EX-99.5 (II) 4 dex995ii.txt FORM OF VARIABLE ANNUITY APPLICATION (CLASS L) MetLife Investors(R) INDIVIDUAL SEND APPLICATION AND CHECK TO: Home Office Address (no correspondence) VARIABLE ANNUITY First MetLife Investors Insurance Company 200 Park Avenue . New York, NY 10166 APPLICATION Policy Service Office: P.O. Box 10366 First MetLife Investors Variable Annuity Class L Des Moines, Iowa 50306-0366 FOR ASSISTANCE CALL: 1-800 848-3854
ACCOUNT INFORMATION 1. ANNUITANT Social _____________________________________________________ Security Number ______ -- ______ -- ______ Name (First) (Middle) (Last) Sex [ ]M [ ]F Date of Birth ______/______/______ _____________________________________________________ Address (Street) (City) (State) (Zip) Phone (_____) ______________________________________________ 2. OWNER (COMPLETE ONLY IF DIFFERENT THAN ANNUITANT) Correspondence is sent to the Owner. Social Security/Tax ID Number ______ -- ______ -- ______ _____________________________________________________ Name (First) (Middle) (Last) Sex [ ]M [ ]F Date of Birth/Trust ______ / ______ / ______ _____________________________________________________ Address (Street) (City) (State) (Zip) Phone (_____) ______________________________________________ 3. JOINT OWNER Social Security Number ______ -- ______ -- ______ _____________________________________________________ Name (First) (Middle) (Last) Sex [ ]M [ ]F Date of Birth _______/_______/_______ _____________________________________________________ Address (Street) (City) (State) (Zip) 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 Funding Source of Purchase Payment __________________________________ [ ] 1035 Exchange [ ] Check [ ] Wire Initial Purchase Payment $________________________________________________ Make Check Payable to First MetLife Investors (Estimate dollar amount for 1035 exchanges, transfers, rollovers, etc.) Minimum Initial Purchase Payment: $10,000 (Non-Qualified and Qualified) 4477 (7/05) APPVA1105LNY RIDER 7. BENEFIT RIDERS (subject to 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 Riders (Optional. Only ONE of the following Riders may be elected.) [ ] Guaranteed Minimum Income Benefit Rider (GMIB) [ ] Guaranteed Withdrawal Benefit Rider (GWB) [ ] Guaranteed Minimum Accumulation Benefit Rider (GMAB) The GMIB has limited usefulness in connection with tax-qualified contracts, such as IRAs, because if the GMIB is not exercised on or before the date required minimum distributions must begin under a qualified plan, the certificate owner or beneficiary might be unable to exercise the GMIB benefit under the rider due to the restrictions imposed by the minimum distribution requirements. If you plan to exercise the GMIB after your required minimum distribution beginning date under an IRA, you should consider whether the GMIB is appropriate for your circumstances. You should consult your tax advisor. 2) Death Benefit Riders [ ] Principal Protection (no additional charge) [ ] Annual Step-Up SIGNATURES 8. SPECIAL REQUESTS 9. REPLACEMENTS Does the applicant have any existing life insurance policies or annuity contracts? [ ] Yes [ ] No Is this annuity being purchased to replace any existing life insurance or annuity policy(ies)? [ ] Yes [ ] No If "Yes", applicable disclosure and replacement forms must be attached. 10. 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 First 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 ______________________________________________________ 11. AGENT'S REPORT Is this annuity being purchased to replace any existing life insurance or annuity policy(ies)? [ ] Yes [ ] No ________________________________________________________________________________ Agent's Signature ________________________________________________________________________________ Phone ________________________________________________________________________________ Agent's Name and Number ________________________________________________________________________________ Name and Address of Firm ________________________________________________________________________________ State License ID Number ________________________________________________________________________________ Client Account Number Home Office Program Information: ________________________________ Select one. Once selected, the option cannot be changed. Option A ________________ Option B ________________ 4477 (7/05) APPVA1105LNY