enrollment form (metlife financial freedom select … · 2018-04-30 · mffs-403v1 (04/18) fs...

SECTION 1: Participant I am an employee of and on behalf of the employer I am requesting

(Name of Employer)enrollment as a participant of the plan.

(Name of Employer/Plan)Group plan #:First name Middle name Last name

Address

City State ZIP

Sex MaleFemale

Home telephone # Work telephone # Marital Status Date of birth Social Security #

Employee Identification # (If other than Social Security #) Plan Participation Date (mm/dd/yyyy)

Occupation Are you retired?Yes No

Country of citizenship

Email

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SECTION 2: MetLife Financial Freedom Select class selection Select one class — If no class is selected, the B Class will automatically be chosen.

B Class L Class

SECTION 3: Primary and Contingent Beneficiary(ies) Please note: Both Primary and Contingent Beneficiary percentages must each add up to 100%. Percentages must be in whole numbers, or go out just one decimal place (e.g. 12.5%).

Primary BeneficiaryFirst name Middle name Last name % of

Proceeds

Relationship to Owner(s) Date of birth Social Security number Phone number

Permanent street address City State ZIP

Enrollment form (MetLife Financial Freedom Select®

Variable Annuity) Non-ERISA Tax Sheltered Annuity (TSA) Version 1

Express mail only: MetLife 4700 Westown Parkway Suite 200 West Des Moines, IA 50266

Regular mail: MetLife PO Box 10356 Des Moines, IA 50306-0356

How to submit this form: Please send us the entire form by mail.

Plan funded by the MetLife Financial Freedom Select® product issued by Metropolitan Life Insurance Company (MetLife), New York, NY 10166

Primary ContingentFirst name Middle name Last name % of

Proceeds



Primary ContingentFirst name Middle name Last name % of

Proceeds



SECTION 4: Contributiona. I elect to contribute or (percentage) of my compensation to the plan each pay

period until such time I revoke or amend my election. (If offered under the plan, Roth 403(b) contribution information should be entered separately below.) Roth Employee Salary Reduction - 403(b) Only: X per year Expected First Year Contribution: Employee Employer Lump Sum Direct transfer amount

b. Anticipated date first contribution will be received

$ %

$$ $

$

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SECTION 5: Optional Riders (Available at time of enrollment and may not be changed once elected. There are additional charges for the Riders)

Living Benefit Riders* (Check only one or none)The PredictorSM (Guaranteed Minimum Income Benefit)** MetLife Lifetime Withdrawal Guarantee™*Not available in all states. State availability must be verified for each of the Living Benefit riders. Living benefits may not be available within all plans. Availability depends on plan effective date.

Death Benefit RiderAnnual Step-up** The Guaranteed Minimum Income Benefit (GMIB) may have limited usefulness in a qualified retirement

plan. Required minimum distributions may have the effect of reducing or, in some cases, entirely eliminating the value of this benefit. If you think you would not exercise the GMIB benefit until after your required beginning date (e.g., April 1st after the later of the year you reach 70½ or the year you separate from service), you should consult your tax advisor to determine if the GMIB is appropriate for your circumstances.

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SECTION 6: Allocation selection Indicate the percentage of your initial contributions to be allocated to each funding choice. Percentages must be in whole numbers. This allocation will also apply to future contributions unless changed by the Participant. You may change your allocation at any time. Please note, if there are no Automated Investment Strategies chosen from Section 7 below, complete column 1 only. If any Automated Investment Strategies from Section 7 were chosen, follow the steps as outlined on those pages. All column totals (if utilized) must total 100%. If the MetLife Lifetime Withdrawal Guarantee Rider has been selected, you are limited to only one of the Asset Allocation Portfolio funding choices numbered 1 through 4 on the list below. Equity

Generator* *Select 1 fund only

Equity Generator* *Select 1 fund only

Allocation Funding Options Allocator(Column

1) (Column 2) (Column 3)

% Fixed Interest Account %

% American Funds Bond Fund %

% BlackRock Bond Income %

% Brighthouse/Franklin Low Duration Total Return

%

% MetLife Aggregate Bond Index %

% PIMCO Inflation Protected Bond %

% PIMCO Total Return %

% Western Asset Management U.S. Government

%

% American Funds Growth Fund %% American Funds Growth-Income Fund %% BlackRock Capital Appreciation %

% Brighthouse/Wellington Core Equity Opportunities

%

% Brighthouse/Wellington Large Cap Research

%

% Calvert VP SRI Balanced %% ClearBridge Aggressive Growth %% Jennison Growth %% MetLife Stock Index %% MFS® Value %% T. Rowe Price Large Cap Growth %% Harris Oakmark International %% MetLife MSCI EAFE® Index %% MFS® Research International %% Brighthouse/Artisan Mid Cap Value %% MetLife Mid Cap Stock Index %% Morgan Stanley Mid Cap Growth %% T. Rowe Price Mid Cap Growth %% Victory Sycamore Mid Cap Value %

Allocation Funding Options Allocator(Column 1 con't) (Column 2 con't) (Column

3 con't)

% American Funds Global Small Capitalization Fund

%

% Brighthouse Small Cap Value %% Invesco Small Cap Growth %% Loomis Sayles Small Cap Core %% Loomis Sayles Small Cap Growth %% MetLife Russell 2000® Index %

% Neuberger Berman Genesis %

% T. Rowe Price Small Cap Growth %% Clarion Global Real Estate %% SSGA Growth and Income ETF %% SSGA Growth ETF %

% (1) Brighthouse Asset Allocation 20 Portfolio

%


%


%


%

% Brighthouse Asset Allocation 100 Portfolio

%

% American Funds® Moderate Allocation Portfolio

%

% American Funds® Balanced Allocation Portfolio

%

% American Funds® Growth Allocation Portfolio

%

% Loomis Sayles Global Markets Portfolio %% MFS® Total Return %% Oppenheimer Global Equity %

% Western Asset Management Strategic Bond Opportunities

%

All entries in column

1 must total

100%

All entires in column

3 must total

100%

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SECTION 7: Optional automated investment strategiesIf no automated investment strategy is chosen, only the Allocation column in Section 6 above needs to be completed. However, if selecting automated investment strategy below, please follow the additional instructions below. Please note only one strategy can be selected.

Equity Generator

Allocator

Each month an amount equal to the interest earned in the Fixed Interest Account is transferred to one funding choice you select. Step 1 — Indicate what percentage of your contributions will be allocated to the Fixed Interest Account in Section 6, in column 1. Step 2 — Each month an amount equal to the interest earned in the Fixed Interest Account is transferred to the one fund of your choice in Section 6 in column 3. This should be 100% for the one fund you choose. Step 3 — If the amount of your contributions allocated to the Fixed Interest Account in Section 6, in column 1, line 1 is less than 100%,allocate your remaining contributions to one or more of the funds in Section 6 in column 1. This column must total 100% when complete.

Each month a dollar amount that you select is transferred from the Fixed Interest Account to any funding choice you select. Step 1 — Indicate what percentage of your contributions will be allocated to the Fixed Interest Account in Section 6, in column 1. Step 2 — Please indicate the amount to transfer from the Fixed Interest Account $ per month. ($50 minimum) Step 3 — The amount indicated in Step 2 is transferred from the Fixed Interest Account to any of the funding choices you select in Section 6 in column 3. This column should total 100% when completed. Step 4 — If the amount of your contribution allocated to the Fixed Interest Account in step 1 above is less than 100%, allocate your remaining contributions, (not to be used by the Allocator Strategy), to one or more of the funding choices in Section 6, in column 1. This column must total 100% when complete. Step 5 — Select the day of the month of the first transfer Must be between the 1st and 28th of the month (actual date may vary due to weekends, holidays, etc.) Step 6 — Select the transfer time frame by checking the appropriate box

(mm/dd/yyyy)

For as long as there is money in the Fixed Interest Account orSpecific number of months (ex 12, 24, 36, etc.)

Note: The first transfer will be made on the date the amounts are allocated to the Allocator option. Subsequent transfers will be made on the same day in subsequent months. All amounts in the Fixed Interest Account, including subsequent contributions made to the Fixed Interest Account, will be transferred as part of the Allocator Strategy, if you choose to make transfers for as long as you have money in the Fixed Interest Account.

Please note if the Allocator was selected, another strategy cannot be selected at this time.RebalancerEach quarter amounts are transferred among your current funding choices to bring the percentages of your account balance in each choice back to your original allocation. This strategy will affect 100% of your current and future allocations. In Section 6, use column 1 to choose your funding choices.

Each quarter MetLife will rebalance the amount in the Index Divisions and the Fixed Interest Account (if applicable) to match the allocation percentages for the model you select. MetLife will allocate 100% of your initial and future contributions based on the current allocation for the Index Selector model you choose. The model’s current allocation may change at any time (MetLife will notify you of changes). You may change your choice of model at any time. See your Representative for information on the current allocations for each model and for help in determining your Risk Tolerance. Select one Model:

Index Selector (Not available with MetLife Lifetime Withdrawal Guarantee Rider)

Conservative Conservative to Moderate Moderate Moderate to AggressiveAggressive

SECTION 8: Replacement (Must be completed)

a. Do you have any existing life insurance policies or annuity contracts? b. Will the proposed annuity replace, discontinue, or change any existing policy or

contract?

Yes NoYes No

If "Yes" to either, ensure that any applicable disclosure and replacement forms are attached. Replacement includes any surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or life insurance contract in connection with this enrollment form.

SECTION 9: Authorization & signature(s)(a) Notice to Participant

Alabama, Arkansas, District of Columbia, Louisiana, New Mexico, Ohio, Rhode Island and West Virginia Residents Only: 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 fines and confinement in prison. Colorado Residents Only: 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 Residents Only: 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. Kentucky Residents Only: 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, and Washington Residents Only: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maine Residents Only: A Premium Tax may be assessed. The State Premium Tax is currently 2%. Maryland Residents Only: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey Residents Only: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Oklahoma Residents Only: WARNING: Any person who knowingly, and with 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. Kansas and Oregon Residents Only: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law. Pennsylvania Residents Only: 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 Residents Only: 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 loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of 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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Virginia Residents Only: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW.

(b) Signature(s)I have read and understand the information above. I agree that the above information and statements and those made on all pages of this enrollment form are true and correct to the best of my knowledge and belief and are made as the basis of my enrollment. I have received MetLife’s Customer Privacy Notice, the current prospectus for the MetLife Financial Freedom Select, and all required fund prospectuses. I ACKNOWLEDGE CONTRACT/CERTIFICATE VALUES AND BENEFITS BASED ON THE SEPARATE ACCOUNT ASSETS ARE NOT GUARANTEED AND WILL DECREASE OR INCREASE WITH INVESTMENT EXPERIENCE. I understand that as required by law MetLife Financial Freedom Select restricts distribution of my 403(b) contributions and earnings on them to the extent required by law until I am 59½, except under certain special situations. This does not restrict tax free transfers to other funding vehicles. I also understand that my contributions and earnings may be restricted as defined in the plan document. I understand that the Internal Revenue Code provides tax deferral for 403(b) arrangements and there is no additional tax benefit obtained by funding a TSA with a variable annuity. It is conceivable that certain optional death benefits and living benefits could have adverse tax consequences. I understand that certain tax rules regarding designated Roth 403(b) contracts are not clear and that the Company has the right to allocate benefits, credits and charges between the designated Roth account and the non-Roth account under this Contract or Certificate using a method it deems reasonable based on existing tax guidance.

I/We understand that I/We should notify Metropolitan Life Insurance Company if any information contained in this enrollment form should change.

I/The Owner(s), agree to authorize the Annuitant to reallocate future annuity income and the right to change the beneficiary designation. I agree that neither MetLife nor its representatives shall be liable for any adverse consequences as a result of this authorization.

US Tax Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number, and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I

have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (If you have been notified by the IRS that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return, you must cross out and initial this item.)

3. I am a U.S. citizen or other U.S. person, and 4. I am not subject to FATCA reporting because I am a U.S. person and the account is located within

the United States. (If you are not a U.S. Citizen or other U.S. person for tax purposes, please cross out the last two certifications and complete appropriate IRS documentation.)

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

City & State where enrollment form signedCity State

Signature of Participant Date (mm/dd/yyyy)

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SECTION 10: Representative information Writing agent completes Section 1. All other agents complete Section 2. Commissions will be split in the agreed proportion. Use whole percentages only.a. Does the participant have any existing life insurance policies or annuity contracts? b. Will the proposed annuity replace, discontinue, or change any existing policy or

contract? If "Yes" to either, ensure that any applicable disclosure and replacement forms are attached. Replacement includes any

surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or life insurance contract in connection with this enrollment form.

Yes NoYes No

Statement of Representative: All answers are correct to the best of my knowledge. I have provided the Proposed Participant with MetLife's Customer Privacy Notice, prior to or at the time he/she completed the enrollment form. I have also delivered a current MetLife Financial Freedom Select prospectus, and all required fund prospectuses. I am properly FINRA registered and licensed in the state where the Proposed Participant signed this enrollment form.

Section 1

Representative’s name First name Middle name Last name

DAI # Sales Office Name & Number % Credit

Signature of Representative Date (mm/dd/yyyy) State License I.D.#

Section 2

2nd Representative’s name First name Middle name Last name


Representative’s signature

3rd Representative’s name First name Middle name Last name



Section 2 (continued)

4th Representative’s name First name Middle name Last name



5th Representative’s name First name Middle name Last name



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enrollment form (metlife financial freedom select … · 2018-04-30 · mffs-403v1 (04/18) fs...

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