Life Insurance Application Form

MetLife Life Insurance Application and Forms Package

For use in the State of:

Policy Number:

SECTION I - About the Proposed Insured

First Name Middle Name Last Name

Permanent Address City State Zip

Country of Legal Residence Date of Birth E-Mail Address

Primary Phone Number Alternate Phone Number

Preferred Time to Call Sex Place of Birth

Social Security or Tax ID Number Earned Annual Income Net Worth

U.S. Driver's License Passport Government Issued Photo ID

Issuer of ID ID Number Issue Date Expiration Date

Name of Employer Employer City State Zip

Position/Duties

SECTION II - About the Owner

Owner - Trust/Business Entity Name Tax ID Number Trustee/Owner State

Owner - Other Individual First Name Middle Name Last Name

Permanent Address City State Zip

Country of Legal Residence Citizenship Social Security or Tax ID Number

Date of Birth Phone Number E-Mail Address

Earned Annual Income Net Worth Relationship to Proposed Insured

SECTION III - About the Beneficiary / Beneficiaries

SECTION IV - About Proposed Coverage

Universal Life Variable Life Whole Life Term Life

Product Name Face Amount

Riders and Details

SECTION V - About Existing or Applied for Insurance

Proposed Insured has existing/applied for insurance? Yes No

Owner has existing/applied for insurance? Yes No

SECTION VI - About Payment Information

Premium Payor: Proposed Insured Owner Other

Other Premium Payor Name Social Security or Tax ID Number Relationship

Payment Mode: Annual Semi-Annual Quarterly Monthly Draft

Bank Routing Number Bank Account Number

SECTION VII - General Risk Questions

1. Aviation activity? Yes No

2. Avocation risk activities? Yes No

3. Travel/reside outside U.S. or Canada? Yes No

4. Tobacco/nicotine use ever? Yes No

5. Driver's license suspended/revoked or DUI/DWI? Yes No

6. Insurance declined/postponed/rated? Yes No

7. Felony conviction? Yes No

8. Actively at work? Yes No

SECTION VIII - Personal Physician

Physician Name Practice/Clinic

Street Address City State Zip

Phone Number Date Last Consulted Reason Findings/Treatment

SECTION IX - Additional Information

Agreement / Disclosure

I have read this application for life insurance including any amendments and supplements and agree to the statements provided.

Taxpayer Identification Number Certification

Taxpayer Identification Number

Signatures

New York Illustration Certification

Case/Policy number

Insured First Name Middle Name Last Name

Insured's gender Male Female Unisex Age

Was a sales illustration provided? Yes No

If no sales illustration, choose one of the following:

Financial professional certifies that a signed illustration is not required.

No illustration conforming to the policy as applied for was shown or provided.

Authorization

Company

Proposed Insured Name

Date of Birth

HIV Consent Form

Physician Name

Address

If a physician is not named above, please contact me

Producer Identification & Certification

Purpose of insurance (check all that apply): Estate Planning Business Needs Mortgage Protection Key Person

Method used to arrive at Face Amount Recommendation:

Is this insurance a replacement? Yes No

Have documents been delivered?

Producer Name Sales Office/Agency Number

Riders With No Premium or Cost of Insurance Charge Supplement

Acceleration of Death Benefit Rider

Acceleration of Death Benefit Due to Chronic Illness Rider

I do not want to apply for any rider listed above.

Signature of Proposed Insured Date Signed at City, State

Definition of Replacement - Department of Financial Services of the State of New York

Company: Metropolitan Life Insurance Company New England Life Insurance Company First MetLife Investors Insurance Company

Any existing coverage likely to be lapsed, surrendered, modified, reissued, assigned as collateral, or continued with reduced premium? Yes No

Signature of applicant Date

Second applicant signature Date

Agent or broker signature Date

Authorization to Obtain and Disclose Information

Name of Proposed Insured

Date of Birth Producer Name

Medical Supplement

Proposed Insured First Name Middle Name Last Name

Height Weight

Any health conditions (high blood pressure, heart disease, diabetes, cancer, etc.)? Yes No

Other illness/injury or treatment in past five years? Yes No

Currently receiving treatment or taking medications? Yes No

Scheduled surgery/tests/visits in next six months? Yes No

AIDS diagnosed or treated? Yes No

Additional Medical / Family History Details