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As Of Filer Filing For/On/As Docs:Size Issuer Agent
7/15/04 Metlife Investors USA Separate..A 485BPOS 7/15/04 24:1.0M RR Donnelley/FA
Metlife Investors USA Separate Account A
Document/Exhibit Description Pages Size
1: 485BPOS Metlife Investors (Mli Usa Va) Post-Effective HTML 248K
Amendment No. 6
2: EX-99.1 Certification of Restated Resolultions HTML 30K
22: EX-99.10(I) Consent of Independent Registered Public HTML 11K
Accounting Firm
23: EX-99.10(II) Consent of Sutherland Asbill & Brennan LLP HTML 11K
24: EX-99.10(III) Consent of Council (Mli Usa) HTML 11K
3: EX-99.3(II) Principal Underwriter's and Selling Agreement HTML 24K
4: EX-99.3(III) Amendment to Principal Underwriters and Selling HTML 20K
Agreement
6: EX-99.4(XIX) Form of Contract Schedule [Series C, L, Va, or HTML 48K
Xc]
5: EX-99.4(XVIII) Form of Guaranteed Withdrawal Benefit Rider HTML 33K
(Gwb)
7: EX-99.4(XX) Individual Retirement Annuity Endorsement 8023.1 HTML 38K
(9/02)
8: EX-99.4(XXI) Roth Individual Retirement Annuity Endorsement HTML 32K
9024.1 (9/02)
9: EX-99.4(XXII) 401(A)/403(A) Plan Endorsement 8025.1 (9/02) HTML 15K
10: EX-99.4(XXIII) Tax Sheltered Annuity Endorsement 8026.1 HTML 48K
(9/02)
11: EX-99.4(XXIV) Simple Individual Retirement Annuity HTML 38K
Endorsement 8276 (9/02)
12: EX-99.5(II) Form of Variable Annuity Application Series Va HTML 40K
13: EX-99.6(I) Retstated Certificate of Incorporation of HTML 24K
Associated Traffic Clubs
14: EX-99.6(II) By-Laws HTML 48K
15: EX-99.6(III) Amended Certificate of Incorporation Filed HTML 13K
10/01/79 and Signed 9/27/79
16: EX-99.6(IV) Change of Location of Registered Office/Agent HTML 13K
Filed 2/26/80 and Effective 2/8/80
17: EX-99.6(V) Cert. of Amend. of Certification of Incorp. Signed HTML 16K
4/26/83, Certified 2/12/85
18: EX-99.6(VI) Amended Certificate of Incorporation Filed HTML 23K
10/22/84 and Signed 10/19/84
19: EX-99.6(VII) Amended Certificate of Incorporation Certified HTML 19K
8/31/94 and Signed 10/19/84
20: EX-99.6(VIII) Amended Certificate of Incorporation (Name HTML 15K
Change)
21: EX-99.8(III) Participation Agreement (Effective 2-12-01) HTML 96K
| Form of Variable Annuity Application Series VA |
Exhibit 5(ii)
 |
Send Application and check to: | |||
| MetLife Investors USA Insurance Company | ||||
| Variable Annuity Application | Policy Service Office: P.O. Box 10366 | |||
| Des Moines, Iowa 50306-0366 | ||||
| MetLife Investors USA Variable Annuity Series VA |
For assistance call: 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 | 6. Purchase Payment | |||||
| ¨ NON-QUALIFIED | Funding Source of Purchase Payment | |||||
| QUALIFIED | ¨ 1035 Exchange ¨ Check ¨ Wire | |||||
| ¨ 401 | Initial Purchase | |||||
| ¨ 403(b) TSA Rollover* | Payment $ | |||||
| 408 IRA* (check one of the options listed below) | Make Check Payable to MetLife Investors USA | |||||
| Traditional IRA | SEP IRA | Roth IRA | (Estimate dollar amount for 1035 exchanges, transfers, rollovers, etc.) | |||
| ¨ Transfer | ¨ Transfer | ¨ Transfer | ||||
| ¨ Rollover | ¨ Rollover | ¨ Rollover |
Minimum Initial Purchase Payment: $5,000 Non-Qualified $2,000 Qualified | |||
| ¨ Contribution –Year | ¨ Contribution –Year | ¨ Contribution –Year | ||||
| *The annuitant and owner must be the same person. | ||||||
| 8029 (7/04) |
APPVA-504USAVA |
| RIDERS | 11. Replacements | |
| 7. Benefit Riders (subject to state availability and age restrictions ) |
Does the applicant have any existing life insurance policies or annuity contracts? ¨ Yes ¨ No | |
| 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. |
Is this annuity being purchased to replace any existing life insurance or annuity policy(ies)? ¨ Yes ¨ No | |
|
1) ¨ Guaranteed Minimum Income Benefit Rider (GMIB)* 2) ¨ Guaranteed
Withdrawal Benefit (GWB)* 3) Death Benefit Riders (Check one. If no election is made, the Principal Protection option will apply). ¨ Principal Protection (no additional charge) ¨ Annual Step-Up ¨ Compounded-Plus 4) ¨ Earnings Preservation Benefit Rider 5) ¨ Other
COMMUNICATIONS
8. Telephone Transfer |
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 USA 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. | |
|
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 |
(Owner Signature & Title, Annuitant unless otherwise noted)
(Joint Owner Signature & Title)
(Signature of Annuitant if other than Owner)
Signed at (City) (State)
Date | |
|
SIGNATURES
9. Fraud Statement
Notice to Applicant:
For Arkansas, Kentucky, Louisiana, Maine, New Mexico, Ohio, Pennsylvania, Tennessee 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 |
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 Option C
|
| 8029 (7/04) |
APPVA-504USAVA |