EX-99.(E) 4 b66703a1exv99wxey.txt ENTERPRISE APPLICATION FOR POLICY . . . (METLIFE(R) LOGO) Policy Number ________________________________ APPLICATION FOR LIFE INSURANCE ------------------------------------------------------------------------------------------------------------------------------------ COMPANY (Check the appropriate ONE.) [ ] Metropolitan Life Insurance Company [ ] General American Life Insurance Company The Company indicated in this section is [ ] New England Life Insurance Company [ ] MetLife Investors USA Insurance Company referred to as "THE COMPANY". [ ] MetLife Investors Insurance Company SECTION I - ABOUT THE PROPOSED INSURED ------------------------------------------------------------------------------------------------------------------------------------ For Additional Insureds please complete the ADDITIONAL INSUREDS SUPPLEMENT form. First Name Middle Name Last Name _____________________________________________ _____________________________ ____________________________________________________ Permanent Address City State Zip ______________________________________________________________________ _________________________________ _______ _____________ Country of Legal Residence Date of Birth E-Mail Address ________________________________________________ ___________________________________ ___________________________________________ Primary Phone Number Alternate Phone Number Preferred From [ ]AM To [ ]AM Sex [ ]Male ______________________________ ______________________________ Time to Call _________ [ ]PM _______ [ ]PM [ ]Female Place of Birth Social Security or Tax ID Number Earned Annual Income Net Worth ________________________ _____________________________________________ _____________________________ ________________________ [ ] U.S. Driver's License If not licensed, please indicate other form of ID: [ ] Passport [ ] Government Issued Photo ID Issuer of ID ID Number Issue Date (if any) Expiration Date (if any) ____________________________________ ___________________________ ______________________________ ______________________________ Name of Employer Employer City State Zip Position/Duties __________________________________ _________________________________ _______ _____________ __________________________________ ------------------------------------------------------------------------------------------------------------------------------------ NON U.S. CITIZENS ONLY - Country of Citizenship Green Card/Visa Type Expiration Date ____________________________________________________________ ________________________________________ __________________________ Country of Permanent Residence ID Number Years in the U.S. ____________________________________________________________ ________________________________________ __________________________ ------------------------------------------------------------------------------------------------------------------------------------ SECTION II - ABOUT THE OWNER - Complete ONLY if the Owner is NOT the Proposed Insured. ------------------------------------------------------------------------------------------------------------------------------------ [ ] OWNER - TRUST / BUSINESS ENTITY - Name of Entity Tax ID Number Trustee / Owner State ____________________________________________________________ _____________________________________ _________________________ [ ] Trust [ ]Business Entity [ ] Charity [ ] Qualified Pension Plan - Complete the appropriate REQUIRED form(s). [ ] OWNER - OTHER INDIVIDUAL First Name Middle Name Last Name _________________________________________________ _____________________________ ____________________________________________ Permanent Address City State Zip _________________________________________________________________ __________________________________ ________ ____________ Country of Legal Residence Citizenship Social Security or Tax ID Number Date of Birth Phone Number __________________________ _________________ ________________________________ ________________ _________________________ E-Mail Address Earned Annual Income Net Worth Relationship to Proposed Insured ______________________________________________ ____________________ ___________________ __________________________________ Please indicate form of ID: [ ] U.S. Driver's License [ ] Passport [ ] Government Issued Photo ID Issuer of ID ID Number Issue Date (if any) Expiration Date (if any) _______________________________ _______________________________________ _______________________ __________________________ [ ] CHECK IF OWNERSHIP SHOULD REVERT TO INSURED UPON OWNER AND CONTINGENT OWNER'S DEATHS. ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 1 SECTION III - ABOUT THE BENEFICIARY / BENEFICIARIES For additional Beneficiaries, use Section IX - Additional Information. ------------------------------------------------------------------------------------------------------------------------------------ [ ] Check here if the Owner is the Primary Beneficiary. For Primary or Contingent Beneficiaries who are NOT the Owner, complete the table below. Social Security Percentage Beneficiary Date of Relationship to Number of Proceeds Type Name (First, Middle, Last) Birth Proposed Insured (Optional) (if not equal) -------------- -------------------------------------------------- ------- ---------------- ---------------- -------------- Primary [ ] Primary [ ] Contingent [ ] Primary [ ] Contingent [ ] Check here to include all living and future natural or adopted children of the Proposed Insured as Contingent Beneficiaries. (Name all living children above.) - If a Custodian is acting on behalf of a minor Beneficiary listed above, please use CO-OWNER/CONTINGENT OWNER AND UTMA DESIGNATIONS SUPPLEMENT form. - Federal law states that if someone with special needs has assets over $2,000, they may lose eligibility for government benefits. SECTION IV - ABOUT PROPOSED COVERAGE Check the desired coverage(s). ------------------------------------------------------------------------------------------------------------------------------------ [ ] UNIVERSAL LIFE [ ] VARIABLE LIFE - [ ] WHOLE LIFE [ ] TERM LIFE Product Name Product Name Product Name _________________________________________________ _______________________________________ ______________________________________ Face Amount* Face Amount* Face Amount* _________________________________________________ _______________________________________ ______________________________________ Riders and Details Riders and Details Riders and Details _________________________________________________ _______________________________________ ______________________________________ [ ] Coverage Continuation (UL only) _______________________________________ ______________________________________ Disability Waiver: [ ] Disability Waiver Disability Waiver: [ ] Specified Premium ___________________________ Dividend Options: [ ] Convertible [ ] Non-Convertible [ ] Monthly Deduction (VUL only) [ ] Paid-Up Additions Death Benefit Option [ ] Other, please specify: ____________________________ Definition of Life Insurance: _______________________________________ [ ] Guideline Premium Test [ ] Automatic Premium Loan Requested [ ] Cash Value Accumulation Test Planned Premium - For a full list of riders and options, please consult with your Producer. Year 1 ______________ NOTE: Some riders may require supplement forms to be completed. Years 2 to _____ ______________ - For Variable Life products, please complete the VARIABLE LIFE SUPPLEMENT form. * If Face Amount is equal to or exceeds $1,000,000, please complete the Years ________ to _____ ______________ (UL only) PERSONAL FINANCIAL INFORMATION form. ------------------------------------------------------------------------------------------------------------------------------------ ADDITIONAL OPTIONS One Time (Single) Payment Amount 1035 Exchange Amount Requested Policy Date [ ] Save Age ________________________________ _____________________________________ ___________________________ POLICY OPTIONS [ ] Alternate Policy: Product, Face Amount and Details _____________________________________________________________________________ [ ] Additional Policy: Product, Face Amount and Details ____________________________________________________________________________ [ ] Group Conversion Only - Please complete the GROUP CONVERSION SUPPLEMENT form for either choice. [ ] Group Conversion Alternative ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 2 SECTION V - ABOUT EXISTING OR APPLIED FOR INSURANCE ------------------------------------------------------------------------------------------------------------------------------------ Does the Proposed Insured or Owner have any existing or applied for life insurance or Proposed Insured [ ] Yes [ ] No annuities with this or any other company? Owner [ ] Yes [ ] No If YES, please provide details of any existing or applied for LIFE Insurance on the PROPOSED INSURED only. Amount of Company Insurance Year of Issue Status ------------------------------------------------------------------------ --------- ------------- ----------------------------- ________________________________________________________________________ _________ _____________ [ ] Existing [ ] Applied For ________________________________________________________________________ _________ _____________ [ ] Existing [ ] Applied For ________________________________________________________________________ _________ _____________ [ ] Existing [ ] Applied For ________________________________________________________________________ _________ _____________ [ ] Existing [ ] Applied For In connection with this application, has there been, or will there be with this or any other company any: surrender transaction; loan; withdrawal; lapse; reduction or redirection of premium/consideration; or change transaction (except conversions) involving an annuity or other life insurance? [ ] Yes [ ] No - If YES, complete REPLACEMENT QUESTIONNAIRE AND any other state required replacement forms or 1035 exchange forms. ------------------------------------------------------------------------------------------------------------------------------------ IF PROPOSED INSURED IS FINANCIALLY DEPENDENT ON ANOTHER INDIVIDUAL, INDICATE INDIVIDUAL PROVIDING SUPPORT: [ ] Spouse [ ] Child [ ] Parent [ ] Other ____________________________________ Amount of insurance on individual providing support. Existing Insurance _______________________ Insurance Applied For ________ If Proposed Insured is a minor, are all siblings equally insured? [ ] Yes [ ] No If NO, please provide details: _____________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ SECTION VI - ABOUT PAYMENT INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ PREMIUM PAYOR [ ] Proposed Insured [ ] Owner (If NOT the Proposed Insured.) [ ] Other (Complete the box below.) ------------------------------------------------------------------------------------------------------------------------------------ Other Premium Payor Name Social Security or Tax ID Number Relationship to Proposed Insured or Owner _____________________________________________ ________________________________ _________________________________________________ Reason this Person is the Payor ____________________________________________________________________________________________________________________________________ Permanent Address City State Zip _____________________________________________________________ _____________________________________ ________ _________________ ------------------------------------------------------------------------------------------------------------------------------------ PAYMENT MODE Billing Mode: [ ] Annual [ ] Semi-Annual [ ] Quarterly (Check the appropriate ONE.) [ ] Monthly Draft per Debit Authorization (See next page.) [ ] Monthly Draft per Existing Electronic Payment Number _____________________________ Special Account: [ ] Government Allotment [ ] Salary Deduction [ ] List Bill If Special Account, provide Employer Group Number (EGN) or List Bill Number ___________________________ INITIAL PAYMENT Method of Collection: Amount Collected with Application [ ] Initial Premium by Electronic Funds Transfer (Must be at least a monthly amount.) ___________________________________ [ ] Check (Must be at least 1/12 of an annual premium.) SOURCE OF CURRENT AND FUTURE PAYMENTS (Check ALL that apply.) [ ] Earned Income [ ] Mutual Fund/Brokerage Account [ ] Money Market Fund [ ] Savings [ ] Loans [ ] Certificate of Deposit [ ] Use of Values in another Life Insurance/Annuity Contract [ ] Other _______________________ ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 3 ------------------------------------------------------------------------------------------------------------------------------------ DEBIT AUTHORIZATION - AVAILABLE ONLY IF THE BANK ACCOUNT HOLDER IS THE OWNER AND/OR PROPOSED INSURED. - All others please complete the ELECTRONIC PAYMENT (EP) ACCOUNT AGREEMENT form. The undersigned ("I") hereby authorize the Company with whom I am completing this application to initiate debit entries through Metropolitan Life Insurance Company to the deposit account designated below, at the Financial Institution named below, using the Automated Clearing House. I authorize: 1. Monthly recurring debits; AND 2. Debits made from time to time, as I authorize. This authorization is to remain in full force and effect until the Company has received written notification from me of its termination at such time and in such manner as to afford the Company and the Financial Institution a reasonable opportunity to act on it. Monthly Debit Date: [ ] Issue Date of the Policy (GRAPHIC OF CHECK SHOWING BANK ROUTING/ACCOUNT NUMBERS) [ ] Debit Date on the _________ of each month Bank Account Type: [ ] Checking [ ] Savings Bank Routing Number Bank Account Number ____________________________________ ____________________________ Name of Financial Institution ___________________________________________________________________ - Note: Please attach a voided check or deposit slip to Section IX - Additional Information. We cannot establish banking services from starter checks, cash management, brokerage, or mutual fund checks. We cannot establish banking services from foreign banks UNLESS the check is being paid in U.S. Dollars through a U.S. correspondent bank (the U.S. correspondent bank name must be on the check). ------------------------------------------------------------------------------------------------------------------------------------ SECTION VII - GENERAL RISK QUESTIONS Use Section IX - Additional Information if necessary. ------------------------------------------------------------------------------------------------------------------------------------ 1. Within the past three years has the Proposed Insured flown in a plane other than as a passenger on a commercial airline or does he or she have plans for such activity within the next year? [ ] Yes [ ] No - If YES, please complete a separate AVIATION RISK SUPPLEMENT form for the Proposed Insured. 2. Within the past three years has the Proposed Insured participated in or does he or she plan to participate in ANY of the following? [ ] Yes [ ] No - Underwater sports - SCUBA diving, skin diving, or similar activities - Racing sports - motorcycle, auto, motor boat or similar activities - Sky sports - skydiving, hang gliding, parachuting, ballooning or similar activities - Rock or mountain climbing or similar activities - Bungee jumping or similar activities - If YES, please complete a separate AVOCATION RISK SUPPLEMENT form for the Proposed Insured. 3. Has the Proposed Insured TRAVELED or RESIDED outside the U.S. or Canada within the PAST TWO YEARS; or does he or she plan to TRAVEL or RESIDE outside the U.S or Canada within the NEXT TWO YEARS? [ ] Yes [ ] No If YES, please provide details. Past Future Duration (weeks) Cities and Countries Purpose ----- -------- -------------------------------------------------- ----------------------------- ---------------------------- [ ] [ ] __________________________________________________ _____________________________ ____________________________ [ ] [ ] __________________________________________________ _____________________________ ____________________________ [ ] [ ] __________________________________________________ _____________________________ ____________________________ 4. Has the Proposed Insured EVER used tobacco or nicotine products in any form (e.g., cigars, cigarettes, cigarillos, pipes, chewing tobacco, nicotine patches, or nicotine gum)? If YES, please provide details. [ ] Yes [ ] No Product(s) Frequency / Amount Date Last Used ------------------------------------------------- ------------------------------------------------ ----------------------------- ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 4 5. Has the Proposed Insured EVER had a driver's license suspended or revoked, been convicted of DUI or DWI, or in the last five years had any moving violations? If YES, please provide date(s) and violation(s). [ ] Yes [ ] No ____________________________________________________________________________________________________________________________________ 6. Has the Proposed Insured EVER had an application for life, disability income or health insurance declined, postponed, rated or modified or required an extra premium? If YES, please provide details. [ ] Yes [ ] No ____________________________________________________________________________________________________________________________________ 7. In the past 10 years, has the Proposed Insured been convicted of or pled Guilty or No Contest to a felony? [ ] Yes [ ] No If YES, list type of felony, state, and date of occurrence. ___________________________________________________________________ ____________________________________________________________________________________________________________________________________ 8. Is the Proposed Insured actively at work performing the usual duties of his or her occupation? [ ] Yes [ ] No If NO, please provide details. ________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ SECTION VIII - PERSONAL PHYSICIAN ------------------------------------------------------------------------------------------------------------------------------------ [ ] Check here if Proposed Insured does not have a personal physician. Physician Name Name of Practice or Clinic ________________________________________________________________ ________________________________________________________________ Street Address City State Zip ________________________________________________________________ ______________________________________ ________ ____________ Phone Number Date Last Consulted Reason Findings/Treatment Given/Medication Prescribed _____________________________ ___________________ ____________________________ _______________________________________________ SECTION IX - ADDITIONAL INFORMATION If more space is needed, attach additional sheet(s). ------------------------------------------------------------------------------------------------------------------------------------ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 5 CERTIFICATION / AGREEMENT / DISCLOSURE ------------------------------------------------------------------------------------------------------------------------------------ Was a sales illustration provided for the life insurance policy as applied for? [ ] Yes [ ] No A. If YES, please choose one of the following: [ ] 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. [ ] The sale was made using an illustration with Accelerated Payment. [ ] If illustration was ONLY SHOWN ON A COMPUTER SCREEN, check and complete the details in the box 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) [ ] Male [ ] Female [ ] Unisex 2. Age _______ 3. Rating Class (e.g. Standard Non-smoker) _______________________ [ ] Non-smoker [ ] Smoker 4. Product Name (e.g. GAUL) ______________________________________ 5. Face Amount ___________________________________________________ 6. Dividend Option (Whole Life only) _____________________________ ------------------------------------------------------------------------------------------------------------------------------------ B. If NO, please choose one of the following: [ ] Producer certifies that a signed illustration is NOT REQUIRED by law or the policy applied for is not illustrated in this state. [ ] 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. 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, paramedical/medical exam, amendment(s), or any supplement(s). - Only the Company's President, Vice-President or Secretary 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. - If I have requested a rider that provides an acceleration of death benefit, I have received the appropriate disclosure form. - 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 THE APPROPRIATE SECTION OF THE APPLICATION. - I HAVE RECEIVED THE COMPANY'S PRIVACY NOTICE AND THE LIFE INSURANCE BUYER'S GUIDE. - IF I WAS REQUIRED TO SIGN A NOTICE AND CONSENT FOR HIV TESTING, I HAVE RECEIVED A COPY OF THAT NOTICE. ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 6 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. DISTRICT OF COLUMBIA, TENNESSEE, VIRGINIA, WASHINGTON 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. 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 If not witnessing all signatures, witness should initial next to signature being witnessed and sign below. ------------------------------------------------------------------------------------------------------------------------------------ Signature(s) of all Proposed Insured(s) Date Signed at City, State ______________________________________________________ ____________________ _______________________________________________ ______________________________________________________ ____________________ _______________________________________________ (age 15 or over) - Please complete the ADDITIONAL INSUREDS SUPPLEMENT or CHILD RIDER SUPPLEMENT form(s) if applicable. Signature(s) of all Owner(s) (If NOT the Proposed Date Signed at City, State Insured.) ______________________________________________________ ____________________ _______________________________________________ ______________________________________________________ ____________________ _______________________________________________ (age 15 or over) - If the Owner is a firm or corporation, include Officer's title with signature. - If Co-Owner or Custodian, please complete the CO-OWNER/CONTINGENT OWNER AND UTMA DESIGNATIONS SUPPLEMENT form. Signature of Parent or Guardian Date Signed at City, State ______________________________________________________ ____________________ _______________________________________________ (If Owner or Proposed Insured is under 18, sign here. If not sign above.) Witness to Signatures Licensed Producer Print Name of Producer ______________________________________________________ ______________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------
ENB-7-07 (BARCODE) (07/07) ef 7 (METLIFE(R) LOGO) Policy Number ___________________________ VARIABLE LIFE SUPPLEMENT ------------------------------------------------------------------------------------------------------------------------------------ METLIFE INVESTORS USA INSURANCE COMPANY THIS SUPPLEMENT WILL BE ATTACHED TO AND BECOME PART OF THE APPLICATION WITH WHICH IT IS USED. SECTION I - IMPORTANT INFORMATION FOR THE OWNER ------------------------------------------------------------------------------------------------------------------------------------ - PLEASE READ CAREFULLY. Variable Life Insurance is generally not appropriate for time THE CASH VALUE MAY INCREASE OR DECREASE, EVEN TO THE EXTENT OF horizons of less than 10 years. These are long-term insurance BEING REDUCED TO ZERO, IN ACCORDANCE WITH SEPARATE ACCOUNT products that may have significant short-term surrender INVESTMENT EXPERIENCE. charges. Variable Life Insurance is designed to provide death benefit protection while offering the potential for long-term THE COST OF INSURANCE RATES FOR THIS POLICY MAY CHANGE. THE RATES cash accumulation, and may not be appropriate in situations CURRENTLY BEING CHARGED ARE NOT GUARANTEED, AND THE COMPANY MAY where significant liquidation of assets in the near future may CHARGE THE FULL MAXIMUM GUARANTEED RATES. be expected. ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS AND CASH THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED VALUES, ARE AVAILABLE UPON REQUEST. CONDITIONS. SECTION II - OWNER'S INFORMATION ------------------------------------------------------------------------------------------------------------------------------------ OWNER: [ ] Proposed Insured [ ] Other Individual ------------------------------------------------------------------------------------------------------------------------------------ OTHER INDIVIDUAL INFORMATION ONLY: First Name Middle Name Last Name __________________________________________ ___________________________________________ _________________________________________ Occupation Name of Employer ________________________________________________________________ _________________________________________________________________ Employer City State Zip Position/Duties _____________________________________ _____________ ________ _________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ Tax Bracket (%) _____________________ Is the Owner/Owners an associated person/persons of a Broker/Dealer? [ ] Yes [ ] No 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 If Other, specify: ______________________________________________ SECTION III - COVERAGE INFORMATION - Choose one of the following options. NOTE: Ages 85 and 121 available only by rider. ------------------------------------------------------------------------------------------------------------------------------------ Guaranteed Minimum Death Benefit Option: [ ] 5 Years [ ] 20 Years [ ] To Age 65 [ ] To Age 85 [ ] To Age 121 [ ] Other _____ SECTION IV - INVESTMENT OBJECTIVE AND RISK TOLERANCE ------------------------------------------------------------------------------------------------------------------------------------ Have you completed the Asset Allocation Questionnaire? [ ] Yes [ ] No If YES, please submit with Application for Life Insurance. Choose one INVESTMENT OBJECTIVE below (a, b, c, d, or e). Then choose one RISK TOLERANCE for that specific Investment Objective. Be sure it supports the Investment Objective and your Risk Tolerance for this policy. ----------------------------------------------------------------------------------------------------------------------------- A. [ ] CAPITAL PRESERVATION: Seeks income and stability with minimal risk. RISK TOLERANCE: [ ] Conservative [ ] Conservative to Moderate ----------------------------------------------------------------------------------------------------------------------------- B. INCOME: Seeks current income over time. RISK TOLERANCE: [ ] Conservative [ ] Conservative to Moderate [ ] Moderate ----------------------------------------------------------------------------------------------------------------------------- C. GROWTH & INCOME: Seeks capital appreciation over long term combined with current dividend income. RISK TOLERANCE: [ ] Conservative to Moderate [ ] Moderate [ ] Moderate to Aggressive ----------------------------------------------------------------------------------------------------------------------------- D. GROWTH: Seeks capital appreciation over long term. RISK TOLERANCE: [ ] Moderate [ ] Moderate to Aggressive [ ] Aggressive ----------------------------------------------------------------------------------------------------------------------------- E. AGGRESSIVE GROWTH: Seeks maximum capital appreciation over time by investing in speculative and/or higher risk securities. RISK TOLERANCE: [ ] Moderate to Aggressive [ ] Aggressive ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-42-07 (BARCODE) (07/07) ef 1 SECTION V - OPTIONAL AUTOMATED INVESTMENT STRATEGIES ------------------------------------------------------------------------------------------------------------------------------------ You may select ONLY ONE of the following. IF YOU ARE NOT ELECTING ANY AUTOMATED INVESTMENT STRATEGIES, PLEASE PROCEED TO SECTION VI - INVESTMENT ALLOCATION. [ ] INDEX SELECTOR - No other funding options can be selected when using this strategy. Check only ONE of the categories to the right. MetLife Investors USA will allocate 100% of your net [ ] Conservative premium based on the current allocation for the Index Selector Model you choose. I understand that [ ] Conservative to Moderate the Index Selector strategy will be implemented using the percentage allocations of the model in [ ] Moderate effect on the date of issue of my policy. I also understand that in order to maintain this [ ] Moderate to Aggressive allocation, my account will be automatically rebalanced every quarter. [ ] Aggressive ------------------------------------------------------------------------------------------------------------------------------------ [ ] EQUITY GENERATOR - A percent of premium must be allocated to the Fixed Account when this option is chosen. Automatically transfers the current month's earnings from the Fixed Account into any one of the available funding options on each monthly anniversary. Please elect one funding option, except the Fixed Account, from the list in Section VI - Investment Allocation. _______________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ [ ] 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 in Section VI - Investment Allocation. ------------------------------------------------------------------------------------------------------------------------------------ [ ] ALLOCATOR - The destination funding option(s) chosen cannot include the "source fund". 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. (The value of the "source fund" must be sufficient to ensure a minimum of three consecutive monthly transfers.) 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 in Section VI - Investment Allocation. [ ] 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 fluctuations in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels. ------------------------------------------------------------------------------------------------------------------------------------ [ ] ENHANCED DOLLAR COST AVERAGER (EDCA) - The destination funding option(s) chosen cannot include the Fixed Account. Automatically transfers an amount of money each month from the EDCA fixed account to any number of available funding options each monthly anniversary until the EDCA fixed account is depleted. The amount allocated to the EDCA fixed account may consist of a one-time premium payment plus 1035 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 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 in Section VI - Investment Allocation. The Enhanced Dollar Cost Averager is a form of dollar cost averaging. Dollar cost averaging does not assure a profit against a loss in declining markets. It involves continuous investment in securities regardless of fluctuations in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels. ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-42-07 (BARCODE) (07/07) ef 2 SECTION VI - INVESTMENT ALLOCATION ------------------------------------------------------------------------------------------------------------------------------------ Please select funding options that are appropriate for the RISK TOLERANCE and INVESTMENT OBJECTIVE indicated in Section IV - Investment Objective and Risk Tolerance. 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. Use this column Initial Rebalancer % only if you Premium Allocator $ have chosen Funding Options Allocation % EDCA% Indicate Initial Allocation in an option on -------------------------------------- ------------ ------------ whole percentages; must equal 100%. previous page. FI Mid Cap Opportunities Portfolio ____________ ____________ ----------------------------------------------- -------------- Lazard Mid-Cap Portfolio ____________ ____________ Rebalancer % MetLife Mid Cap Stock Index Portfolio ____________ ____________ Initial Allocator $ FI International Stock Portfolio ____________ ____________ Premium Portfolio Harris Oakmark International Funding Options Allocation %EDCA % Portfolio ____________ ____________ ----------------------------------- ---------- -------------- MFS(R) Research International Fixed Account __________ ______________ Portfolio ____________ ____________ Western Asset Management U.S. Morgan Stanley EAFE(R) Index Government Portfolio __________ ______________ Portfolio ____________ ____________ BlackRock Bond Income Portfolio __________ ______________ BlackRock Legacy Large Cap Growth American Funds Bond Fund __________ ______________ Portfolio ____________ ____________ Lehman(R) Brothers Aggregate Bond FI Large Cap Portfolio ____________ ____________ Index Portfolio __________ ______________ American Funds Growth Fund ____________ ____________ PIMCO Total Return Portfolio __________ ______________ Legg Mason Partners Aggressive Western Asset Management Strategic Growth Portfolio ____________ ____________ Bond Opportunities Portfolio __________ ______________ Jennison Growth Portfolio ____________ ____________ Lord Abbett Bond Debenture Oppenheimer Capital Appreciation Portfolio __________ ______________ Portfolio ____________ ____________ PIMCO Inflation Protected Bond T. Rowe Price Large Cap Growth Portfolio __________ ______________ Portfolio ____________ ____________ BlackRock Diversified Portfolio __________ ______________ Loomis Sayles Small Cap Portfolio ____________ ____________ MFS(R) Total Return Portfolio __________ ______________ Russell 2000(R) Index Portfolio ____________ ____________ Neuberger Berman Real Estate BlackRock Aggressive Growth Portfolio __________ ______________ Portfolio ____________ ____________ Harris Oakmark Focused Value T. Rowe Price Mid-Cap Growth Portfolio __________ ______________ Portfolio ____________ ____________ BlackRock Large Cap Value Franklin Templeton Small Cap Growth Portfolio __________ ______________ Portfolio ____________ ____________ Davis Venture Value Portfolio __________ ______________ Met/AIM Small Cap Growth Portfolio ____________ ____________ FI Value Leaders Portfolio __________ ______________ T. Rowe Price Small Cap Growth Harris Oakmark Large Cap Value Portfolio ____________ ____________ Portfolio __________ ______________ RCM Technology Portfolio ____________ ____________ Neuberger Berman Mid Cap Value Cyclical Growth & Income ETF Portfolio __________ ______________ Portfolio ____________ ____________ Oppenheimer Global Equity Cyclical Growth ETF Portfolio ____________ ____________ Portfolio __________ ______________ MetLife Conservative Allocation BlackRock Strategic Value Portfolio ____________ ____________ Portfolio __________ ______________ MetLife Conservative to Moderate BlackRock Large-Cap Core Allocation Portfolio ____________ ____________ Portfolio __________ ______________ MetLife Moderate Allocation Portfolio ____________ ____________ American Funds Growth-Income Fund __________ ______________ MetLife Moderate to Aggressive Legg Mason Value Equity Portfolio __________ ______________ Allocation Portfolio ____________ ____________ MetLife Stock Index Portfolio __________ ______________ MetLife Aggressive Allocation American Funds Global Small Portfolio ____________ ____________ Capitalization Fund __________ ______________ Janus Forty Portfolio ____________ ____________ OTHER - Write in any available funds not listed above. Funding Options Initial Premium Allocation % Rebalancer %/ Allocator $/ EDCA % ________________________________________________________________ ____________________________ __________________________________ ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-42-07 (BARCODE) (07/07) ef 3 SECTION VII - OTHER IMPORTANT OWNER QUESTIONS ------------------------------------------------------------------------------------------------------------------------------------ 1. I elect to have the monthly deduction from the cash values taken as follows - choose ONE: [ ] 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 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 Date of Prospectus Date of any Prospectus Supplement Package If YES, please indicate: __________________ _________________________________________ 3. Did your Producer review your financial situation, risk tolerance, and investment objectives prior to [ ] Yes [ ] No completing this application? 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 [ ] Yes [ ] No investment return, subject to any guarantees provided by the policy? B. There is no guaranteed minimum cash value and the cash value may increase or decrease depending on the [ ] Yes [ ] No policy's investment return? 5. Do you believe that this policy and the funding options you have selected will meet your insurance needs and [ ] Yes [ ] No financial objectives? 6. If funding options selected do not reflect the risk tolerance in Section IV - Investment Objective and Risk Tolerance, please explain: _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-42-07 (BARCODE) (07/07) ef 4 (METLIFE(R) LOGO) Policy Number ___________________________ VARIABLE LIFE SUPPLEMENT ------------------------------------------------------------------------------------------------------------------------------------ METLIFE INVESTORS USA INSURANCE COMPANY THIS SUPPLEMENT WILL BE ATTACHED TO AND BECOME PART OF THE APPLICATION WITH WHICH IT IS USED. SECTION I - IMPORTANT INFORMATION FOR THE OWNER ------------------------------------------------------------------------------------------------------------------------------------ - PLEASE READ CAREFULLY. Variable Life Insurance is generally not appropriate for time THE CASH VALUE MAY INCREASE OR DECREASE, EVEN TO THE EXTENT OF horizons of less than 10 years. These are long-term insurance BEING REDUCED TO ZERO, IN ACCORDANCE WITH SEPARATE ACCOUNT products that may have significant short-term surrender INVESTMENT EXPERIENCE. charges. Variable Life Insurance is designed to provide death benefit protection while offering the potential for long-term THE COST OF INSURANCE RATES FOR THIS POLICY MAY CHANGE. cash accumulation, and may not be appropriate in situations THE RATES CURRENTLY BEING CHARGED ARE NOT GUARANTEED, AND THE where significant liquidation of assets in the near future may COMPANY MAY CHARGE THE FULL MAXIMUM GUARANTEED RATES. be expected. ILLUSTRATIONS OF BENEFITS, INCLUDING DEATH BENEFITS AND CASH THE DEATH BENEFIT MAY BE VARIABLE OR FIXED UNDER SPECIFIED VALUES, ARE AVAILABLE UPON REQUEST. CONDITIONS. SECTION II - COVERAGE INFORMATION - Choose one of the following options. NOTE: Ages 85 and 121 available only by rider. ------------------------------------------------------------------------------------------------------------------------------------ Guaranteed Minimum Death Benefit Option: [ ] 5 Years [ ] 20 Years [ ] To Age 65 [ ] To Age 85 [ ] To Age 121 [ ] Other _____________________ ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-43-07 (BARCODE) (07/07) ef 1 SECTION III - OPTIONAL AUTOMATED INVESTMENT STRATEGIES ------------------------------------------------------------------------------------------------------------------------------------ You may select ONLY ONE of the following. IF YOU ARE NOT ELECTING ANY AUTOMATED INVESTMENT STRATEGIES, PLEASE PROCEED TO SECTION IV - INVESTMENT ALLOCATION. [ ] EQUITY GENERATOR - A percent of premium must be allocated to the Fixed Account when this option is chosen. Automatically transfers the current month's earnings from the Fixed Account into any one of the available funding options on each monthly anniversary. Please elect one funding option, except the Fixed Account, from the list in Section IV - Investment Allocation. _______________________________________________________________________________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ [ ] 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 in Section IV - Investment Allocation. ------------------------------------------------------------------------------------------------------------------------------------ [ ] ALLOCATOR - The destination funding option(s) chosen cannot include the "source fund". 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. (The value of the "source fund" must be sufficient to ensure a minimum of three consecutive monthly transfers.) 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 in Section IV - Investment Allocation. [ ] 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 fluctuations in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels. ------------------------------------------------------------------------------------------------------------------------------------ [ ] ENHANCED DOLLAR COST AVERAGER (EDCA) - The destination funding option(s) chosen cannot include the Fixed Account. Automatically transfers an amount of money each month from the EDCA fixed account to any number of available funding options each monthly anniversary until the EDCA fixed account is depleted. The amount allocated to the EDCA fixed account may consist of a one-time premium payment plus 1035 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 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 in Section IV - Investment Allocation. The Enhanced Dollar Cost Averager is a form of dollar cost averaging. Dollar cost averaging does not assure a profit against a loss in declining markets. It involves continuous investment in securities regardless of fluctuations in price levels. An investor should consider his/her ability to continue purchases in periods of low price levels. ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-43-07 (BARCODE) (07/07) ef 2 SECTION IV - INVESTMENT ALLOCATION ------------------------------------------------------------------------------------------------------------------------------------ Please select funding options. For more complete information about a specific funding option, including charges and expenses, please read the prospectus carefully. Use this column Initial Rebalancer % only if you Premium Allocator $ have chosen Funding Options Allocation % EDCA% Indicate Initial Allocation in an option on -------------------------------------- ------------ ------------ whole percentages; must equal 100%. previous page. Harris Oakmark International Portfolio ____________ ____________ ----------------------------------------------- -------------- Third Avenue Small Cap Value Portfolio ____________ ____________ Rebalancer % Harris Oakmark Focused Value Portfolio ____________ ____________ Initial Allocator $ MFS(R) Research International Portfolio ____________ ____________ Premium Portfolio Lazard Mid-Cap Portfolio ____________ ____________ Funding Options Allocation %EDCA % Oppenheimer Capital Appreciation ----------------------------------- ---------- -------------- Portfolio ____________ ____________ MetLife Aggressive Strategy Goldman Sachs Mid-Cap Value Portfolio ____________ ____________ Portfolio __________ ______________ Van Kampen Comstock Portfolio ____________ ____________ MetLife Growth Strategy Portfolio __________ ______________ MetLife Stock Index Portfolio ____________ ____________ MetLife Balanced Strategy Portfolio __________ ______________ Lord Abbett Growth and Income Portfolio ____________ ____________ MetLife Moderate Strategy Portfolio __________ ______________ Davis Venture Value Portfolio ____________ ____________ MetLife Defensive Strategy Loomis Sayles Global Markets Portfolio ____________ ____________ Portfolio __________ ______________ Lord Abbett Bond Debenture Portfolio ____________ ____________ RCM Technology Portfolio __________ ______________ PIMCO Inflation Protected Bond MFS(R) Emerging Markets Equity Portfolio ____________ ____________ Portfolio __________ ______________ PIMCO Total Return Portfolio ____________ ____________ Turner Mid-Cap Growth Portfolio __________ ______________ Western Asset Management U.S. Met/AIM Small Cap Growth Portfolio __________ ______________ Government Portfolio ____________ ____________ Legg Mason Partners Aggressive Fixed Account ____________ ____________ Growth Portfolio __________ ______________ Jennison Growth Portfolio __________ ______________ Legg Mason Value Equity Portfolio __________ ______________ Neuberger Berman Real Estate Portfolio __________ ______________ T. Rowe Price Mid-Cap Growth Portfolio __________ ______________ OTHER - Write in any available funds not listed above. Funding Options Initial Premium Allocation % Rebalancer %/ Allocator $/ EDCA % ________________________________________________________________ ____________________________ __________________________________ ------------------------------------------------------------------------------------------------------------------------------------
VLSUP-43-07 (BARCODE) (07/07) ef 3 SECTION V - OTHER IMPORTANT OWNER QUESTIONS ------------------------------------------------------------------------------------------------------------------------------------ 1. I elect to have the monthly deduction from the cash values taken as follows - choose ONE: [ ] 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 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 Date of Prospectus Date of any Prospectus Supplement Package If YES, please indicate: __________________ _________________________________________ 3. Did your 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 ------------------------------------------------------------------------------------------------------------------------------------
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