EX-99.B5 3 0003.txt VARIABLE ANNUITY APPLICATION Variable Annuity Application
Send Application and check to: MetLife Investors USA Insurance Company Policy Service Office: P.O. Box 10366 Des Moines, Iowa 50306-0366 For assistance call: 800 848-3854
MetLife Investors USA Variable Annuity XC ------------------------------------------------------------------------------------------------------------------------------------ ACCOUNT INFORMATION 1. Annuitant ------------------------------------------------------------------------------------------------------------------------------------ Name (First) (Middle) (Last) ------------------------------------------------------------------------------------------------------------------------------------ Address (Street) (City) (State) (Zip) Social Security Number ______________-- ______________-- ______________ Sex / / M / / F Date of Birth ______/______/______ Phone (_____) __________________________________________________
2. Owner (Complete only if different than Annuitant) Correspondence is sent to the Owner. ------------------------------------------------------------------------------------------------------------------------------------ Name (First) (Middle) (Last) ------------------------------------------------------------------------------------------------------------------------------------ Address (Street) (City) (State) (Zip)
Social Security/Tax ID Number _________-- ______________-- ____________ Sex / / M / / F Date of Birth/Trust__________ /_______ / Phone (_____) __________________________________________________
3. Joint Owner ------------------------------------------------------------------------------------------------------------------------------------ Name (First) (Middle) (Last) ------------------------------------------------------------------------------------------------------------------------------------ Address (Street) (City) (State) (Zip)
Social Security Number ______________-- ______________-- ______________ Sex / / M / / F Date of Birth ______/______/______ Phone (_____) __________________________________________________ 4. Beneficiary Show full name(s), address(es), relationship to Owner, Social Security Number(s), and percentage each is to receive. Use the Special Requests section if additional space is needed. Unless specified otherwise in the Special Requests section, if Joint Owners are named, upon the death of either Joint Owner, the surviving Joint Owner will be the primary beneficiary, and the beneficiaries listed below will be considered contingent beneficiaries.
------------------------------------------------------------------------------------------------------------------------------------ Primary Name Address Relationship Social Security Number % Primary Name Address Relationship Social Security Number % Contingent Name Address Relationship Social Security Number % ------------------------------------------------------------------------------------------------------------------------------------ Contingent Name Address Relationship Social Security Number %
5. Plan Type / / Non-Qualified Qualified / / 401 / / 403(b) TSA Rollover*
408 IRA* (check one of the options listed below) Traditional IRA SEP IRA Roth IRA --------------- ----------- --------- / / Transfer / / Transfer / / Transfer / / Rollover / / Rollover / / Rollover / / Contribution - Year______ / / Contribution - Year______/ / Contribution - Year______
*The annuitant and owner must be the same person. 6. Purchase Payment Initial Purchase Payment $_____________________________ Make Check Payable to MetLife Investors USA ----------------------------------------------------------------- RIDERS 7. Benefit Riders (subject to state availability and age restrictions ) These riders may only be chosen at time of application. Please note, there are additional charges for the optional riders. Once elected these options may not be changed. 1) / / Living Benefit Rider 2) Death Benefit Riders (Check one. If no election is made, the Principal Protection option will apply). / / Principal Protection / / Annual Step-Up / / Compounded-Plus 3) / / Earnings Preservation Benefit Rider 4) / / Other ___________________________________________________ ----------------------------------------------------------------- COMMUNICATIONS 8. Telephone Transfer I (We) authorize MetLife Investors USA Insurance Company (MetLife Investors USA) or any person authorized by MetLife Investors USA to accept telephone transfer instructions and/or future payment allocation changes from me (us) and my Registered Representative/Agent. Telephone transfers will be automatically permitted unless you check one or both of the boxes below indicating that you do not wish to authorize telephone transfers. Security First will use reasonable procedures to confirm that instructions communicated by telephone are genuine. I (We) DO NOT wish to authorize telephone transfers for the following (check applicable boxes): / / Owner(s) / / Registered Representative/Agent ----------------------------------------------------------------- SIGNATURES 9. Fraud Statement Notice to Applicant: For Arkansas, Kentucky, Louisiana, Maine, New Mexico, Ohio, Pennsylvania and Washington D.C. Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application or submits a 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. For Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. For New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. 10. Special Requests 11. Replacements Does the applicant have any existing policies or contracts? / / Yes / / No Is this annuity being purchased to replace any existing insurance and annuity policy(s)? / / Yes / / No If "YES", applicable disclosure and replacement forms must be attached. 12. Acknowledgement and Authorization I (We) agree that the above information and statements and those made on all pages of this application are true and correct to the best of my (our) knowledge and belief and are made as the basis of my (our) application. I (We) acknowledge receipt of the current prospectus of MetLife Investors Variable Annuity Account One. PAYMENTS AND VALUES PROVIDED BY THE CONTRACT FOR WHICH APPLICATION IS MADE ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
------------------------------------------------------------------------------------------------------------------------------------ (Owner Signature & Title, Annuitant unless otherwise noted) ------------------------------------------------------------------------------------------------------------------------------------ (Joint Owner Signature & Title) (Signature of Annuitant if other than Owner) Signed at (City) (State) Date
13. Agent's Report ------------------------------------------------------------------------------------------------------------------------------------ Agent's Signature Phone Agent's Name and Number Name and Address of Firm State License ID Number (Required for FL) Client Account Number ------------------------------------------------------------------------------------------------------------------------------------ Home Office Program Information: Select one. Once selected, the option cannot be changed. Option A ______________ Option B _____________ ------------------------------------------------------------------------------------------------------------------------------------ Form 8029 (1/01) APPVA-USAXC