Individual Life
For use in the State of:
New York
Life Insurance Application and Forms Package ENB-7-07-NY (08/15)
Application for Life Insurance Application for Individual Life Insurance for all MetLife affiliated companies. Signatures Required
EILLS-CERT-NY
New York Illustration Certification Required with all New York new business life applications only. To be completed and signed by the applicant. Signatures Required
EAUTH-16-NY
Authorization Proposed Insured’s authorization for release of information to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). Signatures Required
EHIV-04-NY
New York Informed Consent Form for Blood and Urine Testing for the AIDS Virus and Other Conditions Notice and Consent Authorization form for HIV related testing. Note: Use the applicable form for each Proposed Insured's state of residence. Signatures Required
EPID-54-07-NY
Producer Identification & Certification This is to be completed by the Producer attesting to completion of the application and certification of Owner identity. Signatures Required - Producer and Agency Management
MNCR-87-15-NY-1
Riders With No Premium or Cost of Insurance Charge Supplement Required with all New York applications for whole life products plus any other product where the Acceleration of Death Benefit rider is available. Signatures Required
EREPLDIS-NY-DEF
Definition of Replacement Completion required whether Replacement is involved or not. Signatures Required
What customers should know Identity verification:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who applies for life insurance.
What this means for you:
When you apply for a policy, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. APP-PACK-NY (07/16)
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MSIAUTH-05
Authorization to Obtain and Disclose Information Authorization to be signed by the Proposed Insured for release of personal information to the MSI Financial Services, Inc. and to one or more of the listed companies. Signatures Required
EMED-48-07-NY (05/11)
Medical Supplement This form is to be completed by the Proposed Insured regarding his/her health for underwriting purposes. Note: Completion is optional if a full Paramedical/Medical Exam is required. Best practice is to answer all medical questions to enable the underwriter to promptly begin the underwriting process.
What customers should know Identity verification:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who applies for life insurance.
What this means for you:
When you apply for a policy, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. APP-PACK-NY (07/16)
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What producers should know • • • • • •
• • • • • • • •
Incomplete Applications may delay processing. Complete all required sections and obtain all signatures and titles (where required). Do not use pencil to complete this application or use “white out” to make changes. If a change is made to an answer, the respondent must initial the change. When a replacement is involved or if the policy state has adopted a replacement regulation, the appropriate state required replacement form(s) must be signed and dated on, or prior to, the Application date. The NAIC Replacement Notice (EREPLDIS-NAIC) must be completed and signed in certain states if either the Proposed Insured or the Owner has any existing life insurance policies or annuity contracts even if they are not replacing this coverage. While completion of the Medical Supplement (EMED-48-07) is not required if the Proposed Insured is being examined, answering all medical questions (including the full name, address and phone number for each physician consulted) is good field underwriting practice and will enable the underwriter to promptly begin the underwriting process. Complete and sign the Producer Identification & Certification form. Social Security number of the Beneficiary is an optional field. However, this information is valuable in helping us locate Beneficiaries at time of claim. Complete all Supplements and Questionnaires indicated by the applicant's selection in this Application, and submit them WITH this Application. We do not accept cash, traveler's checks, credit cards or money orders as a form of payment for variable life products. Use 'Other' as source of funds if the contract is to be funded in full or in part with monies from a reverse mortgage or home equity loan. If this is one of several "other" fund sources, please provide details in the Section IX - Additional Information. When selecting List Bill as the method of payment, you must also indicate the bill frequency by checking the appropriate box (annual, semiannual, quarterly). In the event the frequency is monthly, please indicate that in Section IX in this application. For details regarding products and riders, as well as a forms inventory for the new business application process, please review the producer tools and the product section of the Producer Portal. Additional Insureds must complete the Additional Insureds Supplement for each life proposed for coverage. Legend for symbols
i - For your information
2
- Refer to supplement - Attention
APP-PACK-NY (07/16)
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Policy Number
Application for Life Insurance Metropolitan Life Insurance Company
SECTION I - About the Proposed Insured For Additional Insureds please complete the Additional Insureds Supplement form. First Name
Middle Name
Last Name
Permanent Address Country of Legal Residence
Alternate Phone Number
Place of Birth U.S. Driver's License
E-Mail Address
Date of Birth
Primary Phone Number
Preferred Time to Call
Social Security or Tax ID Number
Name of Employer
AM
From
Earned Annual Income
ID Number
Zip
Female
Government Issued Photo ID
Passport
State
Expiration Date (if any) Position/Duties
NON U.S. CITIZENS ONLY - Country of Citizenship
Green Card/Visa Type
Expiration Date
Country of Permanent Residence
ID Number
Years in the U.S.
SECTION II - About the Owner
Complete ONLY if the Owner is NOT the Proposed Insured.
OWNER - TRUST / BUSINESS ENTITY - Name of Entity Charity Trust Business Entity OWNER - OTHER INDIVIDUAL First Name
Middle Name
Citizenship
Issuer of ID
Last Name State
Social Security or Tax ID Number Date of Birth Earned Annual Income Net Worth
U.S. Driver's License ID Number
Trustee / Owner State
2 Complete the appropriate administrative form(s).
City
E-Mail Address Please indicate form of ID:
Tax ID Number
Qualified Pension Plan
Permanent Address Country of Legal Residence
Male
Sex
PM
Net Worth
Issue Date (if any)
Employer City
AM
To
PM
If not licensed, please indicate other form of ID:
Issuer of ID
Zip
State
City
Passport Issue Date (if any)
Zip
Phone Number Relationship to Proposed Insured Government Issued Photo ID Expiration Date (if any)
Check if ownership should change to the Insured upon Owner and Contingent Owner’s deaths. 1 of 7 ENB-7-07-NY (08/15)
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SECTION III - About the Beneficiary / Beneficiaries
For additional Beneficiaries, use Section IX - Additional Information.
Check here if the Owner is the Primary Beneficiary. For Primary or Contingent Beneficiaries who are NOT the Owner, complete the table below. Beneficiary Type
Name (First, Middle, Last)
Date of Birth
Relationship to Proposed Insured
Social Security Number (Optional)
Percentage of Proceeds (if not equal)
Primary Primary Contingent Primary Contingent Check here to include all living and future natural or adopted children of the Proposed Insured as Contingent Beneficiaries. (Name all living children above.) 2 If a Custodian is acting on behalf of a minor Beneficiary listed above, please use Co-Owner/Contingent Owner and UTMA Designations Supplement form. Before naming a Beneficiary who has special needs, you should consult a tax advisor regarding any eligibility limits for government benefits payments made to individuals with special needs. SECTION IV - About Proposed Coverage Check the desired coverage(s). Universal Life
Variable Life 2
Term Life
Whole Life
Product Name
Product Name
Product Name
Face Amount*
Face Amount*
Face Amount*
Riders and Details
Riders and Details
Riders and Details
Disability Waiver Dividend Options: Paid-Up Additions Other, please specify:
Disability Waiver:
Coverage Continuation (UL only) Disability Waiver: Specified Premium Monthly Deduction (VUL only) Death Benefit Option Definition of Life Insurance: Guideline Premium Test Cash Value Accumulation Test
Automatic Premium Loan Requested:
Note: Some riders may require supplement forms to be completed.
2 For Variable Life products, please complete the Variable Life Supplement form.
Years 2 to to
Yes No
i For a full list of riders and options, please consult with your Producer.
Planned Premium Year 1 Years
Non-Convertible
Convertible
(UL only)
ADDITIONAL OPTIONS One Time (Single) Payment Amount
* If Face Amount is equal to or exceeds $1,000,000, please complete the Personal Financial Information form.
1035 Exchange Amount
Requested Policy Date
Save Age
POLICY OPTIONS Alternate Policy: Product, Face Amount and Details Additional Policy: Product, Face Amount and Details Group Conversion Only Group Conversion Alternative
} 2 Please complete the Group Conversion Supplement form for either choice. 2 of 7
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SECTION V - About Existing or Applied for Insurance Does the Proposed Insured or Owner have any existing or applied for life insurance or annuities with this or any other company?
Yes Yes
Proposed Insured Owner If YES, please provide details of any existing or applied for Life Insurance on the Proposed Insured only. Amount of Insurance
Company
Year of Issue
No No
Status Existing
Applied For
Existing
Applied For
Existing
Applied For
Existing
Applied For
In connection with this application, has there been, is there intended to be, or will there be with this or any other company any: surrender transaction; loan; withdrawal; lapse; reduction or redirection of premium/consideration; or change transaction Yes No (except conversions) involving an annuity or other life insurance?
2 If YES, complete Replacement Questionnaire AND any other state required replacement forms or 1035 exchange forms. If Proposed Insured is financially dependent on another individual, indicate individual providing support:
Spouse
Child
Parent
Other
Amount of insurance on individual providing support.
Existing Insurance
Insurance Applied For Yes
If Proposed Insured is a minor, are all siblings equally insured?
No
If NO, please provide details: SECTION VI - About Payment Information PREMIUM PAYOR Proposed Insured
Other (Complete the box below.)
Owner (If NOT the Proposed Insured.) Social Security or Tax ID Number
Other Premium Payor Name
Relationship to Proposed Insured or Owner
Reason this Person is the Payor City
Permanent Address
PAYMENT MODE Billing Mode: (Check the appropriate ONE.)
Special Account:
State
Zip
Annual Semi-Annual Monthly Draft per Debit Authorization (See next page.) Monthly Draft per Existing Electronic Payment Number
Quarterly
Government Allotment
List Bill
Salary Deduction
If Special Account, provide Employer Group Number (EGN) or List Bill Number INITIAL PAYMENT
Method of Collection:
Amount Collected with Application
Initial Premium by Electronic Funds Transfer (Must be at least a monthly amount.) Check (Must be at least 1/12 of an annual premium.)
SOURCE OF CURRENT AND FUTURE PAYMENTS (Check ALL that apply.) Earned Income
Mutual Fund/Brokerage Account
Money Market Fund
Certificate of Deposit
Use of Values in another Life Insurance/Annuity Contract
Savings
Loans
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DEBIT AUTHORIZATION
Available only if the bank account holder is the Owner and/or Proposed Insured. 2 All others please complete the Electronic Payment (EP) Account Agreement form.
The undersigned (“I”) hereby authorize the Company with whom I am completing this application to initiate debit entries through Metropolitan Life Insurance Company to the deposit account designated below, at the Financial Institution named below, using the Automated Clearing House. I authorize: 1. Monthly recurring debits; AND 2. Debits made from time to time, as I authorize. This authorization is to remain in full force and effect until the Company has received written notification from me of its termination at such time and in such manner as to afford the Company and the Financial Institution a reasonable opportunity to act on it. Issue Date of the Policy Monthly Debit Date: Debit Date on the Bank Account Type:
Checking
Bank Routing Number
of each month
Savings Bank Account Number
Name of Financial Institution
i Note: Please attach a voided check or deposit slip to Section IX - Additional Information. We cannot establish banking services from starter checks, cash management, brokerage, or mutual fund checks. We cannot establish banking services from foreign banks UNLESS the check is being paid in U.S. Dollars through a U.S. correspondent bank (the U.S. correspondent bank name must be on the check). SECTION VII - General Risk Questions
Use Section IX - Additional Information if necessary.
1. Within the past three years has the Proposed Insured flown in a plane other than as a passenger on a commercial airline or does he or she have plans for such activity within the next year?
Yes
No
Yes
No
Yes
No
Yes
No
2 If YES, please complete a separate Aviation Risk Supplement form for the Proposed Insured. 2. Within the past three years has the Proposed Insured participated in or does he or she plan to participate in any of the following? n Underwater sports - SCUBA diving, skin diving, or similar activities n Racing sports - motorcycle, auto, motor boat or similar activities n Sky sports - skydiving, hang gliding, parachuting, ballooning or similar activities n Rock or mountain climbing or similar activities n Bungee jumping or similar activities
2 If YES, please complete a separate Avocation Risk Supplement form for the Proposed Insured. 3. Does the Proposed Insured plan to travel or reside outside the U.S. or Canada within the next two years? If YES, please provide details. Cities and Countries
Duration (weeks)
Purpose
4. Has the Proposed Insured EVER used tobacco or nicotine products in any form (e.g., cigars, cigarettes, cigarillos, pipes, chewing tobacco, nicotine patches, or nicotine gum)? If YES, please provide details. Product(s)
Frequency / Amount
Date Last Used
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5. Has the Proposed Insured EVER had a driver's license suspended or revoked, been convicted of DUI or DWI, or in the last five years been convicted of any moving violations? If YES, please provide date(s) and violation(s).
6. Has the Proposed Insured EVER had an application for life, disability income or health insurance declined, postponed, rated or modified or required an extra premium? If YES, please provide details.
Yes
No
Yes
No
7. In the past 10 years, has the Proposed Insured been convicted of a felony (this includes convictions based on a plea of Guilty or No Contest)? If YES, list type of felony, state, and date of occurrence.
Yes
No
8. Is the Proposed Insured actively at work performing the usual duties of his or her occupation? If NO, please provide details.
Yes
No
SECTION VIII - Personal Physician Check here if Proposed Insured does not have a personal physician. Physician Name
Name of Practice or Clinic
Street Address
City
Phone Number
Date Last Consulted
SECTION IX - Additional Information
Reason
State
Zip
Findings/Treatment Given/Medication Prescribed
If more space is needed, attach additional sheet(s).
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Agreement / Disclosure I have read this application for life insurance including any amendments and supplements and to the best of my knowledge and belief, all statements are true and complete. I also agree that: n My statements in this application and any amendment(s), paramedical/medical exam and supplement(s) are the basis of any policy issued. n This application and any amendment(s), paramedical/medical exam, and supplement(s) to this application will be attached to and become part of the new policy. n No information will be deemed to have been given to the Company unless it is stated in this application, paramedical/medical exam, amendment(s), or any supplement(s). n Only the Company’s President, Vice-President or Secretary may: (a) make or change any contract of insurance; (b) make a binding promise about insurance; or (c) change or waive any term of an application, receipt, or policy. n Except as stated in the Temporary Insurance Agreement and Receipt, no insurance will take effect until a policy is delivered to the Owner and the full first premium due is paid. n If I have requested a rider that provides an acceleration of death benefit, I have received the appropriate disclosure form. n I understand that receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. A discount is associated with the acceleration and an administrative charge will be required upon exercise of the benefit. n I understand that paying my insurance premiums more frequently than annually may result in a higher yearly out-of-pocket cost or different cash values. n If I intend to replace existing insurance or annuities, I have so indicated in the appropriate section of the application. n I have received the Company’s Privacy Notice and the Life Insurance Buyer’s Guide. n If I was required to sign a Notice and Consent for HIV Testing, I have received a copy of that Notice.
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Taxpayer Identification Number Certification Under penalties of perjury, I, the Owner, certify that: n The number shown in this application is my correct taxpayer identification number, and I am not subject to backup withholding because: (a) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends; or (b) the IRS has notified me that I am not subject to backup withholding. (If you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return, you must cross out and initial this item.) n I am a U.S. citizen or a U.S. resident alien for tax purposes. (If you are not a U.S. citizen or a U.S. resident alien for tax purposes, please cross out this certification and complete form W-8BEN).
i Please note: The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Signatures
If not witnessing all signatures, witness should initial next to signature being witnessed and sign below.
Signature(s) of all Proposed Insured(s)
Date
Signed at City, State
u u (age 14 1/2 or over) 2 Please complete the Additional Insureds Supplement or Child Rider Supplement form(s) if applicable. Signed at City, State Signature(s) of all Owner(s) (If NOT the Proposed Insured.) Date u u (age 14 1/2 or over) i If the Owner is a firm or corporation, include Officer's title with signature. 2 If Co-Owner or Custodian, please complete the Co-Owner/Contingent Owner and UTMA Designations Supplement form. Signature of Parent or Guardian
Date
Signed at City, State
u (If Owner or Proposed Insured is under 18, sign here. If not sign above.) Witness to Signatures Licensed Producer
Print Name of Producer
u
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Life Insurance
New York Illustration Certification Metropolitan Life Insurance Company
SECTION 1: Insured Information First name
Middle name
Case/Policy number Last name
Insured’s gender (as illustrated) Age Male Female Unisex Was a sales illustration provided for the life insurance as applied for? Yes No If Yes, choose the applicable checkbox(es) and sign below. If No, see applicable checkbox(es) below. An illustration was signed and matches the policy applied for. It is included with this application. An illustration was shown or provided but is different from the policy applied for. If this box is checked, then sign the acknowledgement below. An illustration conforming to the policy as issued will be provided no later than the time the policy is delivered. If the illustration was only shown on a computer screen, check, complete the details on page 2 and sign. The Owner also must sign and receive a copy of the completed form. Also check here if the sale was made using an illustration with Accelerated Payment. If no sales illustration was provided for the life insurance as applied for, please choose one of the following: The Financial professional certifies that a signed illustration is not required by law or the policy applied for is not illustrated in New York. No illustration conforming to the policy as applied for was shown or provided prior to or at the time of this application. If this box is checked, then sign the acknowledgement below. An illustration conforming to the policy as issued will be provided no later than the time the policy is delivered.
SECTION 2: Authorization (for page 1 only) Applicant Acknowledgement - I hereby acknowledge that I have applied for a life insurance policy and that no sales illustration or no illustration conforming to the policy I applied for was provided to me prior to or at the time of application. I understand that an illustration conforming to the policy as issued will be provided to me no later than at the time of policy delivery. Signature of Applicant
Date (mm/dd/yyyy)
Agent/Producer Certification - I certify that no sales illustration was provided or that any illustration provided was not for the life insurance policy as applied for by the applicant(s) signing this form. Signature of Agent/Producer
Date (mm/dd/yyyy)
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Complete when illustration is only provided on a computer screen.
SECTION 3: Policy Information
Case/Policy number
(Complete if illustration was shown on computer screen) Type of policy (e.g. Whole Life)
Product name (e.g. Promise Whole Life)
Policy form number
Type of rider(s) (e.g. Disability Waiver) Initial death benefit
Rating class Non-smoker
Guaranteed minimum death benefit A
Death benefit option Dividend option
B
Paid-up additions
5 year
20 year
Premium amount Smoker $
Age 65
Age 85
Age 121
C Premium Payment
Other
Assumed number of years of premiums illustrated
Number of policy years illustrated
Guaranteed Interest Rate(s)
Non-guaranteed Interest Rate(s)
SECTION 4: Authorization (for page 2 only) Applicant Acknowledgement - I acknowledge that I viewed a computer screen illustration based on the information as stated above. No hard copy of the illustration was furnished. I understand that an illustration conforming to the policy as applied for will be provided to me no later than at the time the application is provided to the insurer. Signature of Applicant
Date (mm/dd/yyyy)
Agent/Producer Certification - I certify that I displayed a computer screen illustration to the applicant that complies with state requirements and for which no hard copy was furnished. The illustration was based on the personal and policy information as included above. Signature of Agent/Producer
Date (mm/dd/yyyy)
A signed copy of this certification shall be provided to the applicant at the time it is signed and shall be submitted to the insurer with the application.
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Individual Life
Authorization to Obtain and Disclose Information This form is required in order to underwrite the Policy and for claims purposes. The Company indicated in this section is referred to as "the Company". (Check all that apply.)
Metropolitan Life Insurance Company New England Life Insurance Company First MetLife Investors Insurance Company Metropolitan Tower Life Insurance Company
Please read, sign and return with your Application.
This form was designed to comply with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). For underwriting and claim settlement purposes regarding me or any child(ren) under the age of 18 named below, I authorize: • Any medical practitioner; any medical facility; any other medical entity; any pharmacy or pharmacyrelated service organization; any insurer; any consumer reporting agency; and the MIB Group, Inc. (MIB) to give the Company information about me or such child(ren), including: • personal information and data; • entire medical file for the last ten (10) years, including medical information, records and data (such as: office visits; patient treatment; hospitalization; drugs prescribed; medical test results; information about sexually transmitted diseases; • information related to alcohol and drug abuse and treatment; • information, records and data relating to Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions, including Human Immunodeficiency Virus (HIV) test results; and • information, records and data relating to mental illness. • The Company to redisclose information received pursuant to this Authorization as authorized by me in writing or as otherwise permitted by applicable law. • The Company, or its reinsurers, to make a brief report of my personal health information to MIB. • The Company to request and obtain: consumer; investigative consumer; or motor vehicle reports.
•
Any employer, business associate, financial institution, or government agency to give the Company any information that it may have about: occupations; avocations; driving record; finances; character; reputation; and aviation activities. I understand that: • Information, records and data that the Company receives pursuant to this Authorization will be used and maintained by the Company as described in the Company’s Privacy Notice, a copy of which was given to me. • All or part of the information, records and data that the Company receives pursuant to this Authorization may be disclosed to MIB. Such information may also be disclosed to and used by: any reinsurer; any Company employee; or any vendor who performs a business service for the Company on the insurance applied for or on existing insurance with the Company. Information may also be disclosed as otherwise required or permitted by applicable laws. • Information related to alcohol and drug abuse that has been disclosed to the Company may be protected by Federal Regulations 42 CFR Part 2. This information may be re-disclosed as provided in this Authorization. • Medical information, records and data disclosed may have been subject to federal and state laws or regulations, including federal rules issued by Health and Human Services, 45 CFR Parts 160-164. These rules set forth standards for the use, maintenance and disclosure of such information by
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•
• •
•
health care providers and health plans. Once disclosed to the Company, this information may no longer be subject to those laws or regulations. Information obtained pursuant to this Authorization about me or such child(ren) may be used, to the extent permitted by law, to determine the insurability of other family members. Information relating to HIV test results will only be disclosed as permitted by applicable law. If underwriting determines that an investigative consumer report is needed, I will be contacted by the consumer reporting agency and interviewed in connection with its preparation. I am not required by law to sign this Authorization, but if I do not, the Company will not be able to underwrite my application for life insurance. Health care provider(s) or health care plan(s) asked to release information pursuant to this Authorization cannot condition treatment or payment for treatment or other benefits on my signing it.
• This Authorization will end 24 months from the date on this form or sooner if prescribed by law. For claim settlement purposes, this Authorization shall remain valid for the duration of the claim if a claim is submitted within 24 months from the date on this form. I may revoke it at any time by writing to the Company, Privacy Office, PO BOX 489, Warwick, RI 02887-9954 and advising it that I have revoked this Authorization. Any action taken before the Company has received my revocation will be valid. • I, or my authorized representative, have a right to receive a copy of this form. • A photocopy of this form is as valid as the original form. • I am entitled to receive a copy of the investigative consumer report.
Signatures Print Proposed Insured's first name
Middle initial
Last name
Date of birth (mm/dd/yyyy) If Proposed Insured is under 18, the
Parent or
Guardian is to sign on line for such child. Date (mm/dd/yyyy)
Signature of Proposed Insured Signed at city
Signed at state
As witness, I attest to having observed all parties sign in my presence. Witness to Signature
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Proposed Insured: First Name
Middle Name
New York Informed Consent Form for Blood and Urine Testing for the AIDS Virus and Other Conditions Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Insurer".
Metropolitan Life Insurance Company 200 Park Avenue, New York, NY 10166
New England Life Insurance Company One Financial Center, Boston, MA 02111
I hereby authorize a medical professional to withdraw blood from me by needle and a licensed laboratory through medically accepted procedures to perform blood and/or urine tests in connection with application(s) for insurance coverage I have made to the Insurer named above. These may include, but are not limited to, tests for cholesterol and related blood lipids, diabetes, liver or kidney disorders, immune disorders, the presence of medications, drugs, nicotine, or their metabolites and also the presence of antibodies or antigens to the Human Immunodeficiency Virus (HIV). I understand that the results of these tests will be used to determine my insurability. HIV is the virus that causes AIDS (Acquired Immunodeficiency Syndrome). Positive HIV antibody test results mean that antibodies to the virus are present in the blood and/or urine and that the person has been exposed to the virus. If test results are positive, it does not necessarily mean that the person has AIDS. Such person is, however, at an increased risk of developing AIDS or ARC (AIDS-related conditions). The Company uses FDA approved tests to determine that an HIV result is positive. Further information about HIV testing, AIDS and counseling services
Last Name Company Copy
First MetLife Investors Insurance Company
200 Park Avenue, New York, NY 10166
Metropolitan Tower Life Insurance Company
200 Park Avenue, New York, NY 10166
can be obtained by calling the toll free New York AIDS hotline telephone number: 1-800-541-AIDS. The information provided includes information regarding the meaning of test results and the availability and location of AIDS related counseling services. The Insurer will treat test results as confidential. I understand that if the HIV test results are other than negative the Insurer may disclose a generic code which signifies only a non-specific abnormality of the blood, urine or saliva to the Medical Information Bureau. I understand that the Insurer may disclose information regarding these results to its insurance affiliates, reinsurers, contractors or employees who perform business services for it, or where otherwise permitted or required by law. I understand that, in the event that the HIV test results are other than negative it is recommended that I consult my own physician or other health care provider who can inform me more fully about the implication of the test results and perform further independent testing. I have designated below that physician (or other person) to whom I wish test results sent in the event an adverse underwriting decision is based on HIV test results:
Physician Name Address If a physician or other person is not named above, please contact me.
I hereby consent that the results of these tests including, specifically, the results of tests for HIV antibodies or antigens may be reported to and used by the Company for underwriting purposes. Proposed Insured (Please Print) First
u
Middle
Last
Signature of Proposed Insured or Parent/Guardian
Signature of Witness (Producer)
Date
u
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Producer Identification & Certification
Incomplete information may delay your application.
1. What is the purpose of insurance? (Check ALL that apply.) Estate Planning Charitable Giving Split Dollar Executive Bonus Business Needs - Other Income Protection 2. Method used to arrive at the Face Amount Recommendation? Profiles Needs Analysis Human Life Value
Mortgage Protection Deferred Compensation
Qualified Plan Private Split Dollar Other GSIB Proposal
Buy/Sell Key Person
Other
3. Was this sale made using an illustration with Accelerated Premium? If YES, please indicate number of years.
Yes
yrs.
No
4. Is this insurance a replacement? 5. Have you completed and attached the required replacement forms? 6. Have you attached the Internal Revenue Code Section 1035 form?
Yes Yes Yes
No No No
N/A N/A
Yes
No
Yes Yes
No No
N/A N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
Yes
No
7. Have the following documents been delivered: Yes Privacy Notice, NY Required Notices Yes Beneficiary Locator Yes HIV Notice and Consent Form Compensation Disclosure Notice* Yes Debit Authorization Disclosure Yes Yes ABR/ADBR Disclosure Statement Chronic Illness (ECB) Disclosure
Yes
No No No No No No
N/A N/A N/A N/A
No
N/A
Life Insurance Buyer's Guide Temporary Insurance Agreement and Receipt Military Disclosure Current prospectus for variable products and riders Additional Person Designated to Receive Lapse and Termination Notices
* Required for MetLife Auto & Home. IN NY ONLY for Third party Distributors when a MetLife Wholesaler met/spoke with your client.
8. Did you use only sales material approved for use by the appropriate Company? 9. Did you see all persons to be insured on the date the application was taken?
Yes
No
If NO, why not?
10. Do any of the Beneficiaries (Primary or Contingent) or their dependents have special needs? 11. Are you related to the Proposed Insured(s)?
Yes
No
If YES, indicate relationship 12. Does the Owner want electronic delivery of the policy and related documents, if available? Yes No Certification of Owner Identity: I certify that I personally met with the Owner(s)/legal representative(s) of the entity and reviewed the appropriate identification documents. To the best of my knowledge the documents accurately reflect the identity of the Owner(s)/legal representatives of the entity. I did not meet in person with the Owner(s)/legal representative(s) of the entity or I was otherwise unable to personally review the Owner(s)/entity's identification documents. I certify that, to the best of my knowledge, the Owner(s)/entity's identification information provided by the legal representative(s) either by mail or phone is accurate. I certify that I have truly and accurately recorded on all parts of this application the information supplied by the Proposed Insured(s) and/or the applicant(s). As noted in question #9 above, I have personally observed each Proposed Insured and applicant. Apart from any admissions recorded on the application or any additional comments that I have supplied to underwriting, each appears to me to be healthy. The purpose of this sale has been discussed with the Owner(s) and I believe this application to be an appropriate recommendation. If variable products or securities were discussed, I hold the appropriate licenses for such discussions. Producer Name (Please Print FULL Name)
Sales Office/ Agency Number/ID
Producer Number/ID
Commission Split % 1st Year Renewal
Amount of GDC (for MLD only)
Signatures Name of Producer
u Signature
Date
u Signature
Date
Registered Principal, Manager or Designee Name I have personally reviewed this application for appropriateness of sale. The Producer was appropriately licensed and appointed on the date the application was signed. Life Independent Producers ONLY Does the Producer wish to annualize commissions? If YES, signature of Producer's Manager (GA/MGA/BGA) is required.
Yes
No
1 of 1 EPID-54-07-NY (07/16)
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Policy Number
Riders With No Premium or Cost of Insurance Charge Supplement
Metropolitan Life Insurance Company This supplement will be attached to and become part of the application with which it is used. Please Read Carefully Check the desired rider(s). ACCELERATION OF DEATH BENEFIT RIDER ACCELERATION OF DEATH BENEFIT DUE TO CHRONIC ILLNESS RIDER (If you choose this rider, your Policy will also automatically include the ACCELERATION OF DEATH BENEFIT RIDER. The Acceleration of Death Benefit Due to Chronic Illness Rider and the Acceleration of Death Benefit for Qualified Long-Term Care Services Rider are not available on the same policy. If you choose this rider, your Policy cannot include the Acceleration of Death Benefit for Qualified Long-Term Care Services Rider.) I do not want to apply for any rider listed above. The above riders do not have a premium or cost of insurance charge. Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. A discount is associated with any acceleration of the death benefit. An administrative charge will be required upon exercise of the rider benefit.
Signatures Date
Signed at City, State
Signature(s) of all Owner(s) (If NOT the Proposed Insured.) Date
Signed at City, State
Signature of Proposed Insured u (age 14 1/2 or over)
u u (age 14 1/2 or over) i If the Owner is a firm or corporation, include Officer's title with signature.
2
If Co-Owner or Custodian, please complete the Co-Owner/Contingent Owner and UTMA Designations Supplement form.
Signature of Parent or Guardian
Date
Signed at City, State
u (If Owner or Proposed Insured is under 18, sign here. If not sign above.)
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Individual Life & Disability
Appendix 11 - Definition of replacement - Department of Financial Services of the State of New York Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Company".
Metropolitan Life Insurance Company First MetLife Investors Insurance Company
New England Life Insurance Company
In order to determine whether you are replacing or otherwise changing the status of existing life insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent or broker is required to ask you the following questions and explain any items that you do not understand. As part of your purchase of a new life insurance policy or a new annuity contract, has existing coverage been, or is it likely to be: Yes No 1. Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated? Yes No 2. Changed or modified into paid-up insurance; continued as extended term insurance or under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? Yes No 3. Changed or modified so as to effect a reduction either in the amount of the existing life insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? 4. Reissued with a reduction in amount such that any cash values are released, including Yes No all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? Yes No 5. Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of Dividend Accumulations or Paid-Up Additions is to be borrowed or withdrawn on one or more existing policies? Yes No 6. Continued with a stoppage of premium payments or reduction in the amount of premium paid? If you have answered yes to any of the above questions, a replacement as defined by New York Insurance Regulation 60 has occurred or is likely to occur and your agent or broker is required to provide you with the Important Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts. You will also receive a completed disclosure statement no later than the time your new policy or new contract is delivered.
Signatures Signature of applicant
Date (mm/dd/yyyy)
Signature of applicant
Date (mm/dd/yyyy)
To the best of my knowledge, a replacement is involved in this transaction: Signature of agent or broker
EREPLDIS-NY-DEF
Yes
No
Date (mm/dd/yyyy)
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Individual Life & Disability
Appendix 11 - Definition of replacement - Department of Financial Services of the State of New York Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Company".
Metropolitan Life Insurance Company
New England Life Insurance Company
First MetLife Investors Insurance Company In order to determine whether you are replacing or otherwise changing the status of existing life insurance policies or annuity contracts, and in order to receive the valuable information necessary to make a careful comparison if you are contemplating replacement, the agent or broker is required to ask you the following questions and explain any items that you do not understand. As part of your purchase of a new life insurance policy or a new annuity contract, has existing coverage been, or is it likely to be: Yes No 1. Lapsed, surrendered, partially surrendered, forfeited, assigned to the insurer replacing the life insurance policy or annuity contract, or otherwise terminated? 2. Changed or modified into paid-up insurance; continued as extended term insurance or Yes No under another form of nonforfeiture benefit; or otherwise reduced in value by the use of nonforfeiture benefits, dividend accumulations, dividend cash values or other cash values? 3. Changed or modified so as to effect a reduction either in the amount of the existing life Yes No insurance or annuity benefit or in the period of time the existing life insurance or annuity benefit will continue in force? 4. Reissued with a reduction in amount such that any cash values are released, including Yes No all transactions wherein an amount of dividend accumulations or paid-up additions is to be released on one or more of the existing policies? Yes No 5. Assigned as collateral for a loan or made subject to borrowing or withdrawal of any portion of the loan value, including all transactions wherein any amount of Dividend Accumulations or Paid-Up Additions is to be borrowed or withdrawn on one or more existing policies? 6. Continued with a stoppage of premium payments or reduction in the amount of premium Yes No paid? If you have answered yes to any of the above questions, a replacement as defined by New York Insurance Regulation 60 has occurred or is likely to occur and your agent or broker is required to provide you with the Important Notice Regarding Replacement or Change of Life Insurance Policies or Annuity Contracts. You will also receive a completed disclosure statement no later than the time your new policy or new contract is delivered.
Signatures Signature of applicant
Date (mm/dd/yyyy)
Signature of applicant
Date (mm/dd/yyyy)
To the best of my knowledge, a replacement is involved in this transaction: Signature of agent or broker
EREPLDIS-NY-DEF
Yes
No
Date (mm/dd/yyyy)
Page 1 of 1 (08/15) Applicant Copy Fs
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Authorization to Obtain and Disclose Information American General Life Insurance Company Assurity Life Insurance Company AXA Equitable Life Insurance Company Banner Life Insurance Company Companion Life Insurance Company Crump Life Insurance Services Fidelity Security Life First MetLife Investors Insurance Company First Symetra National Life Insurance Company of NY Gerber Life Guardian Life Insurance Company of America John Hancock Life Insurance Company New York John Hancock Life Insurance Company USA Legal & General American Insurance Company
Name of Proposed Insured First
Liberty Life Lincoln Life and Annuity Company of New York Lincoln National Life Insurance Company Lloyd's of London Massachusetts Mutual Life Insurance Company MetLife Insurance Company USA Metropolitan Life Insurance Company Nationwide Life Insurance Company New England Life Insurance Company North American Company for Life and Health Insurance Pacific Life & Annuity Company NY Pacific Life Insurance Company Penn Mutual Principal Life Insurance Company
Middle
Principal National Life Protective Life & Annuity Insurance Co. Protective Life Insurance Company Prudential Insurance Co. of America The Standard The State Life Insurance Company Symetra Transamerica Financial Life Insurance Co. NY Transamerica Life Insurance Company United of Omaha Life Insurance Company United States Life Insurance of New York Voya Reliastar Life Insurance Company Voya Reliastar Life Insurance Company of NY Voya Security Life of Denver William Penn Life Insurance Company of NY
Last
Date of Birth
Producer's Information Name
MetLife Case number (CAS number)
Office
For the purpose of determining that I, the proposed insured named above, am eligible for proposed insurance, I authorize any: (1) person licensed to provide health care services; (2) hospital; (3) clinic or other medical facility; (4) insurer; (5) health care plan; (6) consumer reporting agency (including, for these purposes, MIB Group, Inc., “MIB”); (7) financial institution; (8) employer; and (9) family members and associates, to furnish information about me to one or more of the companies identified above when this Authorization (or a copy of it) is presented. I further authorize all such persons, except MIB, to give such information to the Enterprise General Insurance Agency, Inc ("Enterprise GA"), or its authorized representatives. The types of information that may be disclosed include: • My entire medical file for the last ten (10) years, including information regarding my mental and physical health (other than psychotherapy notes); and • Other information, such as information about my other insurance coverage; hazardous activities;
Phone number
character; general reputation; finances; occupation; and other personal traits. I understand that medical and health related information may be protected by federal and state laws, including federal privacy rules issued by the Department of Health and Human Services, 45 CFR Parts 160-164, and may no longer be subject to those rules once released pursuant to this Authorization. I understand that the Enterprise GA and the companies named above may disclose information obtained under this Authorization to third parties only to the extent permitted or required by applicable state and federal laws. Such disclosures include (but are not limited to) disclosures pursuant to an Authorization signed by me and disclosures to reinsurers, MIB, and other persons who perform business, professional or insurance tasks related to the proposed insurance. I understand that I have a right to revoke this Authorization at any time and may do so by writing to Enterprise GA at the above address. I further understand, however, that any action taken in
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reliance on this Authorization prior to receipt of my revocation by Enterprise GA will remain valid. This Authorization will be valid for 12 months after the date it is signed. A copy of this Authorization
will be as valid as the original. I understand I have a right to receive a copy of this Authorization and may receive a copy by requesting it from my producer.
Signature of Proposed Insured Named Above or Legally Authorized Representative of Proposed Insured
Date
If signing as Legal Representative, print name below and describe legal authority (e.g., parent or court appointed guardian of a minor child): Signed at City,
State
Signature of Minor Child
Date
(only if Proposed Insured and is aged 15 or more, or otherwise required) Signed at City,
State
Legal Representative/Relationship
Enterprise General Insurance Agency, Inc (A MetLife Company) 300 Davidson Avenue, 1st Floor, East Wing Somerset, NJ 08873
(Original to be retained by Enterprise GA; Copy to Proposed Insured (or Authorized Representative))
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Policy Number
Medical Supplement Company (Check the appropriate ONE.) The Company indicated in this section is referred to as "the Company".
Metropolitan Life Insurance Company New England Life Insurance Company First MetLife Investors Insurance Company This supplement will be attached to and become part of the application with which it is used.
SECTION I - Medical Questions
If more space is needed, attach additional sheet(s).
i If FULL PARAMEDICAL/MEDICAL EXAM is required, completion of this Medical Supplement form is OPTIONAL. Last Name
Middle Name
Proposed Insured - First Name
1. Please provide Proposed Insured's height and weight:
Height (ft. in.)
Weight (lbs.)
Has the Proposed Insured experienced a change in weight greater than 10 pounds in the past 12 months? If YES, please specify: Pounds Lost
High Blood Pressure Chest Pain Heart Attack Heart Murmur Diabetes High Cholesterol Cancer / Tumor / Polyp
Letter
H. I. J. K. L. M. N.
Asthma / Bronchitis Emphysema Sleep Apnea Seizures Stroke / TIA Paralysis Multiple Sclerosis
Name of Health Professional (Include City & State)
O. P. Q. R. S. T. U.
Parkinson's Disease Alzheimer's Disease Memory Loss Colitis Cirrhosis Hepatitis Arthritis
Date / Duration of Illness
Heart Arteries / Veins Lungs / Respiratory System Gastrointestinal / Digestive System Liver / Pancreas Kidney / Bladder
Letter
Name of Health Professional (Include City & State)
G. H. I. J. K. L.
Yes
No
Prostate Reproductive Organs Brain / Nervous System Blood (except HIV) Lymph Nodes Immune System Date / Duration of Illness
V. W. X. Y.
Lupus Anemia Depression / Anxiety Eating Disorder
Diagnosis / Treatment / Medication
3. Other than as indicated above, has the Proposed Insured EVER had any disease or disorder of any of the following? If YES, please check ALL that apply and provide details in table below. A. B. C. D. E. F.
No
Reason
Pounds Gained
2. Has the Proposed Insured EVER been diagnosed, received treatment, or consulted with a health professional for any of the following? If YES, please check ALL that apply and provide details in table below. A. B. C. D. E. F. G.
Yes
M. N. O. P. Q. R.
Yes
No
Thyroid / Other Glands Eyes Ears / Nose / Throat Skin Muscles / Bones / Joints Emotional / Psychological Disorder Diagnosis / Treatment / Medication
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4. Other than as indicated previously, within the past five years, has the Proposed Insured had any illness, injury, surgery, physical exam, consultation, or medical test (e.g. laboratory tests, EKG, etc.) other than a test for HIV or been a patient in a hospital or other medical facility?
Yes
No
5. Is the Proposed Insured currently receiving any treatment or taking any prescription or nonprescription medications or supplements?
Yes
No
6. Does the Proposed Insured have any surgery, medical tests other than a test for HIV, treatment or visits with a health professional scheduled in the next six months?
Yes
No
7. Has the Proposed Insured ever been diagnosed with or treated by a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS)?
Yes
No
8. Has the Proposed Insured ever used cocaine, heroin, or other illicit drugs or controlled substances except as prescribed by a health professional?
Yes
No
9. Has the Proposed Insured ever sought, been advised to seek, or received counseling or treatment for the use of alcohol or drugs from a health professional or support group?
Yes
No
If YES, please provide details in table below for Questions 4 - 9. Number
Name of Health Professional (Include City & State)
Date / Duration of Illness
Diagnosis / Treatment / Medication
SECTION II - Family History Has a parent or sibling ever had: heart disease; coronary artery disease; vascular disease; stroke/cerebrovascular disease; diabetes; cancer; or kidney disease? If YES, please provide details in table below. Relationship to Age(s) if Age(s) at Proposed Insured Living Death
Yes
No
State of Health (Specific Conditions) or Cause of Death
Father Mother Sibling Sibling Sibling
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