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Exhibit 5(m)
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MetLife Insurance Company of Connecticut DOLLAR COST AVERAGING PROGRAM
MetLife Life and Annuity Company of Connecticut
Xxx Xxxxxxxxx - Xxxxxxxx, XX 00000-0000 METLIFE RETIREMENT ACCOUNT
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PURPOSE OF REQUEST: [ ] Initiate Program [ ] Change Current Instructions [ ] Cancel Program
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OWNER INFORMATION
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Owner Name Owner SS#
_______________________________________________________________ __________________________________________________________________
Account Number (Existing accounts only) _______________________________
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PROGRAM INFORMATION
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- A minimum Contract Value of $5,000 is required to start the program. The minimum transfer amount is $400.
- The Program will generally begin the next business day following receipt of initial payment AND completed DCA Form and usually
no later than 15 business days after receipt.
- If subsequent payments are received while a DCA program is running: the payment will be allocated to the existing DCA "FROM"
investment option, and the DCA program will be recalculated.
- If subsequent payments are received after the DCA program has ended, the payment(s) will be allocated to the current investment
options.
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PROGRAM INSTRUCTIONS
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FREQUENCY (select one): [ ] Monthly [ ] Quarterly
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FOR NEW BUSINESS ONLY:
INITIAL PAYMENT AMOUNT TO BE ALLOCATED TO THE DCA 'FROM' INVESTMENT OPTION (select one):
[ ] Full Initial Purchase Payment
[ ] __________% of initial Purchase Payment
SELECT YOUR DCA "FROM" OPTION from the following (select one):
[ ] 6-month DCA Special (if available)
[ ] 12-month DCA Special (if available)
[ ] Other __________________________________________ $_____________________________
(Indicate investment option name) (Indicate amount of transfer)
FOR IN-FORCE CONTRACTS ONLY:
What amount would you like transferred each month or quarter? ______________________________________________________________________
What investment option would you like the dollars transferred FROM? ________________________________________________________________
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SELECT ONE OPTION BELOW FOR YOUR DCA DESTINATION INVESTMENT OPTIONS AND ALLOCATIONS:
[ ] As listed on application (new business only) [ ] As listed on page 2
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SEE PAGE 2 FOR DESTINATION INVESTMENT OPTIONS
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X-00000XXX (XXX CODE) ORDER #L-19243 1 of 3; Rev. 11/06
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INVESTMENT OPTIONS Identify the investment option(s) you would like the dollars transferred into (total must equal 100%) NOTE:
Investment options shown below with an asterisk (*) may not be available to all contracts. For more information, call your
representative or our Customer Service Center.
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NAME CODE PCT NAME CODE PCT
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AIM VI Core Equity Fund* AA __________% Xxxx Xxxxx Partners Variable Total Return
American Funds Global Growth Fund IL __________% Portfolio* AE __________%
American Funds Growth Fund IG __________% Lord Xxxxxx Bond Debenture Portfolio AF __________%
American Funds Growth-Income Fund II __________% Lord Xxxxxx Growth and Income Portfolio HL __________%
Batterymarch Mid-Cap Stock Portfolio 1M __________% Lord Xxxxxx Growth and Income Series Fund -
BlackRock Aggressive Growth Portfolio DQ __________% Class VC FK __________%
BlackRock Bond Income Portfolio 4W __________% Lord Xxxxxx Mid-Cap Value Series Fund -
BlackRock Large-Cap Core Portfolio DR __________% Class VC FL __________%
BlackRock Money Market Portfolio 1K __________% Met/AIM Capital Appreciation Portfolio KC __________%
Credit Suisse Emerging Markets Portfolio* AU __________% Met/AIM Small Cap Growth Portfolio FY __________%
Delaware VIP Small Cap Value Series AP __________% MetLife Aggressive Allocation Portfolio H9 __________%
Dreman Small-Cap Value Portfolio F0 __________% MetLife Conservative Allocation Portfolio H5 __________%
Dreyfus VIF Appreciation Portfolio DP __________% MetLife Conservative to Moderate Allocation
Dreyfus VIF Developing Leaders Portfolio DS __________% Portfolio H6 __________%
FI Large Cap Portfolio (Fidelity) 4G __________% MetLife Investment Diversified Bond Fund OB __________%
FI Value Leaders Portfolio (Fidelity) 4F __________% MetLife Investment International Stock Fund OI __________%
Fidelity VIP Contrafund(R) Portfolio FT __________% MetLife Investment Large Company Stock Fund OC __________%
Fidelity VIP Dynamic Capital Appreciation MetLife Investment Small Company Stock Fund OE __________%
Portfolio* D2 __________% MetLife Moderate Allocation Portfolio H7 __________%
Fidelity VIP Mid Cap Portfolio D1 __________% MetLife Moderate to Aggressive Allocation
Xxxxxx Oakmark International Portfolio 4C __________% Portfolio H8 __________%
Janus Aspen Series Mid Cap Growth MFS(R)Total Return Portfolio HT __________%
Portfolio JA __________% MFS(R)Value Portfolio BD __________%
Janus Aspen Series Worldwide Growth Xxxxxxxxx Xxxxxx Real Estate Portfolio I3 __________%
Portfolio* WW __________% Xxxxxxxxxxx Global Equity Portfolio IK __________%
Janus Capital Appreciation Portfolio US __________% PIMCO VIT Real Return Portfolio PR __________%
Xxxx Xxxxx Partners Managed Assets PIMCO VIT Total Return Portfolio PM __________%
Portfolio UA __________% Pioneer Fund Portfolio UP __________%
Xxxx Xxxxx Partners Variable Adjustable Pioneer Mid-Cap Value Portfolio FW __________%
Rate Income Portfolio BI __________% Pioneer Strategic Income Portfolio HP __________%
Xxxx Xxxxx Partners Variable Aggressive Xxxxxx VT Discovery Growth Fund* OV __________%
Growth Portfolio SG __________% Xxxxxx VT International Equity Fund* ON __________%
Xxxx Xxxxx Partners Variable All Cap Xxxxxx VT Small Cap Value Fund OP __________%
Portfolio AD __________% Xxxxxxxxx Developing Markets Securities Fund VQ __________%
Xxxx Xxxxx Partners Variable Appreciation Xxxxxxxxx Foreign Securities Fund VG __________%
Portfolio 1N __________% Third Avenue Small Cap Value Portfolio IT __________%
Xxxx Xxxxx Partners Variable Dividend Xxx Xxxxxx LIT Xxxxxxxx Portfolio NJ __________%
Strategy Portfolio* G1 __________% Xxx Xxxxxx LIT Enterprise Portfolio* NP __________%
Xxxx Xxxxx Partners Variable Equity Index Xxx Xxxxxx LIT Strategic Growth Portfolio* NY __________%
Portfolio GF __________% Xxxxx Fargo VT Advantage Small/Mid Cap Value
Xxxx Xxxxx Partners Variable Fundamental Fund* AT __________%
Value Portfolio* KR __________% Western Asset Management High Yield Bond
Xxxx Xxxxx Partners Variable High Income Portfolio UB __________%
Portfolio HH __________% Western Asset Management U.S. Government
Xxxx Xxxxx Partners Variable International Portfolio GV __________%
All Cap Growth Portfolio* HI __________% Fixed Account (if available) __________%
Xxxx Xxxxx Partners Variable Investors __________%
Portfolio C2 __________% __________%
Xxxx Xxxxx Partners Variable Large Cap TOTAL: 100%
Growth Portfolio AB __________%
Xxxx Xxxxx Partners Variable Premier
Selections All Cap Growth Portfolio* P1 __________%
Xxxx Xxxxx Partners Variable Small Cap
Growth Opportunities Portfolio C9 __________%
Xxxx Xxxxx Partners Variable Small
Cap Growth Portfolio* SS __________%
Xxxx Xxxxx Partners Variable Social
Awareness Stock Portfolio SA __________%
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PLEASE READ AND SIGN PAGE 3
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X-00000XXX (XXX CODE) ORDER #L-19243 2 of 3; Rev. 11/06
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Dollar Cost Averaging will remain in effect until the balance in the "From" investment option is depleted or until this
authorization is canceled. Dollar Cost Averaging does not guarantee profits or prevent losses in a declining market. This strategy
requires regular investment regardless of fluctuating price levels. Potential investors should consider their financial ability to
continue purchases through periods of low prices levels.
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OWNER'S SIGNATURE DATE
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X-00000XXX (XXX CODE) ORDER #L-19243 3 of 3; Rev. 11/06
