Domestic Violence/Abuse Confidentiality and Confidential Communications Request

Individual Requesting Confidentiality I am a victim of domestic violence or other abuse, or a protected individual under certain state laws, and I request confidentiality.

* First Name

* Last Name

* Current Address of Record

* City

* State

* Zip

Invalid Zip Code

Date of Birth

* MM

* DD

* YYYY

Invalid Date

Social Security/ID No.

Alternative Contact Information(Please select one)

I request that MetLife send communications of claim-related or policy-related information to me by the following alternative means or at the following alternative locations:

In Care of

what's this?

Alternative Address

City

State

Zip Code

Invalid Zip Code

Alternative Phone

Alternative Email

I do not wish to change my contact information (address, phone number, or email) at this time. However, I am requesting that my information be treated with enhanced security measures. (Note: if alternative contact information is not provided, then claim-related and/or policy-related information will continue to be sent to your current address, phone number, and/or email address of record.)

Please select atleast one Checkbox

Protective Order

I have a court-issued order of protection. Please e-mail to AskCompliance@metlife.com

I do not have a court-issued order of protection.

Please select atleast one Checkbox

Product Information

(Separated by commas if there are multiple)

Please select at least one Product

Joint Brokerage Accounts: If you own a joint brokerage account, the broker-dealer is unable to keep your information secure from the other joint owner. As such, the broker-dealer will NOT change the address on its records if you have a joint brokerage account.

*The Farmers Insurance Group^® has acquired the MetLife Auto & Home business from MetLife, Inc. Therefore, the MetLife companies are no longer affiliated with MetLife Auto & Home and are no longer responsible for any of MetLife Auto & Homes’ activities. The Farmers Insurance Group will be responsible for your policy and its administration going forward. To submit a request for information protection, please provide your name, state, and policy number(s) to usw.ask.compliance@farmersinsurance.com.

Primary Insured Person For group coverage, including Group Life, Dental, and Vision, please provide:

Primary Insured's Name

Social Security/ID No.

Date of Birth

MM

DD

YYYY

Invalid Date

Relation

Parents, Guardians, or Legal Representatives

Parent or Guardian

If the covered individual is a child younger than 18 years old and the person making this request is the child’s parent or guardian, please provide the following information:

Name of child

Parent or Guardian's Name

Relationship to Child

Contact Phone

Must contain numbers (XXX-XXX-XXXX)

Contact Email

Invalid Email

For Guardians, please send guardianship documentation as soon as possible to MetLife’s Compliance Department at AskCompliance@metlife.com

Legal Representative

If a legal representative, such as a power of attorney, is making the request on behalf of the covered individual, please provide the following information.

Legal Representative's Name

Relationship to Covered Individual

XXX-XXX-XXXX

Must contain numbers (XXX-XXX-XXXX)

Contact Email

Invalid Email address

Please send Power of Attorney documentation as soon as possible to MetLife’s Compliance Department at AskCompliance@metlife.com

Domestic Violence/Abuse Confidentiality and Confidential Communications Request

Confidentiality Request for Victims of Domestic Violence and Other Endangered Individuals, including Protected Individuals

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