MetLife Investors USA Variable Annuity Series VA

Social

Security Number                        –                        –                       

Name             (First)            (Middle)             (Last)

Correspondence is sent to the Owner.

Social

Security/Tax ID Number                    –                    –                   

Name             (First)            (Middle)             (Last)

Social

Security Number                       –                        –                       

Name             (First)            (Middle)             (Last)

Minimum Initial Purchase Payment:

$5,000 Non-Qualified         $2,000 Qualified

8029 (7/04)

7. Benefit Riders (subject to state availability and age restrictions )

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)*
* Only one (GMIB or GWB) may be elected

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)