.
.
.
EXHIBIT 5(g)
MetLife Insurance Company of Connecticut GROUP VARIABLE ANNUITY MASTER APPLICATION
One Cityplace . Hartford, CT 06103
BLUEPRINT/GOLD TRACK EXPRESS
SECTION I - CONTRACT OWNER INFORMATION
Please print or type all information
- ------------------------------------------------------------------------------
Employer/Sponsor Name:
- ------------------------------------------------------------------------------
Employer's Tax ID Number: Plan Year End:
- ------------------------------------------------------------------------------
Employer's Address:
- ------------------------------------------------------------------------------
Employer's Phone Number: Employer's Fax Number:
- ------------------------------------------------------------------------------
Employer's Organization or Business Type:
[ ] Corporation [ ] Professional Service Corporation
[ ] S Corporation [ ] Limited Liability Company (LLC)
[ ] Partnership (including LLC Partnership) [ ] Sole Proprietorship
NOTE: IF THE EMPLOYER/PLAN SPONSOR IS A LLC THAT IS NOT TAXED AS A CORPORATION,
A PARTNERSHIP OR A SOLE PROPRIETORSHIP, THE APPLICANT MUST PROVIDE ADDITIONAL
SATISFACTORY INFORMATION AS PART OF ITS APPLICATION TO PURCHASE THE ANNUITY
CONTRACT. PLEASE COMPLETE THE EMPLOYER/PLAN SPONSOR CERTIFICATION REGARDING
PURCHASE OF QUALIFIED ANNUITY. AN APPLICANT THAT IS UNABLE TO COMPLETE THIS
CERTIFICATION IS INELIGIBLE TO PURCHASE THIS ANNUITY, BUT MAY APPLY FOR A
DIFFERENT ANNUITY THAT THE COMPANY OFFERS TO PLANS.
On written request, we will provide you within reasonable time, reasonable
factual information regarding the benefits and provisions of the annuity
contract. If for any reason you are not satisfied with the annuity contract,
you may return the annuity contract within 10 days after it is delivered to
you. If you are 65 or older on the annuity contract date, you may return the
contract within 30 days after it is delivered to you. Should you decide to
cancel the contract, we will refund the value of the amounts allocated to the
contract (less purchase payment credits applied, if any). A contract charge,
premium tax or withdrawal/surrender charges, if any, will not be deducted from
the amount we refund.
PLEASE SEE PAGE 2 FOR INVESTMENT OPTIONS
L-24767AZ ORDER # L-24770AZ Rev. 05/06; 1 of 5
SECTION II - INVESTMENT SELECTIONS
(Please select the investment options desired for your plan. Please note: An
investment option cannot be offered initially under your plan if it has not
been selected on this form.)
[ ] CHECK HERE TO SELECT ALL FUNDS
[ ] American Funds Global Growth Fund IL [ ] Legg Mason Partners Variable Small Cap Growth
Opportunities Portfolio C9
[ ] American Funds Growth Fund IG [ ] Legg Mason Partners Variable Social
Awareness Stock Portfolio SA
[ ] American Funds Growth-Income Fund II [ ] Legg Mason Partners Variable Total Return
Portfolio AE
[ ] Batterymarch Mid-Cap Stock Portfolio 1M [ ] Lord Abbett Bond Debenture Portfolio AF
[ ] BlackRock Aggressive Growth Portfolio DQ [ ] Lord Abbett Growth and Income Portfolio --
Class B HL
[ ] BlackRock Bond Income Portfolio 4W [ ] Lord Abbett Growth and Income Series Fund
-- Class VC FK
[ ] Dreyfus VIF Appreciation Portfolio DP [ ] Lord Abbett Mid Cap Value Series Fund
-- Class VC FL
[ ] Dreyfus VIF Developing Leaders Portfolio DS [ ] Mercury Large-Cap Core Portfolio DR
[ ] Federated High Yield Portfolio 4E [ ] Met/AIM Capital Appreciation Portfolio KC
[ ] FI Large Cap Portfolio (Fidelity) 4G [ ] MetLife Aggressive Allocation Portfolio H9
[ ] FI Value Leaders Portfolio (Fidelity) 4F [ ] MetLife Conservative Allocation Portfolio H5
[ ] Fidelity VIP Contrafund(R) Portfolio FT [ ] MetLife Conservative to Moderate Allocation
Portfolio H6
[ ] Fidelity VIP Mid Cap Portfolio D1 [ ] MetLife Investment Diversified Bond Fund OB
[ ] Franklin Small-Mid Cap Growth Securities Fund UW [ ] MetLife Investment International Stock Fund CI
[ ] Harris Oakmark International Portfolio 4C [ ] MetLife Investment Large Company Stock Fund OC
[ ] Janus Aspen Series Mid Cap Growth Portfolio JA [ ] MetLife Investment Small Company Stock Fund OE
[ ] Janus Capital Appreciation Portfolio 4A [ ] MetLife Moderate Allocation Portfolio H7
[ ] Lazard Retirement Small Cap Portfolio RS [ ] MetLife Moderate to Aggressive Allocation
Portfolio H8
[ ] Legg Mason Partners Investment Grade Bond Fund 4O [ ] MFS(R) Total Return Portfolio 4I
[ ] Legg Mason Partners Small Cap Value Fund SF [ ] MFS(R) Value Portfolio BD
[ ] Legg Mason Partners Variable Adjustable Rate
Income Portfolio BI [ ] Neuberger Berman Real Estate Portfolio I3
[ ] Legg Mason Partners Variable Aggressive
Growth Portfolio SG [ ] PIMCO VIT Total Return Portfolio PM
[ ] Legg Mason Partners Variable All Cap Portfolio AD [ ] Pioneer Fund Portfolio UP
[ ] Legg Mason Partners Variable Appreciation
Portfolio 1N [ ] Pioneer Strategic Income Portfolio 4J
[ ] Legg Mason Partners Variable Diversified
Strategic Income Portfolio 1O [ ] Putnam VT Small Cap Value Fund OP
[ ] Legg Mason Partners Variable Equity Index
Portfolio GF [ ] T. Rowe Price Large Cap Growth Portfolio IF
[ ] Legg Mason Partners Variable Growth and Income
Portfolio I1 [ ] Templeton Developing Markets Securities Fund VQ
[ ] Legg Mason Partners Variable High Yield Bond
Portfolio CJ [ ] Templeton Foreign Securities Fund VG
[ ] Legg Mason Partners Variable Investors
Portfolio C2 [ ] Templeton Growth Fund, Inc. 4Y
[ ] Legg Mason Partners Variable Large Cap Growth
Portfolio AB [ ] Van Kampen LIT Comstock Portfolio NJ
[ ] Legg Mason Partners Variable Money Market
Portfolio HM [ ] Van Kampen LIT Emerging Growth Portfolio NY
[ ] Legg Mason Partners Variable Premier Selections
All Cap Growth Portfolio P1 [ ] Western Asset Management U.S. Government
Portfolio GV
[ ] Fixed Account
L-24767AZ Order # L-24770AZ Rev. 05/06; 2 of 5
SECTION III - PLAN COMPLIANCE INFORMATION
- -------------------------------------------------------------------------------
Third Party Administrator
- -------------------------------------------------------------------------------
TPA Contact Name
- -------------------------------------------------------------------------------
TPA Address
- -------------------------------------------------------------------------------
TPA Phone Number: TPA Fax Number:
- -------------------------------------------------------------------------------
External Trustee (if applicable)
- -------------------------------------------------------------------------------
External Trustee Contact Name
- -------------------------------------------------------------------------------
External Trustee Address
- -------------------------------------------------------------------------------
Trustee Phone Number: Trustee Fax Number:
- -------------------------------------------------------------------------------
SECTION IV - REPLACEMENT INFORMATION
- -------------------------------------------------------------------------------
WILL THIS CONTRACT REPLACE ANY EXISTING ANNUITY CONTRACT(S)? [ ] YES [ ] NO
If YES, please provide the following information:
- -------------------------------------------------------------------------------
Existing Company Name (Where are the Plan Assets?)
- -------------------------------------------------------------------------------
Existing Company Address
- -------------------------------------------------------------------------------
Existing Contract(s) & Number(s)
- -------------------------------------------------------------------------------
Existing Company Contact Name Phone Number
- -------------------------------------------------------------------------------
Existing TPA (if different than Section III) Phone Number
- -------------------------------------------------------------------------------
SECTION V - ADDITIONAL INFORMATION
- -------------------------------------------------------------------------------
Please provide any additional information or unique processes specific to this
plan:
L-24767AZ Order # L-24770AZ Rev. 05/06; 3 of 5
ACKNOWLEDGMENT AND SIGNATURES REQUIRED
- -------------------------------------------------------------------------------
NOTICE OF INSURANCE FRAUD: The following states require insurance applicants to
acknowledge a fraud warning statement. Please refer to and read the fraud
warning statement for your state as indicated below. Your signature(s) below
confirms that you have read the applicable warning for your state.
ALASKA, ARIZONA, ARKANSAS, DELAWARE, IDAHO, INDIANA, KENTUCKY, LOUISIANA,
MAINE, MINNESOTA, NEW JERSEY, NEW MEXICO, OHIO, OKLAHOMA, TENNESSEE, TEXAS,
VIRGINIA, WASHINGTON D.C., WEST VIRGINIA, AND ALL STATES NOT LISTED BELOW.
WARNING: 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 criminal
and civil penalties, including imprisonment, fines and denial of insurance
benefits.
CALIFORNIA: For your protection California law requires the following to appear
on this form: Any person who knowingly presents a false or fraudulent claim for
payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
FLORIDA: 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.
NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any
insurance company, files a statement of claim containing any false, incomplete
or misleading information is subject to prosecution and punishment for
insurance fraud, as provided in RSA 638:20.
NEW YORK: 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 shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
PENNSYLVANIA: 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.
PUERTO RICO: Any person who, knowingly and with the intent to defraud, presents
false information in an insurance request form, or who presents, helps or has
presented a fraudulent claim for the payment of a loss or other benefit, or
presents more than one claim for the same damage or loss, will incur a felony,
and upon conviction will be penalized for each violation with a fine no less
than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars,
or imprisonment for a fixed term of three (3) years, or both penalties. If
aggravated circumstances prevail, the fixed established imprisonment may be
increased to a maximum of five (5) years; if attenuating circumstances prevail,
it may be reduced to a minimum of two (2) years.
SEE PAGE 5 FOR REQUIRED SIGNATURES
L-24767AZ Order # L-24770AZ Rev. 05/06; 4 of 5
ACKNOWLEDGMENTS: I acknowledge the following: (1) I have received the
Disclosure Memorandum of MetLife Separate Account QPN for Variable Annuities
provided by MetLife Insurance Company of Connecticut; (2) the group annuity
contract, if issued, supersedes every written or oral statement concerning the
contract; (3) an annuity contract does not confer any tax deferral benefit
beyond what is already offered by a tax-qualified retirement plan; (4) I
selected this annuity contract for reasons other than tax deferral; and (5) the
person that solicited the Plan's purchase of this contract provided a
plain-language explanation of the commissions that MetLife Insurance Company of
Connecticut will pay to the person who soliciated the sale of this annuity.
Further more, I understand that the contract will take effect when the first
premium payment is received, and the application is approved in the Home Office
of MetLife Insurance Company of Connecticut. All payments and values provided
by the contract applied for, when based on investment experience of a separate
account, are variable and there are no guarantees as to a fixed dollar amount.
No agent is authorized to make changes to the contract or application. I
understand that MetLife Insurance Company of Connecticut may amend this
contract to comply with changes in the Internal Revenue Code and related
Regulations.
- -------------------------------------------------------------------------------
EMPLOYER SIGNATURE DATE
- -------------------------------------------------------------------------------
I acknowledge that all data representations and signatures recorded by me or in
my presence in response to my inquiry and request and all such representations
and signatures are accurate and valid to the best of my knowledge and belief.
WILL THE CONTRACT APPLIED FOR REPLACE ANY EXISTING ANNUITY CONTRACT?
[ ]YES [ ] NO
- -------------------------------------------------------------------------------
Agent/Representative Name Social Security Number Telephone Number
- -------------------------------------------------------------------------------
Agent/Representative Signature Date License Number
- -------------------------------------------------------------------------------
Agent Representative Name Social Security Number Telephone Number
- -------------------------------------------------------------------------------
Agent/Representative Signature Date License Number
- -------------------------------------------------------------------------------
FOR METLIFE RESOURCES USE ONLY (Circle one)
C/E/G/H
- -------------------------------------------------------------------------------
L-24767AZ ORDER # L-24770AZ Rev. 05/06; 5 of 5