EXHIBIT 5(J)
MetLife Insurance Company of Connecticut 401(K) GROUP ANNUITY
One Cityplace . Hartford, CT 06103
GROUP MASTER DATA SHEET
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.
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 INVESTMENT OPTIONS
[ ] 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 Bl [ ] 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-21015A GTE/BP; Rev. 11/06 1 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-21015 A GTE/BP; Rev. 11/06 2 of 4
NOTICES OF INSURANCE FRAUD
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The following states require insurance applicants to be given a fraud warning
statement. Please read the appropriate fraud warning statement for the state
you reside in as indicated below.
ARKANSAS, LOUISIANA, NEW MEXICO: 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.
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 life insurance, and civil damages. It is also unlawful for 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 respect to a settlement or award payable from
insurance proceeds. Such acts shall be reported to the Colorado Division of
Insurance with the Department of Regulatory Agencies to the extent required by
applicable law.
DISTRICT OF COLUMBIA: 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.
KENTUCKY: 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.
MAINE, TENNESSEE, WASHINGTON: 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: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
OHIO: 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.
OKLAHOMA: WARNING: Any person who knowingly, and with the intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete, or misleading information is
guilty of a felony.
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 intention to defraud,
includes false information in an application for insurance or files, assists,
or abets in the filing of a fraudulent claim to obtain payment of a loss or
other benefit, or files more than one claim for the same damage or loss,
commits a felony, and if found guilty shall be punished for each violation with
a fine no less than five thousand dollars ($5,000), not to exceed ten thousand
dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both.
If aggravating circumstances exist, the fixed jail term may be increased to a
maximum of five (5) years; and if mitigating circumstances are present, the
jail term may be reduced to a minimum of two (2) years.
FLORIDA: A person who knowingly and with intent to injure, defraud or deceive
any insurance company files a statement of claim containing false, incomplete
or misleading information is guilty of a felony of the third degree.
PLEASE SEE PAGE 4 FOR REQUIRED SIGNATURES
L-21015 A GTE/BP; REV. 11/06 3 OF 4
ACKNOWLEDGMENT AND SIGNATURES REQUIRED
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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.
FURTHERMORE, 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-21015A GTE/BP; Rev. 11/06 4 of 4