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EXHIBIT 5(i)
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
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Employer/Sponsor Name:
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Employer's Tax ID Number: Plan Year End:
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Employer's Address:
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Employer's Phone Number: Employer's Fax Number:
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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. 11/06; 1 of 4
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
[ ] BlackRock High Yield Portfolio 4E [ ] Lord Abbett Mid Cap Value Series Fund
-- Class VC FL
[ ] BlackRock Large-Cap Core Portfolio DR [ ] Met/AIM Capital Appreciation Portfolio KC
[ ] Dreyfus VIF Appreciation Portfolio DP [ ] MetLife Aggressive Allocation Portfolio H9
[ ] Dreyfus VIF Developing Leaders Portfolio DS [ ] MetLife Conservative Allocation Portfolio H5
[ ] FI Large Cap Portfolio (Fidelity) 4G [ ] MetLife Conservative to Moderate Allocation
Portfolio H6
[ ] FI Value Leaders Portfolio (Fidelity) 4F [ ] MetLife Investment Diversified Bond Fund OB
[ ] Fidelity VIP Contrafund(R) Portfolio FT [ ] MetLife Investment International Stock Fund OI
[ ] Fidelity VIP Mid Cap Portfolio D1 [ ] MetLife Investment Large Company Stock Fund OC
[ ] Franklin Small-Mid Cap Growth Securities Fund UW [ ] MetLife Investment Small Company Stock Fund OE
[ ] Harris Oakmark International Portfolio 4C [ ] MetLife Moderate Allocation Portfolio H7
[ ] Janus Aspen Series Mid Cap Growth Portfolio JA [ ] MetLife Moderate to Aggressive Allocation
Portfolio H8
[ ] Janus Capital Appreciation Portfolio 4A [ ] MFS(R) Total Return Portfolio 4I
[ ] Legg Mason Partners Investment Grade Bond Fund 4O [ ] MFS(R) Value Portfolio BD
[ ] Legg Mason Partners Small Cap Value Fund SF [ ] Neuberger Berman Real Estate Portfolio I3
[ ] Legg Mason Partners Variable Adjustable Rate
Income Portfolio BI [ ] PIMCO VIT Total Return Portfolio PM
[ ] Legg Mason Partners Variable Aggressive Growth
Portfolio SG [ ] Pioneer Fund Portfolio UP
[ ] Legg Mason Partners Variable All Cap Portfolio AD [ ] Pioneer Strategic Income Portfolio 4J
[ ] Legg Mason Partners Variable Appreciation
Portfolio 1N [ ] Putnam VT Small Cap Value Fund OP
[ ] Legg Mason Partners Variable Diversified
Strategic Income Portfolio 1O [ ] T. Rowe Price Large Cap Growth Portfolio IF
[ ] Legg Mason Partners Variable Equity Index
Portfolio GF [ ] Templeton Developing Markets Securities Fund VQ
[ ] Legg Mason Partners Variable Global High Yield
Bond Portfolio CJ [ ] Templeton Foreign Securities Fund VG
[ ] Legg Mason Partners Variable Growth and Income
Portfolio I1 [ ] Templeton Growth Fund, Inc. 4Y
[ ] Legg Mason Partners Variable Investors Portfolio C2 [ ] Third Avenue Small Cap Value Portfolio IT
[ ] 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 Strategic 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. 11/06; 2 of 4
SECTION III - PLAN COMPLIANCE INFORMATION
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Third Party Administrator
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TPA Contact Name
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TPA Address
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TPA Phone Number: TPA Fax Number:
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External Trustee (if applicable)
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External Trustee Contact Name
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External Trustee Address
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Trustee Phone Number: Trustee Fax Number:
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SECTION IV - REPLACEMENT INFORMATION
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WILL THIS CONTRACT REPLACE ANY EXISTING ANNUITY CONTRACT(S)? [ ] YES [ ] NO
If YES, please provide the following information:
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Existing Company Name (Where are the Plan Assets?)
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Existing Company Address
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Existing Contract(s) & Number(s)
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Existing Company Contact Name Phone Number
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Existing TPA (if different than Section III) Phone Number
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SECTION V - ADDITIONAL INFORMATION
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Please provide any additional information or unique processes specific to this
plan:
L-24767AZ ORDER # L-24770AZ Rev. 11 /06; 3 of 4
ACKNOWLEDGMENT AND SIGNATURES REQUIRED
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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.
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EMPLOYER SIGNATURE DATE
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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
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Agent/Representative Name Social Security Number Telephone Number
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Agent/Representative Signature Date License Number
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Agent Representative Name Social Security Number Telephone Number
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Agent/Representative Signature Date License Number
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FOR METLIFE RESOURCES USE ONLY (Circle one)
C/E/G/H
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L-24767AZ ORDER # L-24770AZ Rev. 11/06; 4 of 4