Continuation of Group Optional Life Coverage Form

Dear Retiree:
Congratulations on your Retirement! As a retiree of an employer participating in the State insurance
benefits offered through the South Carolina Public Employee Benefit Authority (PEBA), you are eligible
to continue your optional group life insurance coverage. Your premium will not be deducted from your
retirement annuity payment. You will be billed directly by MetLife for this insurance coverage.
Your first quarterly billing statement will be sent under separate cover. Please pay special attention to the
payment due date reflected on that statement.
In order for you to take advantage of this option, MetLife must receive page 2 of this letter back within 31
days from the date of your retirement. This will be your only chance to take advantage of this
opportunity. If you are not yet age 70, your existing coverage will be reduced at age 70 to an amount
equal to 65% of the original amount in force. In the future, if you decide that you are no longer interested
in maintaining this life insurance coverage, you may cancel at any time by calling our Customer Service
Center at the number below.
Also enclosed is a Beneficiary Designation Form. Please take a moment to complete this beneficiary
designation form to ensure your life insurance benefits are paid according to your wishes. Please complete
the form and return it along with the election portion of this letter to MetLife at the following address.
MetLife Recordkeeping Center
P. O. Box 14401
Lexington, KY 40512-4401
Fax: 1-866-545-7517
If you should have any questions regarding this letter or your options as a retiree, you may contact the
MetLife Customer Service Center at 866-492-6983, Monday through Friday, between the hours of 8:00
AM and 11:00 PM Eastern Time.
Sincerely,
MetLife Recordkeeping Services
Encl. Beneficiary Designation Form
L0613329332 [exp1215][All States][DC,GU,MP,PR,VI]
Metropolitan Life Insurance Company, New York, NY

The State of South Carolina. Policy Number: 9143046
Employee Information: Employee SSN _______________
________________________________________ _____________
Last Name First Name Middle Initial DOB (mm/dd/yy)
________________________________________________________________
Address City State Zip Code
My current insurance coverage amount is $_______________ (To be completed by Benefits
Administrator or Public Employee Benefit Authority staff), and I wish to continue my insurance coverage in the
amount of $_______________ (Increments of $10,000).
Optional Life Ins. Amt.
If there has been a reduction in coverage due to age, please provide the amount of coverage prior to reduction
$________________
____________Last Day Worked
__________________Active Group Coverage Termination Effective Date
____________ Date of Retirement
Retiree Signature_____________________________
Date____________________
I UNDERSTAND THAT THE INSURANCE I WISH TO CONTINUE WILL NOT BECOME EFFECTIVE UNLESS I HAVE
FULLY COMPLETED THIS FORM. THIS FORM MUST BE COMPLETED IN ITS ENTIRETY OR IT WILL BE RETURNED
TO ME.
Benefits Administrator Name (Print): ______________________
Employer Group #:_____________________________________
Employer Group Name: _______________________________________
Signature of verification by Benefits Administrator ______________________Date______________
(Or Public Employee Benefit Authority staff).
____________________________________________________________________________________
I HAVE ALREADY RECEIVED A PORTION OF MY COVERAGE UNDER THE ACCELERATED BENEFITS OPTION (ABO)
AND UNDERSTAND MY CONTINUED COVERAGE WILL EQUAL THE REMAINING COVERAGE IN EFFECT.
Retiree Signature (If applicable) ________________________
Date_____________________
L0613329332 [exp1215][All States][DC,GU,MP,PR,VI]
Metropolitan Life Insurance Company, New York, NY