SEC Info  
    Home      Search      My Interests      Help      Sign In      Please Sign In

New England Variable Annuity Separate Account, et al. – ‘485APOS’ on 1/16/08 – ‘EX-99.5(VIII)’

On:  Wednesday, 1/16/08, at 4:28pm ET   ·   Private-to-Public:  Document/Exhibit  –  Release Delayed   ·   Accession #:  950135-8-196   ·   File #s:  333-51676, 811-08828

Previous ‘485APOS’:  ‘485APOS’ on 7/26/05   ·   Next & Latest:  ‘485APOS’ on 4/22/08   ·   4 References:   

Find Words in Filings emoji
 
  in    Show  and   Hints

  As Of                Filer                Filing    For·On·As Docs:Size              Issuer               Agent

 1/16/08  New England Var Annuity Sep Acct  485APOS¶               6:630K                                   Bowne of Boston/FANew England Variable Annuity Separate Account American Forerunner Series

Post-Effective Amendment
Filing Table of Contents

Document/Exhibit                   Description                      Pages   Size 

 1: 485APOS     New England Variable Annuity Separate Account        145    793K 
 6: COVER     ¶ Comment-Response or Cover Letter to the SEC            1      2K 
 2: EX-99.4(XIX)  EX-99.4(XIX) Guaranteed Minimum Death Benefit        8±    29K 
                Rider Nel-640-1 (4/08)                                           
 3: EX-99.4(XXI)  EX-99.4(XXI) Guaranteed Minimum Income Benefit       7     35K 
                Rider-Living Benefit Nel-S60-4(04/08)                            
 4: EX-99.4(XXII)  EX-99.4(XXII) Lifetime Guaranteed Withdrawal        8     38K 
                Benefit Rider Nl-690-4(04/08)                                    
 5: EX-99.5(VIII)  EX-99.5(VIII) Form of Application Afsapp (Gmdb)     4     32K 
                (04/08)                                                          


‘EX-99.5(VIII)’   —   EX-99.5(VIII) Form of Application Afsapp (Gmdb) (04/08)

EX-99.5(VIII)1st Page of 4TOCTopPreviousNextBottomJust 1st
 

. . . [Enlarge/Download Table] New England Financial(R) Administrative Office A MetLife Company NEW ENGLAND FINANCIAL PO Box 14594 Des Moines Iowa 50306-3594 NEW ENGLAND LIFE INSURANCE COMPANY 501 Boylston Street, Boston, Massachusetts 02116-3700 VARIABLE ANNUITY APPLICATION TO American Forerunner Series(R) Contract Number (if assigned) No._____________________________________ AMERICAN FORERUNNER SERIES(R) CLASS SELECTION: Select One Class - If no class is selected, the Standard Class will automatically be chosen. [ ] STANDARD CLASS [ ] P CLASS [ ] C CLASS [ ] L CLASS [ ] B PLUS CLASS* *IF B PLUS CLASS IS CHOSEN, PLEASE COMPLETE THE BONUS DISCLOSURE FORM. 1. ANNUITANT AND OWNER(S) ANNUITANT (Annuitant will be the Owner unless Owner section is completed.) Name (First, Middle Initial, Last) Gender [ ] M [ ] F Date of Birth Street Address Social Security # City, State & ZIP Code E-mail Address Marital Status Home Telephone # Work Telephone # Relationship to Owner OWNER - NON-QUALIFIED ONLY (Complete if the Owner is different from the Annuitant.) Name (First, Middle Initial, Last) TYPE: [ ] Individual [ ] Custodian [ ] Trust** Gender Date of Birth/Trust Date [ ] Corporation*** [ ] M [ ] F Street Address Social Security # or Tax I.D. # (TIN) City, State & ZIP Code E-mail Address Marital Status Home Telephone # Work Telephone # Relationship to Annuitant * * Trust ownership is permitted only where the trust is for the benefit of a natural person. If owner is a trust, please complete the trustee certification form. *** Ownership by a Corporation is permitted only where an employer is purchasing a SEP, SIMPLE, or Qualified Plan for its employees. State availability must be verified. JOINT OWNER - NON-QUALIFIED ONLY Name (First, Middle Initial, Last) Gender [ ] M [ ] F Date of Birth Street Address Social Security # City, State & ZIP Code E-mail Address Marital Status Home Telephone # Work Telephone # Relationship to Owner NOTE: If two people are named as Joint Owners, either Owner may exercise any and all rights under the contract unless the Owner specifies otherwise in writing. ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. AFS APP (04/08) 1 GMDB (04/08) eF
EX-99.5(VIII)2nd Page of 4TOC1stPreviousNextBottomJust 2nd
VARIABLE ANNUITY APPLICATION 2. PRIMARY AND CONTINGENT BENEFICIARY(IES) [Enlarge/Download Table] -------------------------- ---------------------------------- --------------------- ----------------- --- Beneficiary Type Name (First, Middle Initial, Last) Relationship to Owner Social Security # % -------------------------- ---------------------------------- --------------------- ----------------- --- [ ] Primary [ ] Contingent -------------------------- ---------------------------------- --------------------- ----------------- --- [ ] Primary [ ] Contingent -------------------------- ---------------------------------- --------------------- ----------------- --- [ ] Primary [ ] Contingent -------------------------- ---------------------------------- --------------------- ----------------- --- [Enlarge/Download Table] (Note: To be used to determine whom will be paid/assume all rights under the contract on the Owner's death. The Owner's estate will be paid/assume all rights if no Beneficiary is named. Not applicable to Annuitant's death if the Natural Owner and Annuitant are different and the Annuitant predeceases the Owner. Payment/assumption will be made in equal shares to the survivors unless otherwise specified in writing by the Owner. If the primary beneficiaries predecease the Owner, the contingent beneficiaries will be paid/assume all rights. If more than three beneficiaries are named, attach a separate sheet.) 3. CONTRACT APPLIED FOR: [ ] Non-qualified [ ] IRA [ ] Roth IRA [ ] SEP [ ] SIMPLE IRA [ ] Qualified Plan__________________________________________ [ ] Decedent IRA [ ] Other_______________________________________ 4. PURCHASE PAYMENT(S): Complete a line for each individual deposit. Select a Payment Method, Payment Type and Source of Funds from the columns below. If there are more than 5 Purchase payments, attach a separate sheet. Payment #1 Payment Method:__________________ Payment Type:___________________________ Amount:______________________________________ Source of Funds:__________________________________________________________ Tax Year:____________________________________ Payment #2 Payment Method:__________________ Payment Type:___________________________ Amount:______________________________________ Source of Funds:__________________________________________________________ Tax Year:____________________________________ Payment #3 Payment Method:__________________ Payment Type:___________________________ Amount:______________________________________ Source of Funds:__________________________________________________________ Tax Year:____________________________________ Payment #4 Payment Method:__________________ Payment Type:___________________________ Amount:______________________________________ Source of Funds:__________________________________________________________ Tax Year:____________________________________ Payment #5 Payment Method:__________________ Payment Type:___________________________ Amount:______________________________________ Source of Funds:__________________________________________________________ Tax Year:____________________________________ Payment Methods: Payment Types: Source of Funds: Check 1035 Exchange Annuity Contract Wire Transfer Bonds Draft* Rollover Certificate of Deposit Contribution Endowment (Maturity Date_____/_____/_____) Discretionary Income (Salary/Bonus) Gift from Immediate Relative Inheritance Legal Settlement Life Insurance Policy Loan Money Market Account*** Mutual Fund Pension Assets** Real Estate Savings Stocks Other *If new, please complete Electronic Payment Account Agreement **Generally includes, but not limited to, 401A, 401K, Defined Contribution Plans, Defined Benefits Plans, etc. ***If any mutual funds were liquidated within the past 6 months to fund this money market, you should indicate "mutual funds" AFS APP (04/08) 2 GMDB (04/08) eF
EX-99.5(VIII)3rd Page of 4TOC1stPreviousNextBottomJust 3rd
[Enlarge/Download Table] 5. REPLACEMENT (MUST BE COMPLETED) (a) DO YOU HAVE ANY EXISTING INDIVIDUAL LIFE INSURANCE OR ANNUITY CONTRACTS? [ ] YES [ ] NO (If "Yes", applicable disclosure and replacement forms must be attached.) (b) WILL THE ANNUITY APPLIED FOR REPLACE OR CHANGE ONE OR MORE EXISTING ANNUITY OR LIFE INSURANCE CONTRACTS? [ ] YES [ ] NO (If "Yes", applicable disclosure and replacement forms must be attached.) NOTE: Replacement includes any surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or life insurance contract in connection with this application. 6. OPTIONAL RIDERS (AVAILABLE AT THE TIME OF APPLICATION AND MAY NOT BE CHANGED ONCE ELECTED. THERE ARE ADDITIONAL CHARGES FOR THE RIDERS.) LIVING BENEFIT RIDERS* (CHECK ONLY ONE OR NONE) [ ] The Predictor(SM), GMIB (Guaranteed Minimum Income Benefit) [ ] The Predictor Plus(SM) (Guaranteed Minimum Income Benefit Plus) (2008 Version) [ ] GMAB (Guaranteed Minimum Accumulation Benefit) [ ] GWB (Guaranteed Withdrawal Benefit)** [ ] Single Life - MetLife Lifetime Withdrawal Guarantee(TM) (2008 Version) [ ] Joint Life - MetLife Lifetime Withdrawal Guarantee(TM) (2008 Version) **GWB is the only living benefit rider available for Decedent IRAs. DEATH BENEFIT RIDERS* (CHECK ONLY ONE OR NONE) If no selection is made, the Standard Death Benefit at no additional charge will be provided. [ ] Annual Step Up (Option 1) [ ] Enhanced Death Benefit (Option 2) Can only be elected without any living benefit riders, or only with the Predictor Plus (2008 Version) OTHER RIDERS* [ ]EPB (Earnings Preservation Benefit)*** *** If chosen, please complete and sign EPB form. *All riders may be subject to state availability 7. AUTHORIZATION AND SIGNATURE(S) (a)IMPORTANT STATE NOTICES: 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 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. 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. (b)STATE FRAUD STATEMENTS: ARKANSAS, LOUISIANA, 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. FLORIDA RESIDENTS ONLY: 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. 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. AFS APP (04/08) 3 GMDB (04/08) eF
EX-99.5(VIII)Last Page of 4TOC1stPreviousNextBottomJust 4th
[Enlarge/Download Table] VARIABLE ANNUITY APPLICATION ------------------------------------------------------------------------------------------------------------------------------------ 7. AUTHORIZATION AND SIGNATURE(S) (CONTINUED) (b)STATE FRAUD STATEMENTS (CONTINUED): MAINE, TENNESSEE 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. 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: 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. (c)SIGNATURES: I hereby represent my answers to the above questions to be correct and true to the best of my knowledge and belief. I have received New England Life Insurance Company's Privacy Notice, and the current prospectus for the American Forerunner Series(SM). I UNDERSTAND THAT ALL VALUES PROVIDED BY THE CONTRACT/CERTIFICATE BEING APPLIED FOR, WHICH ARE BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO THE AMOUNT. Under the Joint Life Version of the Lifetime Withdrawal Guarantee, the rider will automatically continue only if the surviving spouse of the Owner, as of the date of the Owner's death, continues the contract. I understand that there is no additional tax benefit obtained by funding an IRA or other qualified plan with a variable annuity. I understand that The Internal Revenue Service may take the position that the use of certain death benefit or living benefit riders may adversely affect the qualification of the IRA Contract. PLEASE CONSULT THE TAX SECTION OF THE PROSPECTUS FOR FURTHER DETAILS. IF the Owner is a corporation, partnership or trust, print the name of the Owner and have one or more officers, partners or trustees sign. Earnings in this contract may be taxable annually to the Owner. (CONSULT YOUR TAX ADVISOR.) I HAVE READ THE STATE FRAUD STATEMENT IN SECTION 7(b) ABOVE APPLICABLE TO ME. LOCATION WHERE THE APPLICATION IS SIGNED --------------------------------------------------------------------------------------- City & State ------------------------------------------------------------------------------------------------------------------------------- Signature of Owner Date ------------------------------------------------------------------------------------------------------------------------------- Signature of Joint Owner Date 8. REPRESENTATIVE INFORMATION STATEMENT OF REPRESENTATIVE All answers are correct to the best of my knowledge. I have provided the Proposed Owner with New England Life Insurance Company's Customer Privacy Notice, prior to or at the time he/she completed the application form. I have also delivered a current American Forerunner Series prospectus; and reviewed the financial situation of the Proposed Owner as disclosed, and believe that a multi-funded annuity contract would be suitable. I am properly FINRA registered and licensed in the state where the Proposed Owner signed this application. (a) Does the applicant have existing life insurance policies or annuity contracts? [ ] YES [ ] No (If "Yes", applicable disclosure and replacement forms must be attached.) (b) Do you have reason to believe that the replacement or change of any existing life insurance policies and annuity contracts may be involved? [ ] YES [ ] NO (If "Yes", applicable disclosure and replacement forms must be attached.) NOTE: Replacement includes any surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or life insurance contract in connection with this application. ------------------------------------------------------------------------------------------------------------------------------------ Signature of Representative Date ------------------------------------------------------------------------------------------------------------------------------------ Printed Representative Name Phone # State License I.D. # AFS APP (04/08) 4 GMDB (04/08) eF

4 Subsequent Filings that Reference this Filing

  As Of               Filer                 Filing    For·On·As Docs:Size             Issuer                      Filing Agent

 4/24/24  New England Var Annuity Sep Acct  485BPOS     4/29/24    4:3.5M                                   Donnelley … Solutions/FA
 4/24/23  New England Var Annuity Sep Acct  485BPOS     5/01/23    5:3.6M                                   Donnelley … Solutions/FA
 4/25/22  New England Var Annuity Sep Acct  485BPOS     4/29/22    8:2.8M                                   Donnelley … Solutions/FA
 4/28/21  New England Var Annuity Sep Acct  485BPOS     4/30/21    4:29M                                    Donnelley … Solutions/FA
Top
Filing Submission 0000950135-08-000196   –   Alternative Formats (Word / Rich Text, HTML, Plain Text, et al.)

Copyright © 2024 Fran Finnegan & Company LLC – All Rights Reserved.
AboutPrivacyRedactionsHelp — Fri., Apr. 26, 2:29:44.2pm ET