Exhibit 5
MetLife (R)
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Metropolitan Life Insurance Company FORCOMPANYUSEONLY
Xxx Xxxxxxx Xxxxxx, Xxx Xxxx, XX 00000-0000
No.____________________
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Variable Annuity Application
Contract/Certificate Applied for: [_] Non-Qualified [_] Traditional IRA [_] Xxxx XXX [_] SEP
1. Annuitant and Owner(s)
Annuitant (Annuitant will be the Owner unless Owner section is completed.)
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Name (First, Middle Initial, Last) Sex [_] M [_] F Date of Birth
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Street Address Social Security #
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City, State & ZIP Code Marital Status
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Home Telephone # Work Telephone # Relationship to Owner
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Owner-Non-Qualified Only (Complete if the Owner is different from the Annuitant.)
If owner is a trust, please complete the trustee certification form.
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Name (First, Middle Initial, Last) Type: [_] Individual [_] Custodian [_] Trustee Sex [_] M [_] F Date of Birth/Trust
[_] Corporation
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Street Address Social Security # or Tax I.D. # (TIN)
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City, State & ZIP Code Marital Status
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Home Telephone # Work Telephone # Relationship to Annuitant
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Joint Owner-Non-Qualified Only
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Name (First, Middle Initial, Last) Type: [_] Individual [_] Custodian [_] Trustee Sex [_] M [_] F Date of Birth
[_] Corporation
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Street Address Social Security # or Tax I.D. # (TIN)
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City, State & ZIP Code Marital Status
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Home Telephone # Work Telephone # Relationship to Owner
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(Note: If two people are named as Joint Owners, either Owner may exercise any and all rights under the contract unless the Owner
specifies otherwise in writing.)
2. Primary and Contingent Beneficiary(ies) If owner is a trust, the trust must be the beneficiary.
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Beneficiary Type Name (First, Middle Initial, Last) Relationship to Owner Social Security #
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[_] Primary [_] Contingent
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[_] Primary [_] Contingent
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[_] Primary [_] Contingent
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(Note: To be used to determine whom will be paid/assume all rights under the contract on the Owner's death. The Owner's estate will
be paid/assume all rights if no Beneficiary is named. Not applicable to Xxxxxxxxx's death if the Owner and Annuitant are different
and the Annuitant predeceases the Owner. Payment/assumption will be made in equal shares to the survivors unless otherwise specified
in writing by the Owner. If the primary beneficiaries predecease the Owner, the contingent beneficiaries will be paid/assume all
rights.)
3. Purchase Payment(s)
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Initial Purchase Payment $ and/or transfers: $ _________________________
Payment method: [_] Check [_] Wire [_] 1035 Exchange [_] Transfer [_] Rollover [_] Other
Prior Tax Year __________________________ Current Tax Year _____________________
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4. Replacement (Must be completed)
(a) Do you have any existing individual life insurance or annuity contracts?
[_] Yes [_] No
(b) Have you taken, or will you be taking, any money from a life insurance
policy or annuity contract to put into the annuity you are applying for?
This includes full or partial withdrawals of dividends or cash values,
loans, pledging as collateral, reissuing with less cash value, suspension
or reduction of premium loan or purchase payment, automatic premium or
invoking an accelerated payment. [_] Yes [_] No (Note: If "Yes", the
Representative must complete a MetLife Annuity Replacement Questionnaire.)
5. Optional Riders are available at time of application and may not be changed
once elected. There are additional charges for the Riders.
Death Benefit Riders (check only one or none)
[_] Annual Step Up [_] Greater of Annual Step
Up and 5% Annual Increase
Other Riders (check one, both or none)
[_] GMIB (Guaranteed Minimum Income Benefit) [_] Earnings Preservation
Benefit Rider
6. Authorization and Signature(s)
(a) Notice to Applicant(s)
Florida Residents Only 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.
Arkansas, District of Columbia, Kentucky, Louisiana, Maine, New Mexico,
Ohio, and Pennsylvania Residents Only Any person who knowingly and with
intent to defraud any insurance company or other person files an
application for insurance 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.
New Jersey Residents Only Any person who includes any false or misleading
information is subject to criminal and civil penalties.
(b) Signatures If the Owner is a corporation, partnership or trust, print the
name of the Owner and have one or more officers, partners or trustees sign.
Earnings in this contract may be taxable annually to the Owner. (Consult
your tax advisor.) I hereby represent my answers to the above questions to
be correct and true to the best of my knowledge and belief. I have received
MetLife's Notice of Privacy Policies and Practices, the current prospectus
for the Variable Annuity, and all required fund prospectuses. I understand
that all values provided by the contract/certificate being applied for,
which are based on the investment experience of the Separate Account, are
variable and are not guaranteed as to the amount. I understand that there
is no additional tax benefit obtained by funding an IRA with a variable
annuity.
Location where the application is signed _________________________________
City & State
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Signature of Annuitant Date
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Signature of Owner (If different than Annuitant) Date
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Signature of Joint Owner Date
7. Representative Information
Statement of Representative All answers are correct to the best of my
knowledge. I have provided the Proposed Owner with MetLife's Notice of
Privacy Policies and Practices, prior to or at the time he/she completed
the application form. I have also delivered a current Variable Annuity
prospectus, and all required fund prospectuses; and reviewed the financial
situation of the Proposed Owner as disclosed, and believe that a
multifunded annuity contract would be suitable. I am properly licensed in
the state where the Proposed Owner signed this application.
(a) Do you have reason to believe that the replacement or change of any
existing insurance or annuity may be involved? [_] Yes [_] No
______________________________________________________________________________
Signature of Representative Date
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Printed Representative Name (First, Middle Initial, Last) State License I.D. #
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[_] District Agency Index # Or [_] Social Security # (Required) Representative Agency Telephone #
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