EX-99.(D)(I)4 5 d100939dex99di4.txt VARIABLE LIFE SUPPLEMENT INDIVIDUAL LIFE [LOGO OF MetLife] VARIABLE LIFE SUPPLEMENT This form is required when applying [Graphic] Please complete and for a variable life policy return with your Application. METROPOLITAN LIFE INSURANCE COMPANY This Supplement will be attached to Proposed Insured's name and become part of the Application with which it is used. ______________________________ SECTION 1: IMPORTANT INFORMATION FOR THE OWNER (PLEASE READ CAREFULLY.) Variable Life Insurance is generally REDUCED TO ZERO, IN ACCORDANCE WITH not appropriate for time horizons of SEPARATE ACCOUNT INVESTMENT less than 10 years. Variable Life EXPERIENCE. Insurance is designed to provide death benefit protection while THE COST OF INSURANCE RATES AND OTHER offering the potential for long-term CHARGES FOR THIS POLICY MAY CHANGE, cash accumulation, and may not be BUT THEY WILL NEVER EXCEED THE appropriate in situations where GUARANTEED MAXIMUM COST OF INSURANCE significant liquidation of assets in RATES OR ANY MAXIMUM CHARGES STATED the near future may be expected. IN YOUR POLICY. THE DEATH BENEFIT MAY BE VARIABLE OR ILLUSTRATIONS OF BENEFITS, INCLUDING FIXED UNDER SPECIFIED CONDITIONS. THE DEATH BENEFITS AND CASH VALUES, ARE CASH VALUE MAY INCREASE OR DECREASE, AVAILABLE UPON REQUEST. EVEN TO THE EXTENT OF BEING SECTION 2: INVESTMENT ALLOCATION Premium allocation must total 100%.
INITIAL PREMIUM FUNDING OPTIONS ALLOCATION % ---------------------------------------- --------------- Fixed Account Barclays Aggregate Bond Index Portfolio MetLife Mid Cap Stock Index Portfolio MetLife Stock Index Portfolio MSCI EAFE(R) Index Portfolio Russell 2000(R) Index Portfolio INVESTMENT ALLOCATION TOTAL
SECTION 3: 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.
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2. Have you received a prospectus for the policy applied for? If YES, please indicate: [_] Yes [_] No Date of prospectus Prospectus book number Date(s) of any prospectus supplement package __________________ ______________________ ____________________________________________ 3. Did your Financial Professional review your financial situation, risk tolerance, and [_] Yes [_] No investment objectives prior to 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 [_] Yes [_] No on the Policy's investment return. B. There is no guaranteed minimum cash value and the cash value may increase or [_] Yes [_] No decrease depending on the Policy's investment return? 5. Do you believe that this Policy and the funding options you have selected will meet your [_] Yes [_] No insurance needs and financial objectives?
SECTION 4: SIGNATURE SIGNATURES ARE ONLY REQUIRED FOR A TELE-APPLICATION SUBMISSION. Print name of Owner _______________________________________ [GRAPHIC] Signature(s) of all Owner(s) (IF NOT THE Date (MM/DD/YYYY) Signed at City, State PROPOSED INSURED.) _________________ ________________________ _______________________________________ Date (MM/DD/YYYY) Signed at City, State _______________________________________ _________________ ________________________ (AGE 14 1/2 OR OVER) [GRAPHIC] Signature of Parent or Guardian of the Owner Date (MM/DD/YYYY) Signed at City, State _______________________________________ _________________ ________________________ (IF OWNER IS UNDER THE AGE OF 18, PARENT OR GUARDIAN MUST SIGN HERE.) Print name of Financial Professional _______________________________________ [GRAPHIC] Financial Professional signature Date (MM/DD/YYYY) Signed at City, State _______________________________________ _________________ ________________________
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