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Metlife Investors USA Separate Account A, et al. · 485BPOS · On 7/15/04 · EX-99.5(II)

Filed On 7/15/04, 5:20pm ET   ·   Accession Number 1193125-4-118992   ·   SEC Files 333-54464, 811-03365

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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

Post-Effective Amendment
Filing Table of Contents

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 


EX-99.5(II)   —   Form of Variable Annuity Application Series Va


This exhibit is an HTML Document rendered as filed.  [ Alternative Formats ]



  Form of Variable Annuity Application Series VA  

Exhibit 5(ii)

 

LOGO         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)*
* 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)

  APPVA-504USAVA

Filing Submission 0001193125-04-118992   –   Alternative Formats (Word / Rich Text, HTML, Plain Text, et al.)

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