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METLIFE LEGAL ENROLLMENT FORM | Group Name: STATE OF FLORIDA | |||||||||
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| CAUTION: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a claim statement or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. | CAUTION: Employee must complete sections 1-10. Review plan details before completing an enrollment form. | ||||||||||
| NOTE: Eligible class of employees – all active full-time employees in participating agencies. | |||||||||||
| 1. Employee Name Test T Test | |||||||||||
| 2. Employee Mailing Address T, T, T 32327 | |||||||||||
| 3. Date of Birth | 4. Gender Option 1 | 5. Cell Phone | 6. Social Security Number 000000000 | ||||||||
| 7. Agency and County of Work Location T | 8. People First ID# | 9. Date of Hire | Personal Email Address chelseahatton@aol.com | ||||||||
| I hereby apply for a MetLife Legal Plan. I understand that the Company may decline to accept this application if it is not completed during the enrollment periods predetermined by the Company and the Sponsoring Employer. I further understand that, if accepted, my coverage will take effect (if actively at work) on the day following the end of the payroll period in which the first payroll deduction is made. I also certify that I am an Employee of the Sponsoring Employer in an Eligible Class (as specified above), and authorize my Employer to deduct from my earnings an amount sufficient to pay the premium for this insurance. I hereby acknowledge that I have received the outline of coverage describing insurance for which I am now applying. | |||||||||||
| Payroll Deduction Authorization | Employee Signature: |
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| Date: March 11, 2025 at 12:27 pm | |||||||||||
| Licensed Resident Agent: Douglas Moore, LUTCF, CSFP President & CEO, Capital Insurance Agency, Inc. |
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| Miscellaneous Deduction Code 0257 | Date Processed | Processed By | Effective Date of Coverage | ||
| Monthly Premium: $20.75 Bi-Weekly Premium: $9.58 | |||||