EX-99.(E) 3 b61223a2exv99wxey.txt ENTERPRISE APPLICATION FOR POLICY . . . 1 PART I CHECK THE APPROPRIATE COMPANY. OFFICE USE ONLY: APPLICATION FOR [ ] METROPOLITAN LIFE INSURANCE COMPANY [ ] METLIFE INVESTORS INSURANCE COMPANY INDIVIDUAL AND 200 Park Avenue, New York, NY 10166 13045 Tesson Ferry Road, St. Louis, MO 63128 MULTI-LIFE LIFE INSURANCE [ ] NEW ENGLAND LIFE INSURANCE COMPANY [ ] GENERAL AMERICAN LIFE INSURANCE COMPANY 501 Boylston Street, Boston, MA 02116-3700 13045 Tesson Ferry Road, St. Louis, MO 63128 [ ] METLIFE INVESTORS USA INSURANCE COMPANY 222 Delaware Avenue, Suite 900, PO Box 25130, Wilmington, DE 19899 The Company indicated above is referred to as "the Company". SECTION 1 1. PROPOSED INSURED #1 PROPOSED INSURED(S) Name _________________________________________________________________________________________________ FIRST MIDDLE LAST Street _______________________________________________________________________________________________ City __________________________________________ State ______________________ Zip ___________________ * If less than 3 years, Years at this address* ________________________ SSN/Tax ID _________________________________________ add prior residence Home Phone Number (___________________________) Best TIME to call: FROM _______________ address in Additional Work Phone Number (___________________________) [ ] Daytime [ ] Evening TO _________________ Information Section, Cell Phone Number (___________________________) Best NUMBER to call: [ ] Home [ ] Work [ ] Cell Page 13. Driver's License Number _______________________ State ______________________________________________ License Issue Date ____________________________ License Expiration Date ____________________________ Marital Status [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed Date of Birth _________________________________ State/Country of Birth _____________________________ MONTH DAY YEAR Sex [ ] Male [ ] Female Net Worth $_________________________________________ Annual Earned Income $_________________________ Annual Unearned Income $____________________________ Employer's Name ______________________________________________________________________________________ NOTE: Street _______________________________________________________________________________________________ P.O. Box numbers City __________________________________________ State ______________________ Zip ___________________ CANNOT be accepted for Position/Title/Duties _________________________ Length of Employment _______________________________ street addresses. 2. PROPOSED INSURED #2 Life 2, Spouse, Designated Life, Person to be covered under Applicant's Waiver of Premium Benefit Relationship to Proposed Insured #1 Name _________________________________________________________________________________________________ FIRST MIDDLE LAST (ARROW) Street _______________________________________________________________________________________________ IF ADDRESS IS SAME City __________________________________________ State ______________________ Zip ___________________ AS PROPOSED Years at this address* ________________________ SSN/Tax ID _________________________________________ INSURED #1, Home Phone Number (___________________________) Best TIME to call: WRITE "SAME". Work Phone Number (___________________________) [ ] Daytime [ ] Evening Cell Phone Number (___________________________) Best NUMBER to call: [ ] Home [ ] Work [ ] Cell Driver's License Number _______________________ State ______________________________________________ Issue Date ____________________________________ Expiration Date ____________________________________ ADDITIONAL Marital Status [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed INSUREDS: Date of Birth _________________________________ State/Country of Birth _____________________________ See Supplemental MONTH DAY YEAR Forms Package. Sex [ ] Male [ ] Female Net Worth $_________________________________________ Annual Earned Income $_________________________ Annual Unearned Income $____________________________ Employer's Name ______________________________________________________________________________________ Street _______________________________________________________________________________________________ City __________________________________________ State ______________________ Zip ___________________ Position/Title/Duties _________________________ Length of Employment _______________________________
ENB-7-05 FF (05/05) 2 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 3. DEPENDENT SPOUSE OR MINOR SECTION 1 A. Are any persons to be insured a dependent spouse? [ ] YES [ ] NO PROPOSED IF YES, please provide: INSURED(S) Amount of EXISTING insurance on spouse of Proposed Insured $_______________ (continued) Amount of insurance APPLIED FOR on spouse of Proposed Insured $_______________ B. 1. Are any persons to be insured a dependent minor? [ ] YES [ ] NO IF YES, please provide: Amount of EXISTING insurance on father/guardian $_______________ Amount of insurance APPLIED FOR on father/guardian $_______________ Amount of EXISTING insurance on mother/guardian $_______________ Amount of insurance APPLIED FOR on mother/guardian $_______________ 2. Are all siblings of this dependent minor equally insured? [ ] YES [ ] NO IF NO, please provide details: ______________________________________________________________________________________________________ 1. EXISTING OR APPLIED FOR INSURANCE SECTION 2 A. Do any of the Proposed Insureds or Owners have any exisitng or applied for EXISTING OR life insurance (L) or annuity (A) contracts with this or any other company? APPLIED FOR INSURANCE PROPOSED INSURED [ ] YES [ ] NO OWNER [ ] YES [ ] NO IF YES IF YES, provide details on PROPOSED INSURED ONLY: Some states require the completion of an PROPOSED additional form. See INSURED TYPE AMOUNT OF YEAR OF ACCIDENTAL EXISTING OR instructions on the cover (#1, #2, OTHER) COMPANY (L, A) INSURANCE ISSUE DEATH AMOUNT APPLIED FOR of the Replacement --------------- ------- ------ --------- ------- ------------ ----------- Forms Package. [ ] E _______________ _______ ______ _________ _______ ____________ [ ] A [ ] E _______________ _______ ______ _________ _______ ____________ [ ] A [ ] E _______________ _______ ______ _________ _______ ____________ [ ] A [ ] E _______________ _______ ______ _________ _______ ____________ [ ] A [ ] E _______________ _______ ______ _________ _______ ____________ [ ] A B. Do any of the Proposed Insureds have any application for disability insurance (D) or critical illness insurance (C) or long term care insurance (LTC) applied for or planned with THIS Company or its affiliates? [ ] YES [ ] NO IF YES, provide: Proposed Insured (#1, #2, other) __________ Type (D, C, LTC) __________ 2. REPLACEMENT Applicable replacement A. In connection with this application, has there been, or will there be with and 1035 exchange this or any other company any: surrender transaction; loan; withdrawal; lapse; forms can be found reduction or redirection of premium/consideration; or change transaction in Replacement (except conversions) involving an annuity or other life insurance? [ ] YES [ ] NO Forms Package. IF YES,complete Replacement Questionnaire and Disclosure AND any other state required replacement forms. B. Is this an exchange under Internal Revenue code section 1035? [ ] YES [ ] NO IF YES, complete the 1035 Exchange Authorization FOR EACH AFFECTED POLICY.
ENB-7-05 FF (05/05) 3 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 3 OWNER IDENTITY OF PRIMARY OWNER(Check one.) [ ] Proposed Insured #1 COMPLETE QUESTION 1 ONLY. [ ] Proposed Insured #2 COMPLETE QUESTION 1 ONLY. [ ] Other Person COMPLETE QUESTIONS 1 AND 2. [ ] Entity COMPLETE QUESTION 3 ONLY. 1. OWNER IDENTIFICATION (ARROW) [ ] U.S. Driver's License already provided on page 1 (Proposed Insured) IF U.S. DRIVER'S LICENSE [ ] U.S. Driver's License [ ] Green Card [ ] Passport [ ] Other GOVERNMENT ISSUED ALREADY PROVIDED, NO Issuer of ID __________________________________ ID Issue Date ________________________________________ FURTHER INFORMATION IS ID Reference Number ___________________________ ID Expiration Date ___________________________________ REQUIRED. 2. OWNER OTHER THAN PROPOSED INSURED(S) NOTE: Name _________________________________________________________________________________________________ P.O. Box numbers FIRST MIDDLE LAST CANNOT be accepted for Street _______________________________________________________________________________________________ street addresses. City ____________________________________________ State ______________________ Zip ___________________ Phone Number (________________________________) IF CUSTODIAN Citizenship _____________________________________ Country of Permanent Residence _____________________ is acting on behalf of a Date of Birth ___________________________________ SSN/Tax ID _________________________________________ minor under UTMA/UGMA, MONTH DAY YEAR please complete Additional Relationship to Proposed Insured(s) __________________________________________________________________ Owner Form in Supplemental Employer's Name ______________________________________________________________________________________ Forms package. Street _______________________________________________________________________________________________ City ____________________________________________ State ______________________ Zip ___________________ Position/Title/Duties ___________________________ Length of Employment _______________________________ [ ] Check if you wish ownership to revert to Insured upon Owner and Contingent Owner's death. 3. ENTITY/TRUST AS OWNER Entity/Trust Type: [ ] C Corporation [ ] S Corporation [ ] LLC [ ] Partnership [ ] Sole Proprietorship [ ] Trust IF TRUST Tax ID Number ___________________________________ Date of Trust ______________________________________ Complete Trust MONTH DAY YEAR Certification form in Name of Entity/Trust _________________________________________________________________________________ Supplemental Forms Package. Name of Trustee(s) ___________________________________________________________________________________ Street _______________________________________________________________________________________________ City ____________________________________________ State ______________________ Zip ___________________ IF BUSINESS Proposed Insured(s) Relationship to Entity ___________________________________________________________ Complete Business Nature of Business ____________________________________________ Business Phone _______________________ Supplement form in Is entity publicly traded? [ ] YES [ ] NO Supplemental Forms Package. IF NO,please supply one of the following documents: (Indicate which one you are supplying.) [ ] Articles of Incorporation/Government Issued Business License [ ] LLC Operating Agreement [ ] Partnership Agreement [ ] Government Issued Certificate of Good Standing
ENB-7-05 FF (05/05) 4 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 4 BENEFICIARY(IES) NOTE: Federal law states if you leave someone with special needs any assets over $2,000, they may lose eligibility for most government benefits. CONTINGENT BENEFICIARIES ONLY [ ] Check here if you want any and all living and future natural or adopted children of Proposed Insured #1 to be included as Contingent Beneficiaries. Name any living children as beneficiaries below. (ARROW) [ ] PRIMARY [ ] CHECK HERE AND DO NOT Name _________________________________________________________________________________________________ COMPLETE IF PRIMARY FIRST MIDDLE LAST BENEFICIARY IS SAME AS Street _______________________________________________________________________________________________ TRUST OR ENTITY OWNER. City ____________________________________________ State ______________________ Zip ___________________ Date of Birth ___________________________________ SSN/Tax ID NOT REQUIRED If there is a court MONTH DAY YEAR appointed legal Guardian Relationship to Proposed Insured(s) __________________________________________________________________ for Beneficiary, provide Percent of Proceeds ______ (Multiple Beneficiaries will receive an equal percentage of proceeds unless name and address in otherwise instructed.) Additional Information Section, Page 13. [ ] PRIMARY [ ] CONTINGENT Name _________________________________________________________________________________________________ FIRST MIDDLE LAST Street _______________________________________________________________________________________________ City ____________________________________________ State ______________________ Zip ___________________ Date of Birth ___________________________________ SSN/Tax ID NOT REQUIRED MONTH DAY YEAR Relationship to Proposed Insured(s) __________________________________________________________________ Percent of Proceeds ______ (Multiple Beneficiaries will receive an equal percentage of proceeds unless otherwise instructed.) [ ] PRIMARY [ ] CONTINGENT Name _________________________________________________________________________________________________ FIRST MIDDLE LAST Street _______________________________________________________________________________________________ City ____________________________________________ State ______________________ Zip ___________________ Date of Birth ___________________________________ SSN/Tax ID NOT REQUIRED MONTH DAY YEAR Relationship to Proposed Insured(s) __________________________________________________________________ Percent of Proceeds ______ (Multiple Beneficiaries will receive an equal percentage of proceeds unless otherwise instructed.) SECTION 5 Custodian's name _____________________________________________________________________________________ CUSTODIAN ACTING FOR MINOR FIRST MIDDLE LAST BENEFICIARY(IES) as custodian for _____________________________________________________________________________________ NAME(S) OF MINOR(S) under the ________________________________________________ Uniform Transfers [or Gifts] to Minors Act. NAME OF STATE Street _______________________________________________________________________________________________ City ____________________________________________ State ______________________ Zip ___________________ Relationship to Minor(s) _____________________________________________________________________________
ENB-7-05 FF (05/05) 5 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 1. PRODUCT & FACE AMOUNT SECTION 6 Product Name _________________________________________________________________________________________ INFORMATION REGARDING Face Amount $_________________________ (Complete Personal Financial Supplement if $1,000,000 or more.) INSURANCE APPLIED FOR [ ] Group Conversion* Optional Benefits and Riders: [ ] Guaranteed Survivor Plus Purchase Options (GSPO+)* Option Period(s): _____________________________________________________ $_______________________ COMPLETE FOR FIRST DESIGNATED LIFE [ ] Guaranteed Survivor Income Benefit (GSIB) [ ] Term Rider Specify: ______________________ $____________________________________________________ [ ] Life Guaranteed Purchase Option (LGPO) *Complete these forms, [ ] Acceleration of Death Benefit Rider (ADBR)* if applicable: [ ] Enricher Options (PAIR/VABR)*Specify: _________________________________ $_______________________ - ADBR [ ] Long Term Care Guaranteed Purchase Option (LTC-GPO) - Enricher/Equity [ ] Disability Waiver (DW) Specify: _______________________________________ $_______________________ Additions - Group Conversion [ ] Other ____________________________________________________________________________________________ - GSPO+ Special Requests/Other: These forms can [ ] Save Age [ ] Specific Policy Date ______________________________________________________________ be found in [ ] Other ____________________________________________________________________________________________ the Supplemental ______________________________________________________________________________________________________ Forms Package. Check here if [ ] alternate OR [ ] additional policy is requested and provide full details below. Include SIGNED & DATED illustration for each policy requested. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. ADDITIONAL INFORMATION FOR WHOLE LIFE PRODUCTS Do you request automatic payment of premium in default by Policy Loan (for traditional plans), if available? [ ] YES [ ] NO Dividend Options: [ ] Paid-up Additions [ ] VAI Equity Additions* [ ] Premium Reduction [ ] Cash [ ] Accumulations/DWI [ ] Other ____________________________________________________________________________________________ 3. ADDITIONAL INFORMATION FOR UNIVERSAL LIFE/VARIABLE LIFE PRODUCTS For Variable Life, also Planned Premium Amount: Year 1 $____________________ Excess/Lump Sum $______________________________ complete Variable Duration of premium payments _________________________________________________________________________ Life Supplement. Planned annual unscheduled payment (if applicable): $_________________________________________________ Renewal Premium (if applicable): $____________________________________________________________________ Death Benefit Option/Contract Type ___________________________________________________________________ Definition of Life Insurance Test: [ ] Guideline Premium Test [ ] Cash Value Accumulation Test (if available under policy applied for) Guaranteed to age: (VUL only) [ ] 65 [ ] 75 [ ] 85 [ ] 5 years [ ] Other ___________________ 4. ADDITIONAL INFORMATION FOR QUALIFIED PLANS Qualified/Non-Qualified Plan number __________________________________________________________________ EGN/PENSION NUMBER
ENB-7-05 FF (05/05) 6 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 7 1. PAYMENT MODE (Check one.) PAYMENT INFORMATION DIRECT BILL: [ ] Annual [ ] Semi-Annual [ ] Quarterly ELECTRONIC PAYMENT: [ ] Monthly If MONTHLY ELECTRONIC SPECIAL ACCOUNT: [ ] Government Allotment [ ] Salary Deduction PAYMENT is chosen, complete Additional Details: Electronic Payment Account Agreement. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. SOURCE OF CURRENT AND FUTURE PAYMENTS (Check all that apply.) [ ] Earned Income [ ] Mutual Fund/Brokerage Account [ ] Money Market Fund [ ] Savings [ ] Use of Values in another Life Insurance/Annuity Contract [ ] Certificate of Deposit [ ] Loans [ ] Other ________________________________________________________________________________ NOTE: 3. PAYMENT It is Company Policy to not accept cash, traveler's Amount collected with application $___________________________________________________________________ checks, or money orders as (Must equal at least one monthly premium.) a form of payment for Premium Payor: Variable Life Products. [ ] Proposed Insured #1 [ ] Proposed Insured #2 [ ] Primary Owner [ ] Other Name _____________________________________________________________________________________________ Relationship to Proposed Insured(s) and Owner ____________________________________________________ Reason this person is the Payor __________________________________________________________________ 4. BILLING ADDRESS INFORMATION [ ] Proposed Insured #1 Address [ ] Proposed Insured #2 Address [ ] Primary Owner's Address [ ] Other Premium Payor's/Alternate Billing Address (Provide details here.) Street _______________________________________________________________________________________________ City __________________________________________ State ____________________ Zip ___________________ [ ] Special Arrangements ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ E-MAIL ADDRESSES (optional) Proposed Insured #1 __________________________________________________________________________________ Proposed Insured #2 __________________________________________________________________________________ Primary Owner ________________________________________________________________________________________ Joint/Contingent Owner _______________________________________________________________________________
ENB-7-05 FF (05/05) 7 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 8 The following questions are to be answered for ALL persons to be insured, including those covered by GENERAL RISK QUESTIONS any riders applied for. 1. Within the past three years has ANY person to be insured flown in a plane other than as a passenger on a scheduled airline or have plans for such activity within the next year? [ ] YES [ ] NO IF YES, complete a separate Aviation Supplement for each applicable Proposed Insured. If you need more space, 2. Within the past three years has ANY person to be insured participated in or please use the Additional intend to participate in ANY of the following: Information Section, Page 13. Underwater sports - (SCUBA diving, skin diving, or similar activities); Sky sports - (skydiving, hang gliding, parachuting, ballooning or similar activities); Racing sports - (motorcycle, auto, motor boat or similar activities); Rock or mountain climbing or similar activities; Bungee jumping or similar activities? [ ] YES [ ] NO IF YES, complete a separate Avocation Supplement for each applicable Proposed Insured. 3. Within the PAST TWO YEARS has ANY person to be insured TRAVELED or RESIDED outside the U.S. or Canada? [ ] YES [ ] NO IF YES, for each occurence, please provide Proposed Insured, duration, country and purpose. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. Within the NEXT TWO YEARS does ANY person to be insured INTEND TO TRAVEL or RESIDE outside the U.S. or Canada? [ ] YES [ ] NO IF YES, for each occurence, please provide Proposed Insured, duration, country and purpose. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 5. CITIZENSHIP/RESIDENCY A. Are all persons to be insured U.S. Citizens? [ ] YES [ ] NO IF NO, please provide details: Proposed Insured(s) ________________________________ Country of Citizenship __________________________ Visa Type/ID _______________________________________ Visa Number _____________________________________ Expiration Date ____________________________________ Length of Time in U.S. __________________________ MM/DD/YY [ ] Check here if currently applying for a Social Security number. B. Are all persons to be insured permanent residents of the United States? [ ] YES [ ] NO IF NO, please provide details: Proposed Insured(s) __________________________________________________________________________________ Country of Residence _________________________________________________________________________________
ENB-7-05 FF (05/05) 8 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 8 GENERAL RISK The following questions are to be answered for ALL persons to be insured, including those covered by QUESTIONS (continued) any riders applied for. 6. In the last five years, has ANY person to be insured used tobacco products (e.g., cigarettes; cigars; pipes; smokeless tobacco; chew; etc.) or nicotine substitutes (e.g., patch, gum)? [ ] YES [ ] NO IF YES, please provide details: Proposed Insured(s) ______________________________ Date Last Used ____________________________________ Type _________________________________________________________________________________________________ Amount/Frequency _____________________________________________________________________________________ If you need more space, 7. Has ANY person to be insured: EVER had a driver's license suspended or please use the Additional revoked; EVER been convicted of DUI or DWI; or had, in the last five years, Information Section, Page any moving violations? [ ] YES [ ] NO 13. IF YES, please provide Proposed Insured, date and violation. Proposed Insured(s) __________________________________________________________________________________ Details: _____________________________________________________________________________________________ ______________________________________________________________________________________________________ 8. Has any person to be insured EVER had an application for life, disability income or health insurance declined, postponed, rated or modified or required an extra premium? [ ] YES [ ] NO IF YES, please provide details: Proposed Insured(s) __________________________________________________________________________________ Details: _____________________________________________________________________________________________ ______________________________________________________________________________________________________ 9. Are all persons to be insured: actively at work; or a homemaker performing regular household duties; or a student attending school regularly? IF NO, please provide details: [ ] YES [ ] NO Proposed Insured(s) __________________________________________________________________________________ Details: _____________________________________________________________________________________________ Please answer these 10. LONG TERM CARE GUARANTEED PURCHASE OPTION RIDER questions ONLY IF REQUESTING THE LONG TERM A. Does any person to be insured under this rider currently use any mechanical equipment such as: a CARE GUARANTEED PURCHASE walker; a wheelchair; long leg braces; or crutches? [ ] YES [ ] NO OPTION RIDER. IF YES, please note which and the reason. ______________________________________________________________________________________________________ Proposed Insured(s) __________________________________________________________________________________ B. Does any person to be insured under this rider need any assistance or supervision with any of the following activities: bathing; dressing; walking; moving in/out of a chair or bed; toileting; continence; or taking medication? [ ] YES [ ] NO Proposed Insured(s) __________________________________________________________________________________
ENB-7-05 FF (05/05) 9 PART II IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 1 1. PHYSICIAN PHYSICIAN Please provide name of doctor, practitioner, or health care facility who can provide the most INFORMATION complete and up to date information concerning the present health of the Proposed Insured(s). PHYSICIAN INFORMATION FOR PROPOSED INSURED #1 [ ] Check here if no doctor, practitioner or health care facility is known. PLEASE NOTE: Physician Name ________________________________________________ Phone Number (_____________________) If FULL PARAMEDICAL Name of Practice/Clinic _______________________________________ Fax Number (_______________________) exam is required, Street________________________________________________________________________________________________ completion of Medical City __________________________________________ State _____________________ Zip ____________________ questions is OPTIONAL Date Last Consulted ___________________________ Reason _____________________________________________ but will expedite MONTH DAY YEAR your application. Findings, treatment given, medication prescribed. If None, check here [ ]. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ PHYSICIAN INFORMATION [ ] PROPOSED INSURED #1 [ ] PROPOSED INSURED #2 [ ] Check here if no doctor, practitioner or health care facility is known. Physician Name ________________________________________________ Phone Number (_____________________) Name of Practice/Clinic _______________________________________ Fax Number (_______________________) Street _______________________________________________________________________________________________ City __________________________________________ State ______________________ Zip ___________________ Date Last Consulted ___________________________ Reason _____________________________________________ MONTH DAY YEAR Findings, treatment given, medication prescribed. If None, check here [ ]. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ SECTION 2 1. HEIGHT/WEIGHT MEDICAL Proposed Insured #1 Height ________________________________ Weight _______________________________ QUESTIONS Proposed Insured #2 Height ________________________________ Weight _______________________________ Has any Proposed Insured experienced a change in weight (greater than 10 pounds) in the past 12 months? [ ] YES [ ] NO IF YES, specify: Proposed Insured #1 Pounds lost ___________________________ Pounds gained ________________________ Proposed Insured #2 Pounds lost ___________________________ Pounds gained ________________________ Reason _______________________________________________________________________________________________
ENB-7-05 FF (05/05) 10 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 2 2. Has a parent (P) or sibling (S) of any person to be insured ever had: heart MEDICAL disease; coronary artery disease; high blood pressure; diabetes; or mental QUESTIONS illness? [ ] YES [ ] NO (continued) IF YES,indicate below: PLEASE NOTE: PROPOSED INSURED RELATIONSHIP TO AGE IF AGE AT STATE OF HEALTH, SPECIFIC CONDITIONS, If FULL PARAMEDICAL (#1, #2) PROPOSED INSURED LIVING DEATH CAUSE OF DEATH exam is required, ---------------- ---------------- ------ ------ ------------------------------------- completion of Medical ________________ [ ] P [ ] S ______ ______ _____________________________________ questions is OPTIONAL ________________ [ ] P [ ] S ______ ______ _____________________________________ but will expedite ________________ [ ] P [ ] S ______ ______ _____________________________________ your application. ________________ [ ] P [ ] S ______ ______ _____________________________________ 3. Has ANY person to be insured EVER received treatment, attention, or advice from any physician, practitioner or health facility for, or been told by any physician, practitioner or health facility that he/she had: OTHER PROPOSED PROPOSED PROPOSED INSURED #1 INSURED #2 INSURED ---------- ---------- -------- YES NO YES NO YES NO A. High blood pressure; chest pain; heart attack; or any other disease or disorder of the heart or circulatory system? [ ] [ ] [ ] [ ] [ ] [ ] B. Asthma; bronchitis; emphysema; sleep apnea; shortness of breath; or any other disease or disorder of the lungs or respiratory system? [ ] [ ] [ ] [ ] [ ] [ ] C. Seizures; stroke; paralysis; Alzheimer's disease; multiple sclerosis; memory loss; Parkinson's disease; progressive neurological disorder; headaches; or any other disease or disorder of the brain or nervous system? [ ] [ ] [ ] [ ] [ ] [ ]
DETAILS: If you ANSWERED YES to any of the above questions, please provide details here.
QUESTION PROPOSED INSURED NAME OF PHYSICIAN DATE/DURATION DIAGNOSIS/SEVERITY NUMBER NAME ADDRESS IF NOT ALREADY PROVIDED OF ILLNESS MEDICATIONS/TREATMENT -------- ---------------- ------------------------------- ------------- --------------------- ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________
ENB-7-05 FF (05/05) 11 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 2 3. Has ANY person to be insured EVER received treatment, attention, or advice from any physician, MEDICAL QUESTIONS practitioner or health facility for, or been told by any physician, practitioner or health (continued) facility that he/she had: OTHER PROPOSED PROPOSED PROPOSED INSURED #1 INSURED #2 INSURED ---------- ---------- --------- YES NO YES NO YES NO PLEASE NOTE: D. Ulcers; colitis; hepatitis; cirrhosis; or any If FULL PARAMEDICAL other disease or disorder of the liver; exam is required, gallbladder; stomach; or intestines? [ ] [ ] [ ] [ ] [ ] [ ] completion of Medical questions is OPTIONAL E. Any disease or disorder of: the kidney; but will expedite bladder; or prostate; or blood, protein or your application. pus in the urine? [ ] [ ] [ ] [ ] [ ] [ ] F. Diabetes; thyroid disorder; or any other endocrine problem(s)? [ ] [ ] [ ] [ ] [ ] [ ] G. Arthritis; gout; or disorder of the muscles, bones or joints? [ ] [ ] [ ] [ ] [ ] [ ] H. Cancer; tumor; polyp; cyst or any skin disease or disorder? [ ] [ ] [ ] [ ] [ ] [ ] I. Anemia; leukemia; or any other disorder of the blood or lymph glands? [ ] [ ] [ ] [ ] [ ] [ ] J. Depression; stress; anxiety; or any other psychological or emotional disorder or symptoms? [ ] [ ] [ ] [ ] [ ] [ ] K. Any disease or disorder of the eyes, ears, nose, or throat? [ ] [ ] [ ] [ ] [ ] [ ]
DETAILS: If you ANSWERED YES to any of the above questions, please provide details here.
QUESTION PROPOSED INSURED NAME OF PHYSICIAN DATE/DURATION DIAGNOSIS/SEVERITY NUMBER NAME ADDRESS IF NOT ALREADY PROVIDED OF ILLNESS MEDICATIONS/TREATMENT -------- ---------------- ------------------------------- ------------- --------------------- ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________
ENB-7-05 FF (05/05) 12 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. SECTION 2 4. Has ANY person to be insured: MEDICAL QUESTIONS OTHER (continued) PROPOSED PROPOSED PROPOSED INSURED #1 INSURED #2 INSURED ---------- ---------- --------- YES NO YES NO YES NO A. Currently, or within the past six months, been under observation or received treatment or taken any medication? (Including over-the -counter medications, vitamins, herbal supplements, etc.) [ ] [ ] [ ] [ ] [ ] [ ] B. For the next six months, scheduled any doctor's visits, medical care, or surgery? [ ] [ ] [ ] [ ] [ ] [ ] PLEASE NOTE: C. During the past five years, had a: checkup; If FULL PARAMEDICAL electrocardiogram; chest x-ray; or medical [ ] [ ] [ ] [ ] [ ] [ ] exam is required, test? completion of Medical questions is OPTIONAL D. During the past five years, had any illness, but will expedite injury or health condition not revealed your application. above; or have been recommended to have any: hospitalization; surgery; medical test; or medication? [ ] [ ] [ ] [ ] [ ] [ ] E. EVER been diagnosed with or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS)? [ ] [ ] [ ] [ ] [ ] [ ] F. EVER tested positive for the AIDS Human Immunodeficiency Virus (HIV) or for antibodies to the AIDS (HIV) virus? [ ] [ ] [ ] [ ] [ ] [ ] G. EVER used heroin, cocaine, barbituates, or other drugs, except as prescribed by a physician or other licensed practitioner? [ ] [ ] [ ] [ ] [ ] [ ] H. EVER received treatment from a physician or counselor regarding the use of alcohol, or the use of drugs, except for medicinal purposes; or received treatment or advice from an organization that assists those who have an alcohol or drug problem? [ ] [ ] [ ] [ ] [ ] [ ]
DETAILS: If you ANSWERED YES to any of the above questions, please provide details here.
QUESTION PROPOSED INSURED NAME OF PHYSICIAN DATE/DURATION DIAGNOSIS/SEVERITY NUMBER NAME ADDRESS IF NOT ALREADY PROVIDED OF ILLNESS MEDICATIONS/TREATMENT -------- ---------------- ------------------------------- ------------- --------------------- ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________ ________ ________________ _______________________________ _____________ _____________________
ENB-7-05 FF (05/05) 13 ADDITIONAL INFORMATION USE THIS PAGE FOR ANY ADDITIONAL INFORMATION. ATTACH A SEPARATE SHEET IF NECESSARY. ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________
ENB-7-05 FF (05/05) 14 CERTIFICATION/AGREEMENT/ DISCLOSURE CERTIFICATION REGARDING SALES ILLUSTRATION Agent must check the appropriate statement below. [ ] Agent certifies that a signed illustration is NOT REQUIRED by law or the policy applied for is not illustrated in this state. [ ] An illustration was signed and MATCHES THE POLICY APPLIED FOR. It is included with this application. [ ] An illustration was shown or provided but is DIFFERENT FROM THE POLICY APPLIED FOR. An illustration conforming to the policy as issued will be provided no later than at the time of policy delivery. [ ] NO ILLUSTRATION CONFORMING TO THE POLICY as applied for was shown or provided prior to or at the time of this application. An illustration conforming to the policy as issued will be provided no later than at the time of policy delivery. [ ] If illustration was ONLY SHOWN ON A COMPUTER SCREEN, check and complete details below. An illustration was displayed on a computer screen. The displayed illustration MATCHES THE POLICY APPLIED FOR but no printed copy of the illustration was provided. An illustration conforming to the policy as issued will be provided no later than at the time of policy delivery. The illustration on the screen included the following personal and policy information: 1. Gender (as illustrated) [ ] M [ ] F [ ] Unisex Age ______________________________________________ 2. Rating class (e.g. standard, smoker) [ ] Preferred [ ] Standard [ ] Non-smoker [ ] Smoker [ ] Other _______________________________________________________________________ 3. Type of policy (e.g. L-98, Whole Life) _________________________________________________________________________________ 4. Initial Death Benefit $___________________________________ Death Benefit Option __________________________________________ 5. Guaranteed Minimum Death Benefit [ ] age 55 [ ] age 65 [ ] age 75 [ ] age 85 [ ] 5 years 6. Dividend Option __________________________________________________________________________________________________________ 7. Riders _________________________________________________________________ $________________________________________________ _________________________________________________________________ $________________________________________________ _________________________________________________________________ $________________________________________________ FRAUD WARNINGS ARKANSAS, KENTUCKY, LOUISIANA, NEW MEXICO, OHIO, OKLAHOMA Any person who knowingly and with intent to defraud any insurance company or any other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties. WASHINGTON D.C., TENNESSEE, VIRGINIA It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. AGREEMENT/DISCLOSURE I HAVE READ THIS APPLICATION FOR LIFE INSURANCE INCLUDING ANY AMENDMENTS AND SUPPLEMENTS AND TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL STATEMENTS ARE TRUE AND COMPLETE. I ALSO AGREE THAT: - My statements in this application and any amendment(s), paramedical/medical exam and supplement(s) are the basis of any policy issued. - This application and any: amendment(s); paramedical/medical exam; and supplement(s) to this application, will be attached to and become part of the new policy. - No information will be deemed to have been given to the Company unless it is stated in this application and paramedical/medical exam, and any supplement(s). - Only the Company's President, Secretary or Vice-President may: (a) make or change any contract of insurance; (b) make a binding promise about insurance; or (c) change or waive any term of an application, receipt, or policy. - Except as stated in the Temporary Insurance Agreement and Receipt, no insurance will take effect until a policy is delivered to the Owner and the full first premium due is paid. It will only take effect at the time it is delivered if: (a) the condition of health of each person to be insured is the same as stated in the application; and (b) no person to be insured has received any medical advice or treatment from a medical practitioner since the date of the application.
ENB-7-05 FF (05/05) 15 CERTIFICATION/AGREEMENT/ (continued) DISCLOSURE - I understand that paying my insurance premiums more frequently than annually may result in a higher yearly out-of-pocket cost or different cash values. - IF I INTEND TO REPLACE EXISTING INSURANCE OR ANNUITIES, I HAVE SO INDICATED IN SECTION 2, QUESTION 2 OF THIS APPLICATION. - I HAVE RECEIVED THE COMPANY'S CONSUMER PRIVACY NOTICE AND, AS REQUIRED, THE LIFE INSURANCE BUYER'S GUIDE. - IF I WAS REQUIRED TO SIGN AN HIV INFORMED CONSENT AUTHORIZATION, I HAVE RECEIVED A COPY OF THAT AUTHORIZATION. TAXPAYER IDENTIFICATION NUMBER CERTIFICATION Under penalties of perjury, I, the Owner, certify that: The number shown in this application is my correct taxpayer identification number, and I am not subject to backup withholding because: (a) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends; OR (b) the IRS has notified me that I am not subject to backup withholding. (If you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return, you must cross out and initial this item.) I am a U.S. citizen or a U.S. resident alien for tax purposes. (If you are not a U.S. citizen or a U.S. resident alien for tax purposes, please cross out this certification and complete form W-8BEN). PLEASE NOTE: The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. SIGNATURES: Signed at City, State __________________________________________ Date ________________________________ If not witnessing (HAND) PROPOSED INSURED #1 __________________________________________________________________________________ all signatures, (age 15 or over) Witness should sign next to the Signed at City, State __________________________________________ Date ________________________________ signature being witnessed. (HAND) PROPOSED INSURED #2 __________________________________________________________________________________ (age 15 or over) Signed at City, State __________________________________________ Date ________________________________ (HAND) OWNER ________________________________________________________________________________________________ (If other than Proposed Insured) (If age 15 or over) If the Owner is a firm or corporation, include Officer's title with signature. Signed at City, State _________________________________________ Date ________________________________ (HAND) PARENT OR GUARDIAN ___________________________________________________________________________________ (If Owner or Proposed Insured(s) is/are under 18, sign here if not signed above.) Signed at City, State __________________________________________ Date ________________________________ (HAND) WITNESS TO SIGNATURES ________________________________________________________________________________ (Licensed Agent/Producer) PLEASE PRINT AGENT/PRODUCER NAME _____________________________________________________________________
ENB-7-05 FF (05/05) VARIABLE LIFE SUPPLEMENT Proposed Insured: ____________________________________________________________________________________ METLIFE INVESTORS USA INSURANCE COMPANY This supplement will be attached to and become part of the application with which it is used. IMPORTANT INFORMATION FOR Variable Life Insurance is generally not appropriate for time horizons of less than 10 years. These THE OWNER - PLEASE READ are long-term insurance products that may have significant short-term surrender charges. Variable Life CAREFULLY Insurance is designed to provide death benefit protection while offering the potential for long-term cash accumulation, and may not be appropriate in situations where significant liquidation of assets in the near future may be expected. THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS. THE CASH VALUE MAY INCREASE OR DECREASE, EVEN TO THE EXTENT OF BEING REDUCED TO ZERO, IN ACCORDANCE WITH SEPARATE ACCOUNT INVESTMENT EXPERIENCE. THE COST OF INSURANCE RATES FOR THIS POLICY MAY CHANGE. THE RATES CURRENTLY BEING CHARGED ARE NOT GUARANTEED, AND THE COMPANY MAY CHARGE THE FULL MAXIMUM GUARANTEED RATES. ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS AND CASH VALUES, ARE AVAILABLE UPON REQUEST. OWNER'S INFORMATION Tax bracket _______% Liquid Net Worth $____________________________________________________________ (Exclude personal residence, automobiles & home furnishings.) Annual Income $________________________ Prior Investment Experience (Choose all that apply and indicate your years of experience.) [ ] Certificate of Deposit ________ years [ ] Stocks ________ years [ ] Mutual Funds _______ years [ ] Money Markets _________________ years [ ] Bonds ___________ years [ ] Other______________________________________________________________________________ ______ years Is Owner(s) an associated person of a broker dealer? [ ] YES [ ] NO INVESTMENT OBJECTIVE AND INVESTMENT OBJECTIVE RISK TOLERANCE RISK TOLERANCE Indicate the investment Have you completed the Asset Allocation Questionnaire? [ ] YES [ ] NO objective for your policy's funding options. IF YES, please submit with application. Indicate risk tolerance below (choose only one). Be sure it supports the investment objective and your risk tolerance for this policy. [ ] Capital Preservation [ ] Conservative [ ] Conservative to Moderate [ ] Income [ ] Conservative [ ] Conservative to Moderate [ ] Moderate [ ] Growth & Income [ ] Moderate [ ] Moderate to Aggressive [ ] Growth [ ] Moderate to Aggressive [ ] Aggressive [ ] Aggressive Growth [ ] Moderate to Aggressive [ ] Aggressive Capital Preservation Seeks income and stability with minimal risk. Income Seeks current income over time. Growth & Income Seeks capital appreciation over long term combined with current dividend income. Growth Seeks capital appreciation over long term. Aggressive Growth Seeks maximum capital appreciation over time by investing in speculative and/or higher risk securities.
CONTINUED VLSUP-42-06 (07/06)eF OPTIONAL AUTOMATED PAGE 2 INVESTMENT STRATEGIES (continued) You may select ONLY ONE of IF YOU ARE NOT ELECTING ANY AUTOMATED INVESTMENT STRATEGIES, PLEASE PROCEED TO THE INVESTMENT the following: ALLOCATION SECTION ON THE NEXT PAGE. [ ] INDEX SELECTOR Check only ONE of the categories below. MetLife will allocate 100% of your net premium based on the current allocation for the Index Selector Model you choose. No other funding options [ ] Conservative [ ] Conservative to Moderate [ ] Moderate can be selected when using [ ] Moderate to Aggressive [ ] Aggressive this strategy. I understand that the Index Selector strategy will be implemented using the percentage allocations of the model in effect on the date of issue of my policy. I also understand that in order to maintain this allocation, my account will be automatically rebalanced every quarters. [ ] EQUITY GENERATOR Automatically transfers the current month's earnings from the Fixed Account into any one of the A percent of premium must available funding options on each monthly anniversary. be allocated to the Fixed Account when this option is Please elect one funding option, except the Fixed Account, from the list on the following pages. chosen. ______________________________________________________________________________________________________ [ ] REBALANCER Automatically rebalances the cash value among the funding options each calendar quarter to return the allocation to the allocation percentages you specify. Choose ONE of the following: [ ] Check here if you wish to rebalance to the allocation percentages chosen for your premium payments. [ ] Check here if you wish to rebalance using different allocation percentages than your premium payments and indicate the allocation percentages in the right-hand column on the following pages. [ ] ALLOCATOR Automatically transfers a set amount of money from the Fixed Account or any other funding option The destination funding ("source fund") to any number of available funding options on each monthly anniversary. (Value of option(s) chosen cannot source fund must be sufficient to ensure a minimum of three consecutive monthly transfers.) include the "source fund". Please indicate the "source fund" from which the transfers are to be made: ______________________________________________________________________________________________________ Please choose ONE of the following transfer options. Indicate the destination funding options and the dollar amount to be transferred to each in the right-hand column on the following pages. [ ] Transfer $__________________________ per month until the "source fund" is depleted. [ ] Transfer $__________________________ per month for _________ months. The Allocator is a form of dollar cost averaging. Dollar cost averaging does not assure a profit or protect against a loss in declining markets. It involves continuous investment in securities regardless of fluctuation in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels. [ ] ENHANCED DOLLAR COST Automatically transfers an amount of money each month from the EDCA fixed account to any number of AVERAGER (EDCA) available funding options each monthly anniversary until the EDCA fixed account is depleted. The The destination funding amount allocated to the EDCA fixed account may consist of a one-time premium payment plus 1035 option(s) chosen cannot Exchange monies in the first policy year. The initial monthly amount transferred is based on the include the Fixed Account. initial EDCA gross amount allocated to the EDCA fixed account, divided by twelve (months). If another eligible payment is received, the EDCA transfer amount will be increased by the subsequent payment, divided by twelve. Please specify the EDCA amount ($10,000 minimum): $________________ Premium payment $________________ Expected 1035 Exchange amount _______% of all 1035 Exchange amounts to be allocated to EDCA (required if an Expected 1035 Exchange amount is specified) Indicate the destination funding options and the percentage to be transferred to each in the right-hand column on the following pages. The Enhanced Dollar Cost Averager is a form of dollar cost averaging. Dollar cost averaging does not assure a profit or protect against a loss in declining markets. It involves continuous investment in securities regardless of fluctuation in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels.
CONTINUED VLSUP-42-06 (07/06) eF INVESTMENT ALLOCATION PAGE 3 (continued) Please select funding options that are appropriate for the RISK TOLERANCE and INVESTMENT OBJECTIVE indicated on the first page of this form. Some funding options may be appropriate for more than one investment objective. For more complete information about a specific funding option, including charges and expenses, please read the prospectus carefully. Indicate Initial Allocation in whole percentages; must equal 100%. Required if an Automated Investment Strategy is chosen on prior page. REBALANCER % ALLOCATOR $ ENHANCED DOLLAR NAME INITIAL PREMIUM ALLOCATION COST AVERAGER % ---- -------------------------- ----------------------------- Fixed Account _____________% _____________________ Western Asset Management U.S. Government Portfolio _____________ _____________________ BlackRock Bond Income Portfolio _____________ _____________________ American Funds Bond Fund _____________ _____________________ Lehman Brothers(R) Aggregate Bond Index Portfolio _____________ _____________________ PIMCO Total Return Portfolio _____________ _____________________ Western Asset Management Strategic Bond Opportunities Portfolio _____________ _____________________ Lord Abbett Bond Debenture Portfolio _____________ _____________________ PIMCO Inflation Protected Bond Portfolio _____________ _____________________ BlackRock Diversified Portfolio _____________ _____________________ MFS(R) Total Return Portfolio _____________ _____________________ Neuberger Berman Real Estate Portfolio _____________ _____________________ Harris Oakmark Focused Value Portfolio _____________ _____________________ BlackRock Large Cap Value Portfolio _____________ _____________________ Davis Venture Value Portfolio _____________ _____________________ FI Value Leaders Portfolio _____________ _____________________ Harris Oakmark Large Cap Value Portfolio _____________ _____________________ Neuberger Berman Mid Cap Value Portfolio _____________ _____________________ Oppenheimer Global Equity Portfolio _____________ _____________________ BlackRock Strategic Value Portfolio _____________ _____________________ BlackRock Investment Trust Portfolio _____________ _____________________ American Funds Growth-Income Fund _____________ _____________________ Legg Mason Value Equity Portfolio _____________ _____________________ MetLife Stock Index Portfolio _____________ _____________________ American Funds Global Small Capitalization Fund _____________ _____________________ FI Mid Cap Opportunities Portfolio _____________ _____________________ Lazard Mid-Cap Portfolio _____________ _____________________ MetLife Mid Cap Stock Index Portfolio _____________ _____________________ FI International Stock Portfolio _____________ _____________________ Harris Oakmark International Portfolio _____________ _____________________ MFS(R) Research International Portfolio _____________ _____________________ Morgan Stanley EAFE(R) Index Portfolio _____________ _____________________ BlackRock Legacy Large Cap Growth Portfolio _____________ _____________________ FI Large Cap Portfolio _____________ _____________________ American Funds Growth Fund _____________ _____________________ Janus Aggressive Growth Portfolio _____________ _____________________ Jennison Growth Portfolio _____________ _____________________ Oppenheimer Capital Appreciation Portfolio _____________ _____________________ T. Rowe Price Large Cap Growth Portfolio _____________ _____________________ Loomis Sayles Small Cap Portfolio _____________ _____________________ Russell 2000(R) Index Portfolio _____________ _____________________ BlackRock Aggressive Growth Portfolio _____________ _____________________ T. Rowe Price Mid-Cap Growth Portfolio _____________ _____________________
CONTINUED VLSUP-42-06 (07/06) eF INVESTMENT ALLOCATION PAGE 4 (continued) REBALANCER % ALLOCATOR $ ENHANCED DOLLAR NAME INITIAL PREMIUM ALLOCATION COST AVERAGER % ---- -------------------------- ----------------------------- Franklin Templeton Small Cap Growth Portfolio _____________% _____________________ Met/AIM Small Cap Growth Portfolio _____________ _____________________ T. Rowe Price Small Cap Growth Portfolio _____________ _____________________ RCM Global Technology Portfolio _____________ _____________________ Cyclical Growth & Income ETF Portfolio _____________ _____________________ Cyclical Growth ETF Portfolio _____________ _____________________ MetLife Conservative Allocation Portfolio _____________ _____________________ MetLife Conservative to Moderate Allocation Portfolio _____________ _____________________ MetLife Moderate Allocation Portfolio _____________ _____________________ MetLife Moderate to Aggressive Allocation Portfolio _____________ _____________________ MetLife Aggressive Allocation Portfolio _____________ _____________________ OTHER Write in any available _________________________________________ _____________ _____________________ funds not listed above. _________________________________________ _____________ _____________________ OTHER 1. I elect to have the monthly deduction from the cash values taken as follows - choose ONE: IMPORTANT OWNER QUESTIONS [ ] Proportionately from the funding options based on the cash value in each at the time of the deduction. [ ] From the Fixed Account or any other specific funding option. Specify _____________________________________________________________________________________ If you have chosen a specific funding option, please note that if at any time that designated funding option has insufficient cash value to pay the entire amount of the monthly policy charges, the remaining portion of these charges will be deducted proportionately from each funding option based on the cash value in each at the time of the deduction. 2. Have you received a prospectus for the policy applied for? [ ] YES [ ] NO IF YES, please indicate: ________________________________________________________________________ Date of prospectus: __________________________________________________________________________________ Date of any prospectus supplement package: ___________________________________________________________ 3. Did your agent/producer review your financial situation, risk tolerance and investment objectives prior to completing this application? [ ] YES [ ] NO IF NO, please indicate on what basis this product was recommended? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 4. Do you understand that: A. The amount and duration of the death benefit may increase or decrease depending on the policy's investment return, subject to any guarantees provided by the policy? [ ] YES [ ] NO B. There is no guaranteed minimum cash value, and the cash value may increase or decrease depending on the policy's investment return? [ ] YES [ ] NO 5. Do you believe that this policy and the funding options you have selected will meet your insurance needs and financial objectives? [ ] YES [ ] NO 6. If funding options selected do not reflect the risk tolerance on the first page of this form, please explain: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
VLSUP-42-06 (07/06) eF VARIABLE LIFE PROPOSED INSURED: ____________________________________________________________________________________ SUPPLEMENT METLIFE INVESTORS USA INSURANCE COMPANY This supplement will be attached to and become part of the application with which it is used. IMPORTANT Variable Life Insurance is generally not appropriate for time horizons of less than 10 years. These INFORMATION FOR are long-term insurance products that may have significant short-term surrender charges. Variable Life THE OWNER - PLEASE Insurance is designed to provide death benefit protection while offering the potential for long-term READ CAREFULLY cash accumulation, and may not be appropriate in situations where significant liquidation of assets in the near future may be expected. THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED CONDITIONS. THE CASH VALUE MAY INCREASE OR DECREASE, EVEN TO THE EXTENT OF BEING REDUCED TO ZERO, IN ACCORDANCE WITH SEPARATE ACCOUNT INVESTMENT EXPERIENCE. THE COST OF INSURANCE RATES FOR THIS POLICY MAY CHANGE. THE RATES CURRENTLY BEING CHARGED ARE NOT GUARANTEED, AND THE COMPANY MAY CHARGE THE FULL MAXIMUM GUARANTEED RATES. ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS AND CASH VALUES, ARE AVAILABLE UPON REQUEST. OWNER'S Tax bracket ________% Liquid Net Worth $___________________________________________ INFORMATION (Exclude personal residence, automobiles & home furnishings.) Annual Income $__________________________ Prior Investment Experience (Choose all that apply and indicate your years of experience.) [ ] Certificate of Deposit _______ years [ ] Stocks _______ years [ ] Mutual Funds _______ years [ ] Money Markets _______ years [ ] Bonds _______ years [ ] Other ____________________________________________________________________________ _______ years Is Owner(s) an associated person of a broker dealer? [ ] YES [ ] NO INVESTMENT INVESTMENT OBJECTIVE RISK TOLERANCE OBJECTIVE AND RISK TOLERANCE Indicate the investment Have you completed the Asset Allocation Questionnaire? [ ] YES [ ] NO objective for your IF YES, please submit with application. policy's funding options. Indicate risk tolerance below (choose only one). Be sure it supports the investment objective and your risk tolerance for this policy. [ ] Capital Preservation [ ] Conservative [ ] Conservative to Moderate [ ] Income [ ] Conservative [ ] Conservative to Moderate [ ] Moderate [ ] Growth & Income [ ] Moderate [ ] Moderate to Aggressive [ ] Growth [ ] Moderate to Aggressive [ ] Aggressive [ ] Aggressive Growth [ ] Moderate to Aggressive [ ] Aggressive Capital Preservation Seeks income and stability with minimal risk. Income Seeks current income over time. Growth & Income Seeks capital appreciation over long term combined with current dividend income. Growth Seeks capital appreciation over long term. Aggressive Growth Seeks maximum capital appreciation over time by investing in speculative and/or higher risk securities.
CONTINUED VLSUP-43-06 (07/06) eF OPTIONAL AUTOMATED PAGE 2 INVESTMENT STRATEGIES (continued) You may select ONLY ONE of IF YOU ARE NOT ELECTING ANY AUTOMATED INVESTMENT STRATEGIES, PLEASE PROCEED TO THE INVESTMENT the following: ALLOCATION SECTION ON THE NEXT PAGE. [ ] EQUITY GENERATOR Automatically transfers the current month's earnings from the Fixed Account into any one of the available funding options on each monthly anniversary. A percent of premium must be allocated to the Fixed Please elect one funding option, except the Fixed Account, from the list on the following pages. Account when this option is chosen. ______________________________________________________________________________________________________ [ ] REBALANCER Automatically rebalances the cash value among the funding options each calendar quarter to return the allocation to the allocation percentages you specify. Choose ONE of the following: [ ] Check here if you wish to rebalance to the allocation percentages chosen for your premium payments. [ ] Check here if you wish to rebalance using different allocation percentages than your premium payments and indicate the allocation percentages in the right-hand column on the following pages. [ ] ALLOCATOR Automatically transfers a set amount of money from the Fixed Account or any other funding option ("source fund") to any number of available funding options on each monthly anniversary. (Value of The destination funding source fund must be sufficient to ensure a minimum of three consecutive monthly transfers.) option(s) chosen cannot include the "source fund". Please indicate the "source fund" from which the transfers are to be made: ______________________________________________________________________________________________________ Please choose ONE of the following transfer options. Indicate the destination funding options and the dollar amount to be transferred to each in the right-hand column on the following pages. [ ] Transfer $________________________________________ per month until the "source fund" is depleted. [ ] Transfer $________________________________________ per month for ______________ months. The Allocator is a form of dollar cost averaging. Dollar cost averaging does not assure a profit or protect against a loss in declining markets. It involves continuous investment in securities regardless of fluctuation in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels. [ ] ENHANCED Automatically transfers an amount of money each month from the EDCA fixed account to any number of DOLLAR COST available funding options each monthly anniversary until the EDCA fixed account is depleted. The AVERAGER amount allocated to the EDCA fixed account may consist of a one-time premium payment plus 1035 (EDCA) Exchange monies in the first policy year. The initial monthly amount transferred is based on the initial EDCA gross amount allocated to the EDCA fixed account, divided by twelve (months). If another The destination funding eligible payment is received, the EDCA transfer amount will be increased by the subsequent payment, option(s) chosen cannot divided by twelve. include the Fixed Account. Please specify the EDCA amount ($10,000 minimum): __________________ $_________________ Premium payment $_________________ Expected 1035 Exchange amount _______% of all 1035 Exchange amounts to be allocated to EDCA (required if an Expected 1035 Exchange amount is specified) Indicate the destination funding options and the percentage to be transferred to each in the right-hand column on the following pages. The Enhanced Dollar Cost Averager is a form of dollar cost averaging. Dollar cost averaging does not assure a profit or protect against a loss in declining markets. It involves continuous investment in securities regardless of fluctuation in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels.
CONTINUED VLSUP-43-06 (07/06) eF PAGE 3 (continued) INVESTMENT Please select funding options that are appropriate for the RISK TOLERANCE and INVESTMENT OBJECTIVE ALLOCATION indicated on the first page of this form. Some funding options may be appropriate for more than one investment objective. For more complete information about a specific funding option, including charges and expenses, please read the prospectus carefully. Indicate Initial Allocation in whole percentages; must equal 100%. Required if an Automated Investment Strategy is chosen on prior page. REBALANCER % ALLOCATOR $ ENHANCED DOLLAR NAME INITIAL PREMIUM ALLOCATION COST AVERAGER % ---- -------------------------- ------------------------ MetLife Aggressive Strategy Portfolio _______________% _______________ MetLife Growth Strategy Portfolio _______________ _______________ MetLife Balanced Strategy Portfolio _______________ _______________ MetLife Moderate Strategy Portfolio _______________ _______________ MetLife Defensive Strategy Portfolio _______________ _______________ RCM Global Technology Portfolio _______________ _______________ MFS(R) Emerging Markets Equity Portfolio _______________ _______________ Turner Mid-Cap Growth Portfolio _______________ _______________ Met/AIM Small Cap Growth Portfolio _______________ _______________ Janus Aggressive Growth Portfolio _______________ _______________ Jennison Growth Portfolio _______________ _______________ Legg Mason Value Equity Portfolio _______________ _______________ Neuberger Berman Real Estate Portfolio _______________ _______________ T. Rowe Price Mid-Cap Growth Portfolio _______________ _______________ Harris Oakmark International Portfolio _______________ _______________ Third Avenue Small Cap Value Portfolio _______________ _______________ Harris Oakmark Focused Value Portfolio _______________ _______________ MFS(R) Research International Portfolio _______________ _______________ Lazard Mid-Cap Portfolio _______________ _______________ Oppenheimer Capital Appreciation Portfolio _______________ _______________ Goldman Sachs Mid-Cap Value Portfolio _______________ _______________ Van Kampen Comstock Portfolio _______________ _______________ MetLife Stock Index Portfolio _______________ _______________ Lord Abbett Growth and Income Portfolio _______________ _______________ Davis Venture Value Portfolio _______________ _______________ Loomis Sayles Global Markets Portfolio _______________ _______________ Lord Abbett Bond Debenture Portfolio _______________ _______________ PIMCO Inflation Protected Bond Portfolio _______________ _______________ PIMCO Total Return Portfolio _______________ _______________ Western Asset Management U.S. Government Portfolio _______________ _______________ Fixed Account _______________ _______________ OTHER Write in any available ______________________________________________ _______________ _______________ funds not listed above ______________________________________________ _______________ _______________ ______________________________________________ _______________ _______________
CONTINUED VLSUP-43-06 (07/06) eF INVESTMENT PAGE 4 (Continued) ALLOCATION OTHER 1. I elect to have the monthly deduction from the cash values taken as follows - choose ONE: IMPORTANT OWNER QUESTIONS [ ] Proportionately from the funding options based on the cash value in each at the time of the deduction. [ ] From the Fixed Account or any other specific funding option. Specify ____________________________________________________________________________________ If you have chosen a specific funding option, please note that if at any time that designated funding option has insufficient cash value to pay the entire amount of the monthly policy charges, the remaining portion of these charges will be deducted proportionately from each funding option based on the cash value in each at the time of the deduction. 2. Have you received a prospectus for the policy applied for? IF YES, please indicate: [ ] YES [ ] NO Date of prospectus: __________________________________________________________________________________ Date of any prospectus supplement package: ___________________________________________________________ 3. Did your agent/producer review your financial situation, risk tolerance and investment objectives prior to completing this application? [ ] YES [ ] NO IF NO, please indicate on what basis this product was recommended? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 4. Do you understand that: A. The amount and duration of the death benefit may increase or decrease depending on the policy's investment return, subject to any guarantees provided by the policy? [ ] YES [ ] NO B. There is no guaranteed minimum cash value, and the cash value may increase or decrease depending on the policy's investment return? [ ] YES [ ] NO 5. Do you believe that this policy and the funding options you have selected will meet your insurance needs and financial objectives? [ ] YES [ ] NO 6. If funding options selected do not reflect the risk tolerance on the first page of this form, please explain: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
VLSUP-43-06 (07/06) eF