5. Authorization and Signature
lifeinsurance 12102019
6 x annual salary
7 x annual salary
8 x annual salary
$5,000
$50,000
Check one:
Standard Rate Nonsmoker Discount Rate (I have not smoked
within the last 12 months.)
Use this form to enroll in University Life Insurance and/or to enroll in Optional Life Insurance or to change your amount of coverage. Please print all
information in black ink. A health statement may be required. Review the information and instructions on the second page of this form.
University of Michigan
1. Faculty or Staff Member Information
2. University Group Term Life Insurance
The maximum life insurance benefit is $1.5 million. You may be required to complete a Health Statement if you are a current participant who
is increasing coverage to a level not exceeding $650,000. Coverage in excess of $650,000 always requires a Health Statement satisfactory to
the insurance company, MetLife. When a health statement is required, you will receive an email from MetLife with instructions.
I hereby authorize the University of Michigan, the employer, to deduct from my wages (salary), until further notice, amounts equal to the contribu-
tions required of me for Group Term Life Insurance under the policy issued to the employer by Metropolitan Life Insurance Company (MetLife).
Name (Last, First, Middle Initial) UMID U.S. Social Security Number
Street Address City State Zip
Date of Hire (Service Date)
Email Address Daytime Phone Number
(if UMID is unknown)
3. Optional Group Term Life Insurance
This plan provides $30,000 of life insurance coverage for you only, fully paid by the university. You must be enrolled in the University Plan to enroll
in the Optional Plan. If you enroll after your 30-day enrollment period (or as specified by your collective bargaining agreement), you must complete
the Health Statement and you will receive an email from MetLife with instructions.
Enroll in University Group Term Life
Check one coverage level:
Designate your Group Term Life Insurance beneficiaries using MetLife's MyBenefits website at: metlife.com/mybenefits
The first time you visit the MyBenefits website you will need to register to create your user name and password. For problems or questions
with registration please call 877-963-8932 (877-9METWEB) for MetLife Web Technical Support.
After you have registered on the MetLife/MyBenefits website, follow these steps to update your beneficiary information:
1. Go to metlife.com/mybenefits
2. Log in using the user name and password you created during registration
3. Click Life Insurance – Group Term Life under the Products & Services tab
4. Click Add/Update Beneficiaries Follow the steps to designate a beneficiary for your life insurance
Be sure to keep your beneficiary information up to date. Log in to metlife.com/mybenefits whenever you need to change your beneficiary
information.
By FAX
Fax it to 734-763-0363.
Keep a copy of the fax
transmission report with your
form in your records.
By Mail Only
Make a copy for your records and send the
original by Campus Mail or U.S. Mail to:
SSC Benefits Transactions
Wolverine Tower
3003 South State Street
Ann Arbor, MI 48109-1276
How to Return Your Signed and Completed Form
lifeinsurance 12102019
Questions?
If you have questions, view hr.umich.edu/benefits-wellness or call the SSC
Contact Center at 734-615-2000 or 866-647-7657 (toll free for off-campus long-
distance calls within the U.S.) Monday through Friday from 8 a.m. to 5 p.m.
Terms and Conditions
You must be enrolled in the University Plan to enroll in the Optional Plan. If you are
a new hire or are newly eligible and enroll in the Optional Plan within 30 days (or
as specified by your bargaining agreement), you will not be required to provide a
health statement as evidence of insurability as long as your Optional Plan coverage
is less than $650,000. You can enroll in the Optional Plan at any time, but after 30
days you will be required to provide evidence of insurability that is satisfactory to
the Metropolitan Life Insurance Company (MetLife). MetLife may also require a
physical examination. See the Health Statement section below.
Health Statement
If a health statement is required for the insurance coverage you select, MetLife
will send you an email with instructions on how to complete the Statement of
Health (SOH).
• IfyouenrollinUniversityLifewithin30days(orasspeciedbyyourcollective
bargaining agreement) as a new hire or newly eligible employee, you do not
need to submit a health statement.
• IfyouenrollinUniversityLifeafterthe30-dayenrollmentperiodasanew
hire or newly eligible employee, you must complete the health statement.
• IfyouenrollintheOptionalPlanwithin30daysasanewhireornewly
eligible employee, you do not need to submit a health statement if you elect
coverage less than $650,000.
• IfyouenrollinOptionalPlancoverageafter30daysforlessthan$650,000,
or increase your current coverage to less than $650,000, you will need to
complete and submit a health statement.
• Ifyouelectcoverageabove$650,000orincreaseyourcoverageto$650,000
or more, you will need to complete a health statement.
Your Cost
The university pays the full cost of your University Group Term Life Insurance.
Your cost for the Optional Plan depends on the coverage you select, your age,
your smoking status, and your salary. See hr.umich.edu/life-insurance for more
information on life insurance plans and rates.
Effective Date
If you are newly eligible, your insurance will become effective on your service
date or the first day you are newly eligible if you enroll within 30 days. If you
are not actively at work on the day your insurance would otherwise become
effective, you will become insured on the day you return to active work. If proof
of insurability is required, your insurance will become effective on the day the
health statement is approved by MetLife, the Benefits Office has been notified,
and you are actively at work.
Your Beneficiary
Designate your Group Term Life Insurance beneficiaries using MetLife’s
MyBenefits website at: metlife.com/mybenefits
The first time you visit the MyBenefits website you will need to register to cre-
ate your user name and password. For problems or questions with registration
please call 877-963-8932 (877-9METWEB) for MetLife Web Technical Support.
Group Term Life Insurance Application
After you have registered on the MetLife/MyBenefits website, follow these
steps to update your beneficiary information:
1. Log in using the user name and password you created during registration
2. Click Life Insurance – Group Term Life under the Products & Services tab
3. Click Add/Update Beneficiaries Follow the steps to designate a beneficiary for
your life insurance
Be sure to keep your beneficiary information up to date. Log in to metlife.com/
mybenefits whenever you need to change your beneficiary information.
• Youmaychooseanybeneciaryyouwish,suchasafamilymember,afriend,
a trust fund, or an organization.
• Youcannameasinglebeneciaryoryoucannametwoormorejointben-
eficiaries to receive the insurance payment.
• YoumaychangeyourbeneciaryatanytimebyloggingintoMetLife’sMy-
Beneficiary website.
• Considerdiscussingyourbeneciarywithyourattorneywhencompleting
this form. The Benefits Office cannot provide legal advice.
• Keepacopyofthisformforyourrecords.
Payment of Group Life Insurance Benefits
• Ifyourinsuranceisinforcewhendeathoccurs,thefullamountofyourinsur-
ance will be paid to your beneficiaries when MetLife receives written proof
of your death. A certified copy of the death certificate is required.
• Yourlifeinsurancewillbepaidinalumpsum,however,othermethodsof
payment may be arranged with MetLife.
• Ifyounamemorethanonebeneciary,paymentwillbemadeinequalshares
to the named beneficiaries who survive you (or in full to the survivor if only
one beneficiary survives you), unless you enter a specific percentage for each
person.
• Ifyoudonotdesignateabeneciary,orifnoneofthebeneciariesyouname
survives you, death benefits will be paid to the first of the following:
• Your surviving spouse;
• Surviving children in equal shares;
• Surviving parents in equal shares;
• Surviving siblings in equal shares;
• Estate
Limitations
The University of Michigan in its sole discretion may modify, amend, or terminate the
benefits provided with respect to any individual receiving benefits, including active
employees, retirees, and their dependents. Although the university has elected to provide
these benefits this year, no individual has a vested right to any of the benefits provided.
Nothing in these materials gives any individual the right to continued benefits beyond
the time the university modifies, amends, or terminates the benefit. Anyone seeking or
accepting any of the benefits provided will be deemed to have accepted the terms of the
benefits programs and the university’s right to modify, amend, or terminate them.
Receipt Confirmation
A confirmation email will be sent to your
UMICH email address within 72 hours of
receipt of your form.