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Population: New or Prospective Non-Represented

Group Universal Life

Employee Coverage

Note: The rates and plan design below are effective 3/1/2012.

Employee Monthly Cost Per $1,000 of Coverage

Select Your Coverage:

GUL/GVUL¹ only	GUL/GVUL¹ with Voluntary Accidental Death and Dismemberment (AD&D) Benefit	AD&D only
Your Age²:
Tobacco User³:
Your Base Pay⁴:
Select Your GUL/GVUL Coverage Option⁵:		x Pay
Select Your AD&D Coverage Option⁵:		x Pay
Extra Monthly Contributions to the Tax Deferred Cash Accumulation Fund⁶: (optional)

Monthly Cost of Employee Coverage:

Dependent Coverage

Select Your Coverage:

GUL/GVUL¹ only	GUL/GVUL¹ with Voluntary Accidental Death and Dismemberment (AD&D) Benefit	AD&D only
Your Spouse's Age²:
Tobacco User³:
Select Your GUL/GVUL Coverage Option:
Select Your AD&D Coverage Option
Extra Monthly Contributions to the Tax Deferred Cash Accumulation Fund: (optional)
Child(ren) Coverage⁷: (if applicable)

Monthly Cost of Dependent Coverage:

Employee and Dependent Coverage

¹GVUL coverage has an additional $2.00 per month administrative fee.

²Please contact MetLife at 1-800-GET-MET8 (1-800-438-6388) for monthly rates for ages 75 and over.

³A tobacco user is someone who has smoked cigarettes, pipes or cigars, used snuff or chewed tobacco during the one-year period prior to the date of the enrollment form.

⁴Your base pay is rounded to the nearest $1,000.

⁵The maximum benefit available is $2,000,000.

⁶This amount must be approved by the Internal Revenue Service; your amount may be changed. For the maximum amount you can contribute, contact MetLife. Call 1-800-571-0400 and follow the voice recognition prompts for Life Insurance Providers, GUL/GVUL.

⁷One price offers coverage per child, regardless of number of children.