EX-99.(E) 5 dex99e.txt ENTERPRISE APPLICATION FOR THE POLICY AND RIDERS PART I CHECK THE APPROPRIATE COMPANY. OFFICE USE ONLY: 1 ___________________________________________________________________________________________________________________________________ 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". ___________________________________________________________________________________________________________________________________ 1. PROPOSED INSURED #1 SECTION 1 PROPOSED Name________________FIRST__________________________MIDDLE______________________LAST_________________________ INSURED(S) 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 MONTH __ DAY __ YEAR ____ State/Country of Birth ____________________________________________ 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 Position/Title/Duties________________________________________ Length of Employment__________________________ for 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_________________________ IF ADDRESS IS SAME Street _____________________________________________________________________________________________________ AS PROPOSED City ___________________________________________________________________________ State _____ Zip ___________ INSURED #1, Years at this address* ___________ SSN/Tax ID ______________________________________________________________ WRITE "SAME". Home Phone Number (_________________________) Best TIME to call: Work Phone Number (_________________________) [ ] Daytime [ ] Evening Cell Phone Number (_________________________) Best NUMBER to call: [ ] Home [ ] Work [ ] Cell Driver's License Number ___________________________________________________ State __________________________ ADDITIONAL Issue Date _________________________________________ Expiration Date _______________________________________ INSUREDS: Marital Status [ ] Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed See Supplemental Date of Birth MONTH __ DAY __ YEAR ____ State/Country of Birth ____________________________________________ 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__________________________
[BAR CODE] ENB-7-05 FF (05/05) 2 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. ___________________________________________________________________________________________________________________________________ SECTION 1 3. DEPENDENT SPOUSE OR MINOR PROPOSED A. Are any persons to be insured a dependent spouse? [ ] YES [ ] NO INSURED(S) IF YES, please provide: (CONTINUED) Amount of EXISTING insurance on spouse of Proposed Insured $______________ 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: ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ SECTION 2 1. EXISTING OR APPLIED FOR INSURANCE EXISTING OR A. Do any of the Proposed Insureds or Owners have any exisitng or applied APPLIED FOR for life insurance (L) or annuity (A) contracts with this or any other company? 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. INSURED TYPE AMOUNT OF YEAR OF ACCIDENTAL EXISTING OR See instructions on (#1, #2, OTHER) COMPANY (L, A) INSURANCE ISSUE DEATH AMOUNT APPLIED FOR the cover of the ____________________________________________________________________________________________________________ Replacement [ ] E Forms Package. [ ] 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)__________ ____________________________________________________________________________________________________________ Applicable replacement 2. REPLACEMENT and 1035 exchange A. In connection with this application, has there been, or will there be with this or forms can be found any other company any: surrender transaction; loan; withdrawal; lapse; reduction or in Replacement redirection of premium/consideration; or change transaction (except conversions) Forms Package. involving an annuity or other life insurance? [ ] YES [ ] NO 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.
[BAR CODE] ENB-7-05 FF (05/05) IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 3 ___________________________________________________________________________________________________________________________________ SECTION 3 IDENTITY OF PRIMARY OWNER (Check One.) OWNER [ ] 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 IF U.S. DRIVER'S [ ] U.S. Driver's License already provided on page 1 (Proposed Insured) LICENSE ALREADY [ ] U.S. Driver's License [ ] Green Card [ ] Passport [ ] Other_________GOVERNMENT ISSUED_______________ PROVIDED, NO FURTHER Issuer of ID ____________________________________________ ID Issue Date ____________________________________ INFORMATION ID Reference Number _____________________________________ ID Expiration Date _______________________________ IS REQUIRED. ____________________________________________________________________________________________________________ 2. OWNER OTHER THAN PROPOSED INSURED(S) NOTE: Name _______________FIRST__________________________MIDDLE______________________LAST_________________________ P.O. Box numbers Street _____________________________________________________________________________________________________ CANNOT be accepted City ___________________________________________________________________________ State _____ Zip ___________ for street addresses. Phone Number (_____________________) IF CUSTODIAN Citizenship ______________________________ Country of Permanent Residence __________________________________ is acting on behalf Date of Birth MONTH __ DAY __ YEAR ____ SSN/Tax ID ________________________________________________________ of a minor under UTMA/ Relationship to Proposed Insured(s) ________________________________________________________________________ UGMA, please complete Employer's Name ____________________________________________________________________________________________ Additional Owner Form Street _____________________________________________________________________________________________________ in Supplemental City ___________________________________________________________________________ State _____ Zip ___________ Forms package. 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 MONTH __ DAY __ YEAR ____ Complete Trust Name of Entity/Trust _______________________________________________________________________________________ Certification form Name of Trustee(s) _________________________________________________________________________________________ in Supplemental Street _____________________________________________________________________________________________________ Forms Package. City ___________________________________________________________________________ State _____ Zip ___________ IF BUSINESS Proposed Insured(s) Relationship to Entity _________________________________________________________________ Complete Business Nature of Business ___________________________________ Business Phone ______________________________________ Supplement form Is entity publicly traded? [ ] YES [ ] NO in Supplemental IF NO, please supply one of the following documents: (INDICATE WHICH ONE YOU ARE SUPPLYING.) Forms Package. [ ] Articles of Incorporation/Government Issued Business License [ ] LLC Operating Agreement [ ] Partnership Agreement [ ] Government Issued Certificate of Good Standing
[BAR CODE] ENB-7-05 FF (05/05) 4 IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. ___________________________________________________________________________________________________________________________________ SECTION 4 NOTE: Federal law states if you leave someone with special needs any assets over BENEFICIARY(IES) $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. ____________________________________________________________________________________________________________ [ ] PRIMARY [ ] CHECK HERE AND Name _______________FIRST__________________________MIDDLE______________________LAST_________________________ DO NOT COMPLETE Street _____________________________________________________________________________________________________ IF PRIMARY City ___________________________________________________________________________ State _____ Zip ___________ BENEFICIARY IS Date of Birth MONTH __ DAY __ YEAR ____ SSN/Tax ID ____________________________________________NOT REQUIRED SAME AS TRUST OR Relationship to Proposed Insured(s) ________________________________________________________________________ ENTITY OWNER. Percent of Proceeds _____ (Multiple Beneficiaries will receive an equal percentage of proceeds unless otherwise instructed.) If there is a court appointed legal [ ] PRIMARY [ ] CONTINGENT Guardian for Beneficiary, provide Name _______________FIRST__________________________MIDDLE______________________LAST_________________________ name and address in Street _____________________________________________________________________________________________________ Additional Information City ___________________________________________________________________________ State _____ Zip ___________ Section, Page 13. Date of Birth MONTH __ DAY __ YEAR ____ SSN/Tax ID ____________________________________________NOT REQUIRED 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 MONTH __ DAY __ YEAR ____ SSN/Tax ID ____________________________________________NOT REQUIRED 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 ___________FIRST____________________MIDDLE____________________LAST_________________________ CUSTODIAN as custodian for __________________________________NAME(S) OF MINOR(S)______________________________________ ACTING under the _____________ NAME OF STATE__________________________ Uniform Transfers [or Gifts] to Minors Act. FOR MINOR Street _____________________________________________________________________________________________________ BENEFICIARY(IES) City ___________________________________________________________________________ State _____ Zip ___________ Relationship to Minor(s)____________________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 5 ___________________________________________________________________________________________________________________________________ SECTION 6 1. PRODUCT & FACE AMOUNT INFORMATION Product Name________________________________________________________________________________________________ REGARDING Face Amount $_______________________________ (COMPLETE PERSONAL FINANCIAL SUPPLEMENT IF $1,000,000 OR MORE.) INSURANCE [ ] Group Conversion* APPLIED FOR 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) [ ] Acceleration of Death Benefit Rider (ADBR)* *Complete these forms, [ ] Enricher Options (PAIR/VABR)* SPECIFY: _______________________ $___________________ if applicable: [ ] Long Term Care Guaranteed Purchase Option (LTC-GPO) . ADBR [ ] Disability Waiver (DW) SPECIFY: ______________________________ $___________________ . Enricher/Equity Additions [ ] Other . Group Conversion . GSPO+ Special Requests/Other: These forms can [ ] Save Age [ ] Specific Policy Date ________________________________________________________________ be found in the Supplemental [ ] Other___________________________________________________________________________________________________ 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, Planned Premium Amount: Year 1 $_______________ Excess/Lump Sum $__________________________________________ also complete Variable Life Supplement. Duration of premium payments________________________________________________________________________________ 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_______________________________________
[BAR CODE] 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 Electronic Additional Details: 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 Amount collected with application $_________________________________________________________________________ to not accept cash, (MUST EQUAL AT LEAST ONE MONTHLY PREMIUM.) traveler's checks, or money orders Premium Payor: as a form of payment [ ] Proposed Insured #1 [ ] Proposed Insured #2 [ ] Primary Owner for Variable Life [ ] Other Products. 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 Proposed Insured #1_________________________________________________________________________________________ ADDRESSES Proposed Insured #2_________________________________________________________________________________________ (OPTIONAL) Primary Owner_______________________________________________________________________________________________ Joint/Contingent Owner______________________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 7 ___________________________________________________________________________________________________________________________________ SECTION 8 The following questions are to be answered for ALL persons to be insured, including those GENERAL RISK covered by any riders applied for. QUESTIONS ____________________________________________________________________________________________________________ 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. ____________________________________________________________________________________________________________ 2. Within the past three years has ANY person to be insured participated in or intend to participate in ANY of the following: 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); If you need more Rock or mountain climbing or similar activities; space, please use the Bungee jumping or similar activities? [ ] YES [ ] NO Additional Information IF YES, complete a separate Avocation Supplement for each Section, Page 13. 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.______________________________________ [ ] 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________________________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) 8 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 GENERAL RISK covered by any riders applied for. QUESTIONS ____________________________________________________________________________________________________________ (CONTINUED) 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____________________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. Has ANY person to be insured: EVER had a driver's license suspended or If you need more revoked; EVER been convicted of DUI or DWI; or had, in the last five space, please years, any moving violations? [ ] YES [ ] NO use the Additional IF YES, please provide Proposed Insured, date and violation. Information Section, Page 13. 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? [ ] YES [ ] NO IF NO, please provide details: Proposed Insured(s)_________________________________________________________________________________________ Details:____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. LONG TERM CARE GUARANTEED PURCHASE OPTION RIDER Please answer these questions ONLY IF A. Does any person to be insured under this rider currently use any REQUESTING THE mechanical equipment such as: a walker; a wheelchair; long leg braces; LONG TERM CARE or crutches? [ ] YES [ ] NO GUARANTEED PURCHASE IF YES, please note which and the reason. OPTION RIDER. ____________________________________________________________________________________________________________ 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)_________________________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) PART II IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 9 ___________________________________________________________________________________________________________________________________ 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____ MONTH__ DAY__ YEAR____ Reason_______________________________________________________ but will expedite 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____ MONTH__ DAY__ YEAR____ Reason_______________________________________________________ Findings, treatment given, medication prescribed.If None, check here [ ]. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 1. HEIGHT/WEIGHT SECTION 2 Proposed Insured #1 Height__________________ Weight__________________ MEDICAL Proposed Insured #2 Height__________________ Weight__________________ QUESTIONS 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______________________________________________________________________________________________________
[BAR CODE] 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 disease; MEDICAL coronary artery disease; high blood pressure; diabetes; or mental illness? [ ] YES [ ] NO QUESTIONS IF YES, indicate below: (CONTINUED) ____________________________________________________________________________________________________________ STATE OF HEALTH, PROPOSED RELATIONSHIP TO AGE IF AGE AT SPECIFIC CONDITIONS, INSURED (#1, #2) PROPOSED INSURED LIVING DEATH CAUSE OF DEATH PLEASE NOTE: ____________________________________________________________________________________________________________ If FULL PARAMEDICAL [ ] P [ ] S exam is required, ____________________________________________________________________________________________________________ completion of Medical [ ] P [ ] S questions is OPTIONAL ____________________________________________________________________________________________________________ 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 ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) IF MORE SPACE IS NEEDED, PLEASE USE THE ADDITIONAL INFORMATION SECTION, PAGE 13. 11 ___________________________________________________________________________________________________________________________________ SECTION 2 3. Has ANY person to be insured EVER received treatment, attention, or advice from any MEDICAL physician, practitioner or health facility for, or been told by any physician, practitioner or QUESTIONS health facility that he/she had: (CONTINUED) 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 pus your application. 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 ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
[BAR CODE] 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 OTHER QUESTIONS PROPOSED PROPOSED PROPOSED (CONTINUED) 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: [ ] [ ] [ ] [ ] [ ] [ ] If FULL PARAMEDICAL exam is required, C. During the past five years, had a: checkup; completion of Medical electrocardiogram; chest x-ray; or medical questions is OPTIONAL test? [ ] [ ] [ ] [ ] [ ] [ ] but will expedite your application. D. During the past five years, had any illness, injury or health condition not revealed 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 ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) 13 ________________________________________________________________________________ ADDITIONAL USE THIS PAGE FOR ANY ADDITIONAL INFORMATION. INFORMATION ATTACH A SEPARATE SHEET IF NECESSARY. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ [BAR CODE] 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.
[BAR CODE] ENB-7-05 FF (05/05) 15 ___________________________________________________________________________________________________________________________________ CERTIFICATION/ (CONTINUED) AGREEMENT/ 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 all signatures, => PROPOSED INSURED #1______________________________________________________________________________________ Witness should (age 15 or over) sign next to the signature being Signed at City, State_____________________________________ Date__________________________________________ witnessed. => PROPOSED INSURED #2______________________________________________________________________________________ (age 15 or over) Signed at City, State_____________________________________ Date__________________________________________ => 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__________________________________________ => PARENT OR GUARDIAN_______________________________________________________________________________________ (If Owner or Proposed Insured(s) is/are under 18, sign here if not signed above.) Signed at City, State_____________________________________ Date__________________________________________ => WITNESS TO SIGNATURES____________________________________________________________________________________ (Licensed Agent/Producer) PLEASE PRINT AGENT/PRODUCER NAME_________________________________________________________________________
[BAR CODE] ENB-7-05 FF (05/05) ___________________________________________________________________________________________________________________________________ PROPOSED INSURED:___________________________________________________________________________________________ [ ] METROPOLITIAN LIFE INSURANCE COMPANY [ ] METLIFE INVESTORS USA INSURANCE COMPANY VARIABLE RIDERS THE COMPANY INDICATED ABOVE IS REFERRED TO AS "THE COMPANY". SUPPLEMENT This supplement will be attached to and become part of the application with which it is used. OWNER'S INFORMATION Tax bracket ____% Liquid Net Worth $__________________________________________ (EXCLUDE PERSONAL RESIDENCE, AUTOMOBILES & HOME FURNISHINGS.) 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 INVESTMENT OBJECTIVE RISK TOLERANCE AND RISK TOLERANCE Indicate the investment Indicate risk tolerance below. (Choose only one.) Be sure it supports YOUR ALLOCATION FOR objective for your the investment objective and your risk tolerance for the rider(s). EACH RIDER APPLIED rider's (or riders') FOR SHOULD MATCH THE funding options. INVESTMENT OBJECTIVE INDICATED HERE. [ ] 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. ___________________________________________________________________________________________________________________________________ IMPORTANT OWNER Have you received a prospectus for the rider(s) applied for? [ ] YES [ ] NO INFORMATION IF YES, please indicate: Date of prospectus__________________________________________________________________________________________ Date of any prospectus supplement package:__________________________________________________________________ CAREFULLY READ THE FOLLOWING: 1. I understand that the initial Net Premium will be allocated to a fixed interest account of a maximum of 20 calendar days until the investment start date as described in the prospectus. 2. I understand that under the rider(s) cited on the next page, the death benefit and cash value attributed to the rider(s) are not guaranteed and may increase or decrease, even to the extent of being reduced to zero, depending upon its investment experience. 3. Upon request, the Company will provide illustration of benefits, including death benefits and cash values.
EFND-5-06 (xx/xx) eF VARIABLE RIDERS SUPPLEMENT PAGE 2 (CONTINUED) ___________________________________________________________________________________________________________________________________ I REQUEST THE FOLLOWING VARIABLE INSURANCE RIDER(S): ___________________________________________________________________________________________________________________________________ [ ] ENRICHER OPTIONS ALLOCATION FOR ENRICHER OPTIONS: (L98 ONLY) Indicate percentage of Net Premium to be allocated to each funding option. For each funding EQUITY ENRICHER option to which an allocation is made, the percentage must be a whole number. Total allocation (OPTION FOR VARIABLE must equal 100%. The percentage will apply to future premiums unless changed by the Owner. ADDITIONAL BENEFITS) ENRICHER Enricher _____________ .0% (OPTION TO PURCHASE FI Mid Cap Opportunities _____________ .0% ADDITIONAL INSURANCE) MetLife Stock Index _____________ .0% ___________________________________________________________________________________________________________________________________ [ ] EQUITY ADDITIONS ALLOCATION FOR EQUITY ADDITIONS: - DIVIDEND OPTION (L98 ONLY) MetLife Stock Index ______100_____.0% VAI - VARIABLE ADDITIONAL INSURANCE ___________________________________________________________________________________________________________________________________ [ ] ADVANTAGE EQUITY ALLOCATION FOR ADVANTAGE EQUITY ENRICHER: ENRICHER Indicate percentage of Net Premium to be allocated to each funding option. For each funding (AWL ONLY) option to which an allocation is made, the percentage must be a whole number. Total allocation OPTION FOR VARIABLE must equal 100%. The percentage will apply to future permiums unless changed by the Owner. ADDITIONAL BENEFITS Fixed Account _________________ .0% Lehman Brothers(R) Aggregate Bond Index _________________ .0% MetLife Mid Cap Stock Index _________________ .0% MetLife Stock Index _________________ .0% Morgan Stanley EAFE(R) Index _________________ .0% Russell 2000(R) Index _________________ .0% ___________________________________________________________________________________________________________________________________ [ ] ADVANTAGE ALLOCATION FOR ADVANTAGE EQUITY ADDITIONS: EQUITY ADDITIONS Indicate percentage of dividends to be allocated to each funding option. For each funding option - DIVIDEND OPTION to which an allocation is made, the percentage must be a whole number. Total allocation must equal (AWL ONLY) 100%. The percentage will apply to future dividends unless changed by the Owner. VAI - VARIABLE ADDITIONAL INSURANCE Fixed Account _________________ .0% Lehman Brothers(R) Aggregate Bond Index _________________ .0% MetLife Mid Cap Stock Index _________________ .0% MetLife Stock Index _________________ .0% Morgan Stanley EAFE(R) Index _________________ .0% Russell 2000(R) Index _________________ .0% ___________________________________________________________________________________________________________________________________ OPTIONAL AUTOMATED REBALANCER INVESTMENT STRATEGY Available only with the Advantage Equity Enricher and Advantage Equity Additions. Automatically rebalances the cash value in the funding options in the same proportion that the Net Premiums or the dividends are then being allocated. Rebalancing occurs at the end of each calendar quarter (as described in the prospectus). [ ] Advantage Equity Enricher [ ] Advantage Equity Additions EFND-5-06 (xx/xx) eF