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Metlife enrollment change form

Section 1 - Health Information - For Life ADandD Disability Benefits 2025

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The document is an enrollment and change form for life and accidental death insurance provided by Metropolitan Life Insurance Company for employees of the WA State Health Care Authority PEBB. It includes sections for personal information, coverage options, tobacco use status, dependent information, beneficiary designation, and declarations regarding the accuracy of the information provided. The form outlines requirements for enrollment, including potential health statements based on coverage amounts and includes fraud warnings specific to various states.

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