LAPPOA MetLife Legal

MetLife Legal

Thank you for your interest in PPOA benefits! This is an interactive form designed to help you have a successful enrollment experience. Please call us at (888) 669-5096 or email support@ppoabenefits.com if you have any questions or need assistance.
Affiliation
Full Name

First NameLast Name
Home Email Address
example@example.com
Birth Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Social Security #
Employee ID
MetLife - Legal Plan
** Monthly rate
*Parents = The birth or adopted Parent(s), and Grandparents of the employee and spouse/domestic partner.
My initials below acknowlege that I understand the "Parents" definition.
MetLife Legal Initials*
Terms and Conditions

I understand that to be eligible for these benefits, I must meet all employment and membership requirements before the end of the enrollment period.

I understand that the plan(s) I selected is/are in a pending status until eligibility has been verified, and that my application may be denied if not completed by the end of the enrollment period.

I understand that all SDPEBA plans automatically renew each benefit year and that dental, vision, and legal plans can only be changed or cancelled due to a qualifying event, or during open enrollment.

I understand that the premiums for the PPOA Benefits plans I select will be combined and deducted as one (1) post-tax deduction and authorize PPOA Benefits to adjust deductions as needed to ensure premiums are current.
By signing below, I acknowledge that I have read, and agree to, ALL of the terms and conditions stated above. I am responsible for all premiums associated with the plan I have selected. I also understand that by enrolling into plans offered by PPOA Benefits, I, and any enrolled dependents, agree to abide by the Terms and Conditions of the Serevice Plan Document.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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