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Exhibit 5(a)
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MetLife Insurance Company of Connecticut MASTER APPLICATION
Xxx Xxxxxxxxx - Xxxxxxxx, XX 00000-0000 GOLD TRACK SELECT
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SECTION I - CONTRACT OWNER INFORMATION
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The Contract Owner will be the "Trustees of" (Retirement Plan Name): Plan Year End (Required):
_____________________________________________________________________________________ ____________________________________________
Employer/Sponsor Name:
____________________________________________________________________________________________________________________________________
Names of Trustees:
____________________________________________________________________________________________________________________________________
Employer's Address:
____________________________________________________________________________________________________________________________________
Employer's Tax ID Number: Employer's Phone Number: Employer's Fax Number:
________________________________________ _____________________________________ _________________________________________________
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SECTION II - PLAN & CONTRACT INFORMATION
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PLAN TYPE (Please check appropriate box(es).) CONTRACT TYPE (If an allocated contract is selected please check the
appropriate Participant Accounting Agreement desired.)
401 PLANS: [ ] ALLOCATED CONTRACT (PLEASE CHECK A, B, C OR D BELOW)
[ ] 401(k) Plan [ ] A. Quarterly statements should be mailed to plan participants.
[ ] Profit Sharing Plan Individual addresses are required. MetLife will prepare form
[ ] Money Purchase Plan 1099R* for tax reporting purposes.
[ ] Target Benefit Plan
[ ] Defined Benefit Plan [ ] B. Quarterly statements should be mailed to plan participants.
Individual addresses are required. Tax reporting will be done by
403(B) AND 457 PLANS: the employer.
[ ] Non-ERISA TSA 403(b)*
[ ] ERISA TSA 403(b) [ ] C. Quarterly statements should be mailed to the employer. Tax
[ ] 457 Deferred Compensation Plan reporting will be done by the employer.
(*allocated contract applies under Contract type) [ ] D. Quarterly statements and 1099R* forms will be prepared by MetLife
and mailed to the employer.
[ ] UNALLOCATED CONTRACT
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[ ] Check here if rollover accounts should be set up * 1099R tax reporting applies to 401, 403, and non-governmental 457 plans.
for participants
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If Participant Accounting is to be performed BY MetLife, a detailed listing of plan contributions by participant is required in a
format approved by MetLife. Data files can be sent to our internet mailbox or on a 3 1/2" diskette. Please check the format you will
use.
MAIL: [ ] LIST XXXX [ ] DISKETTE [ ] SPREADSHEET [ ] INTERNET - E-REMIT
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Please provide the name of the person to call to discuss the contribution file format and delivery:
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PAYROLL CONTACT NAME: Phone Number: Fax Number:
_________________________________________________ _________________________________ ____________________________________________
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Payroll Frequency:
[ ] Weekly [ ] Bi-Weekly (26 per yr.) [ ] Semi-Monthly (24 per yr.) [ ] Monthly
[ ] Quarterly [ ] Other (please describe):
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IF THIS IS AN UNALLOCATED ACCOUNT, FOR INVESTMENT PURPOSES ALL MONEY SOURCES WILL BE TREATED AS ONE SOURCE.
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PLEASE SELECT THE MONEY SOURCES APPLICABLE TO YOUR 401 PLAN:
[ ] Employee Deferral [ ] Rollover [ ] Employer Match [ ] Employer Discretionary
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PLEASE SELECT THE MONEY SOURCES APPLICABLE TO YOUR 403(B) OR 457 PLAN:
[ ] Employee Deferral [ ] Rollover [ ] Employer Match [ ] Employer Discretionary
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ALL MONEY SOURCES WILL BE DIRECTED BY PARTICIPANTS UNLESS OTHERWISE NOTED BELOW. PLEASE INDICATE ANY EMPLOYER DIRECTION OF A MONEY
SOURCE:
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L-21158 A (BAR CODE) ORDER NO. L-21158 REV. 5-06
1 OF 5
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SECTION III - FUNDING OPTION SELECTIONS
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(Please select the funding options desired for your plan. Please note: A funding option cannot be offered initially under your plan
if it has not been selected on this form.)
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[ ] American Funds Global Growth Fund IL [ ] Lord Xxxxxx Bond Debenture Portfolio AF
[ ] American Funds Growth Fund IG [ ] Lord Xxxxxx Growth and Income Portfolio HL
[ ] American Funds Growth-Income Fund II [ ] Lord Xxxxxx Growth and Income Series Fund - Class VC FK
[ ] Batterymarch Mid-Cap Stock Portfolio 1M [ ] Lord Xxxxxx Mid-Cap Value Series Fund - Class VC FL
[ ] BlackRock Aggressive Growth Portfolio DQ [ ] Mercury Large-Cap Core Portfolio DR
[ ] BlackRock Bond Income Portfolio 4W [ ] Met/AIM Capital Appreciation Portfolio KC
[ ] BlackRock Money Market Portfolio 1K [ ] Met/AIM Small Cap Growth Portfolio FY
[ ] Delaware VIP Small Cap Value Series AP [ ] MetLife Aggressive Allocation Portfolio H9
[ ] Dreman Small-Cap Value Portfolio F0 [ ] MetLife Conservative Allocation Portfolio H5
[ ] Dreyfus VIF Appreciation Portfolio DP [ ] MetLife Conservative to Moderate Allocation Portfolio H6
[ ] Dreyfus VIF Developing Leaders Portfolio DS [ ] MetLife Investment Diversified Bond Fund OB
[ ] Federated High Yield Portfolio 4E [ ] MetLife Investment International Stock Fund OI
[ ] FI Large Cap Portfolio (Fidelity) 4G [ ] MetLife Investment Large Company Stock Fund OC
[ ] FI Value Leaders Portfolio (Fidelity) 4F [ ] MetLife Investment Small Company Stock Fund OE
[ ] Fidelity VIP Contrafund(R) Portfolio FT [ ] MetLife Moderate Allocation Portfolio H7
[ ] Fidelity VIP Mid Cap Portfolio D1 [ ] MetLife Moderate to Aggressive Allocation Portfolio H8
[ ] Xxxxxx Oakmark International Portfolio 4C [ ] MFS(R) Total Return Portfolio HT
[ ] Janus Aspen Series Mid Cap Growth Portfolio JA [ ] MFS(R) Value Portfolio BD
[ ] Janus Capital Appreciation Portfolio US [ ] Xxxxxxxxx Xxxxxx Real Estate Portfolio I3
[ ] Lazard Retirement Small Cap Portfolio RS [ ] Xxxxxxxxxxx Global Equity Portfolio IK
[ ] Xxxx Xxxxx Partners Managed Assets Portfolio UA [ ] PIMCO VIT Real Return Portfolio PR
[ ] Xxxx Xxxxx Partners Variable Adjustable Rate Income [ ] PIMCO VIT Total Return Portfolio PM
Portfolio BI [ ] Pioneer Fund Portfolio UP
[ ] Xxxx Xxxxx Partners Variable Aggressive Growth [ ] Pioneer Mid-Cap Value Portfolio FW
Portfolio SG [ ] Pioneer Strategic Income Portfolio HP
[ ] Xxxx Xxxxx Partners Variable All Cap Portfolio AD [ ] Xxxxxx VT Small Cap Value Fund OP
[ ] Xxxx Xxxxx Partners Variable Appreciation Portfolio 1N [ ] Xxxxxxxxx Developing Markets Securities Fund VQ
[ ] Xxxx Xxxxx Partners Variable Equity Index Portfolio GF [ ] Xxxxxxxxx Foreign Securities Fund VG
[ ] Xxxx Xxxxx Partners Variable High Income Portfolio HH [ ] Xxx Xxxxxx LIT Xxxxxxxx Portfolio NJ
[ ] Xxxx Xxxxx Partners Variable Investors Portfolio C2 [ ] Western Asset Management High Yield Bond Portfolio UB
[ ] Xxxx Xxxxx Partners Variable Large Cap Growth [ ] Western Asset Management U.S. Government Portfolio GV
Portfolio AB [ ] Fixed Account
[ ] Xxxx Xxxxx Partners Variable Small Cap Growth
Opportunities Portfolio C9
[ ] Xxxx Xxxxx Partners Variable Social Awareness Stock
Portfolio SA
[ ] Xxxx Xxxxx Partners Variable Total Return Portfolio AE
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Will funding options selected be available on all money sources in the plan? If not, please specify restrictions in detail:
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Please identify how employer-directed sources are to be allocated. Under "Funding Option Name/Code," please print the funding
options to which employer sources are to be directed. Under the "Trustee Account Allocation column," please list the appropriate
percent(s). TAKEOVER PLAN NOTICE: UNLESS SPECIFIC INSTRUCTIONS TO THE CONTRARY ARE SPECIFIED IN SECTION VI, ASSETS TRANSFERRED TO
METLIFE WILL BE INVESTED IN THE BLACKROCK MONEY MARKET PORTFOLIO UNTIL METLIFE RECEIVES THE PARTICIPANT RECORDS TO BE PROCESSED.
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FUNDING OPTION NAME/CODE TRUSTEE ACCOUNT ALLOCATION (Required)
------------------------ -------------------------------------
___________________________________________________________________________________________________________________________________%
___________________________________________________________________________________________________________________________________%
___________________________________________________________________________________________________________________________________%
___________________________________________________________________________________________________________________________________%
(Must equal 100%)
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L-21158 A (BAR CODE) ORDER NO. L-21158 REV. 5-06
2 OF 5
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SECTION IV - PLAN COMPLIANCE INFORMATION
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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:
_______________________________________________________________ __________________________________________________________________
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SECTION V - EXISTING PLAN ASSET INFORMATION
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Will this contract replace any existing Annuity Contract(s)? [ ] Yes [ ] No (If yes, complete information below.)
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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 IV) Phone Number
_____________________________________________________________________________ ____________________________________________________
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SECTION VI - ADDITIONAL INFORMATION
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Please provide any additional information or unique processes specific to this plan:
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QUALIFIED CONTRACT OWNER TELEPHONE TRANSFER/ALLOCATION AUTHORIZATION
(FOR USE WITH ALLOCATED CONTRACTS ONLY)
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The owner (the "owner") of the allocated annuity contract shown above hereby authorizes MetLife Insurance Company of Connecticut
(the "Company") to accept and act upon certain telephone and/or written instructions, as described below, from any participant who
has an individual account under the contract.
The owner understands that participants choosing to participate in the program are subject to the specific terms and conditions of
the program set forth in the separate authorization form that the participant must execute.
The Company may change, modify, amend, or replace the procedures, terms and conditions of the program at any time in its sole
discretion.
This authorization applies to the following transactions:
1. Telephone and/or written instructions requesting the transfer of all or any part of accumulated variable annuity contract
values to a funding vehicle (hereinafter referred to as an "investment alternative") of the variable annuity contract;
2. Telephone and/or written instructions requesting the allocation of all or any part of future contributions to an investment
alternative of the variable annuity contract; and
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The owner understands and agrees that neither the Company nor any person acting on its behalf will be subject to any claim, loss,
liability, cost or expense if it or they acted in good faith in reliance on this authorization, and this authorization will be in
effect until the Company:
- receives written revocation from the Owner; and
- discontinues the privilege of telephone and/or written transfers, as the case may be.
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Telephone Transfer Privileges are included with Participant Accounting Services. If you do not wish to have Telephone Transfer
Privileges available to your plan participants you must opt out of this service by checking the deselection box below. PLEASE NOTE:
IF THIS BOX HAS NOT BEEN CHECKED, THE COMPANY ASSUMES TELEPHONE TRANSFER PRIVILEGES AUTHORIZATION.
[ ] I ELECT TO OPT OUT OF TELEPHONE TRANSFER PRIVILEGES
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L-21158 A (BAR CODE) ORDER NO. L-21158 REV. 5-06
3 OF 5
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NOTICES OF INSURANCE FRAUD
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: 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.
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L-21158 A (BAR CODE) ORDER NO. L-21158 REV. 5-06
4 OF 5
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ACKNOWLEDGEMENTS AND SIGNATURES REQUIRED
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ACKNOWLEDGMENTS: I understand that the contract will take effect when the first premium payment is received, and the application is
approved in the Company's Home Office. 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 the Company may amend this contract to comply with changes in the
Internal Revenue Code and related Regulations. I understand that the Company will provide the Third Party Administrator for this
plan with information that the Company maintains for use in preparing IRS Form 5500 and related schedules. I acknowledge receipt of
the current prospectus(es) for this product.
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SIGNATURES REQUIRED:
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Trustee Name(s) (please print):
____________________________________________________________________________________________________________________________________
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Trustee Signature(s)
____________________________________________________________________________________________________________________________________
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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 presentations and signatures are accurate and valid to the best of my knowledge and belief.
Will the contract applied for replace any existing annuity contract or life insurance policy)? [ ] Yes [ ] No
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Agent/Representative Name (Please print) Social Security Number Telephone # Fax #
_____________________________________________ ____________________________ ______________________________ ____________________
Agent/Representative Signature Date License Number
_____________________________________________ ____________________________ _____________________________________________________
Agent Representative Name (Please print) Social Security Number Telephone # Fax #
_____________________________________________ ____________________________ ______________________________ ____________________
Agent/Representative Signature Date License Number
_____________________________________________ ____________________________ _____________________________________________________
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FOR MLR USE ONLY (Circle one)
C/ E / G/ H
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L-21158 A (BAR CODE) ORDER NO. L-21158 REV. 5-06
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