Post-Effective Amendment
Filing Table of Contents
Document/Exhibit Description Pages Size
1: 485BPOS Mli Usa Series L and L - 4 Year Post-Effective 691 3.48M
Amendment No. 25
3: EX-99.10 Consent of Independent Registered Public 1 7K
Accounting Firm (Deloitte & Touche LLP)
4: EX-99.13 Powers of Attorney 11 75K
2: EX-99.5(VII) Form of Variable Annuity Application 5± 29K
EX-99.5(VII) — Form of Variable Annuity Application
| EX-99.5(VII) | 1st “Page” of 3 | TOC | ↑Top | Previous | Next | ↓Bottom | Just 1st |
|---|
[Enlarge/Download Table]
[LOGO OF METLIFE(R)] VARIABLE ANNUITY APPLICATION SEND APPLICATION AND CHECK TO:
Home Office Address (no correspondence) METLIFE INVESTORS USA INSURANCE COMPANY
222 Delaware Avenue Suite 900 . Wilmington, DE 19899 Policy Service Office: P.O. Box 10366 . Des Moines, Iowa 50306-0366
For Express Mail Only . 4700 Westown Parkway Ste. 200 . West Des Moines, IA 50266-2266
MetLife Investors USA Variable Annuity Series L FOR ASSISTANCE CALL: THE SALES DESK
ACCOUNT INFORMATION
1. ANNUITANT
Social
__________________________________________________________________________ Security Number ___________ -- __________ -- _________
Name (First) (Middle) (Last)
Sex [_] M [_] F Date of Birth _______/_______/______
__________________________________________________________________________ Phone (_____) _______________________________________
Address (Street - No P.O. Box) (City) (State) (Zip)
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 _____/_____/____
__________________________________________________________________________ Phone (_____) _______________________________________
Address (Street - No P.O. Box) (City) (State) (Zip)
3. JOINT OWNER
Social
__________________________________________________________________________ Security Number ___________ -- __________ -- _________
Name (First) (Middle) (Last)
Sex [_] M [_] F Date of Birth _______/_______/______
__________________________________________________________________________ Phone (_____) _______________________________________
Address (Street - No P.O. Box) (City) (State) (Zip)
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 (Street - No P.O. Box) Relationship Social Security Number %
- -
------------------------------------------------------------------------------------------------------------------------------------
Primary Name (Street - No P.O. Box) Relationship Social Security Number %
- -
------------------------------------------------------------------------------------------------------------------------------------
Contingent Name (Street - No P.O. Box) Relationship Social Security Number %
- -
------------------------------------------------------------------------------------------------------------------------------------
Contingent Name (Street - No P.O. Box) Relationship Social Security Number %
ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT,
ARE VARIABLE, MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
5. PLAN TYPE 6. PURCHASE PAYMENT
INDICATE ONLY HOW CONTRACT IS TO BE ISSUED. Funding Source of Purchase Payment
----------------------------------
.. NON-QUALIFIED ...............[_] [_] 1035 Exchange [_] Check [_] Wire
.. QUALIFIED TRADITIONAL IRA* ..[_] Transfer [_] Rollover [_] Contribution - Year _______ Initial Purchase
Payment $____________________________
.. QUALIFIED SEP IRA* ..........[_] Transfer [_] Rollover [_] Contribution - Year _______ Make Check Payable to
MetLife Investors USA
.. QUALIFIED ROTH IRA* .........[_] Transfer [_] Rollover [_] Contribution - Year _______ (Estimate dollar amount for 1035
exchanges, transfers, rollovers, etc.)
.. QUALIFIED 401 ...............[_]
Minimum Initial Purchase Payment:
* THE ANNUITANT AND OWNER MUST BE THE SAME PERSON. $10,000 Non-Qualified/Qualified
8029 (10/07) [BAR CODE] APPUSAL
MAY 2011
Page 1
[Enlarge/Download Table]
RIDERS
7. BENEFIT RIDERS (Subject to state availability and age restrictions. Other restrictions may apply.)
These riders may only be chosen at the time of application. 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 BENEFITS (GMIB)
[_] GMIB Max
[_] GMIB Plus III
GUARANTEED WITHDRAWAL BENEFIT (GWB)
[_] Guaranteed Withdrawal Benefit (GWB)
LIFETIME GUARANTEED WITHDRAWAL BENEFIT (LWG)
[_] Single Life - Lifetime Withdrawal Guarantee (LWG) (2008)
[_] Joint Life - Lifetime Withdrawal Guarantee (LWG) (2008)
* GWB IS THE ONLY LIVING BENEFIT RIDER AVAILABLE TO DECEDENT IRAS. NO LIVING BENEFIT RIDERS ARE AVAILABLE WITH NON-QUALIFIED
DECEDENT.
2) DEATH BENEFIT RIDERS (Check one. If no election is made, the Principal Protection option will be provided at no additional
charge.)
GUARANTEED MINIMUM DEATH BENEFITS (ENHANCED DEATH BENEFITS (EDB))**
[_] EDB Max (May only be selected if GMIB Max or no living benefit rider is elected.)
[_] EDB II (May only be selected if GMIB Plus or no living benefit rider is elected.)
OTHER DEATH BENEFIT RIDERS
[_] Principal Protection (no additional charge)
[_] Annual Step-Up
** EDB RIDERS ARE NOT AVAILABLE IN DECEDENT/STRETCH TAX MARKETS.
3) OTHER
[_] Earnings Preservation Benefit Rider (EPB) (May not be selected if an EDB rider is elected.)
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. MetLife Investors USA 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. 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. FRAUD STATEMENT AND DISCLOSURE
NOTICE TO APPLICANT:
ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA RESIDENTS ONLY: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and
may be subject to civil fines and confinement in prison.
DISTRICT OF COLUMBIA RESIDENTS ONLY: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a claim was provided by the applicant.
KENTUCKY RESIDENTS ONLY: Any person who knowingly and with the intent to defraud any insurance company or other person files an
application for insurance 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.
MAINE, TENNESSEE, VIRGINIA AND WASHINGTON RESIDENTS ONLY: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of
insurance benefits.
MARYLAND RESIDENTS ONLY: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
MASSACHUSETTS RESIDENTS ONLY: The variable annuity for which you are making this application gives us the right to restrict or
discontinue allocations of purchase payments to the Fixed Account and reallocation from the Investment Divisions to the Fixed
Account. This discontinuance right may be exercised for reasons which include but are not limited to our ability to support the
minimum guaranteed interest rate of the Fixed Account when the yields on our Investments would not be sufficient to do so. This
discontinuance will not be exercised in an unfairly discriminatory manner. The prospectus also contains
8029 (10/07) Page 2 APPUSAL
MAY 2011
| EX-99.5(VII) | Last “Page” of 3 | TOC | 1st | Previous | Next | ↓Bottom | Just 3rd |
|---|
[Enlarge/Download Table]
10. FRAUD STATEMENT AND DISCLOSURE (CONTINUED)
additional information about our right to restrict access to the Fixed Account in the future. BY SIGNING THIS APPLICATION, I
ACKNOWLEDGE THAT I HAVE RECEIVED, READ AND UNDERSTOOD THE STATEMENTS IN THIS APPLICATION AND IN THE PROSPECTUS THAT THE FIXED
ACCOUNT MAY NOT BE AVAILABLE AT SOME POINT DURING THE LIFE OF THE CONTRACT INCLUDING POSSIBLY WHEN THIS CONTRACT IS ISSUED. NEW
JERSEY RESIDENTS ONLY: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
NEW MEXICO RESIDENTS ONLY: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and
criminal penalties.
OHIO RESIDENTS ONLY: A person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing false or deceptive statement is guilty of insurance fraud.
PENNSYLVANIA RESIDENTS ONLY: ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED UPON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT
ARE VARIABLE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT. Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of 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.
11. 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 USA Separate Account A. PAYMENTS AND VALUES PROVIDED BY THE CONTRACT FOR WHICH APPLICATION IS MADE
ARE VARIABLE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
I HAVE READ THE STATE FRAUD STATEMENT IN SECTION 10 ABOVE APPLICABLE TO ME.
------------------------------------------------------------------------------------------------------------------------------------
(Owner Signature and Title, Annuitant unless otherwise noted)
------------------------------------------------------------------------------------------------------------------------------------
(Joint Owner Signature and Title)
------------------------------------------------------------------------------------------------------------------------------------
(Signature of Annuitant if other than Owner)
Signed at Date
------------------------------------------------------------------- -----------------------------------------------
(City) (State)
12. AGENT'S REPORT
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.
------------------------------------------------------------------------------------------------------------------------------------
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 ___________
8029 (10/07) Page 3 APPUSAL
MAY 2011
4 Subsequent Filings that Reference this Filing
↑Top
Filing Submission 0001193125-11-103743 – Alternative Formats (Word / Rich Text, HTML, Plain Text, et al.)
Copyright © 2024 Fran Finnegan & Company LLC – All Rights Reserved.
About — Privacy — Redactions — Help —
Sun., May 12, 5:42:31.2pm ET 