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DocuSign Envelope ID: 7A8AEB9B-BFF7-419C-9E5E-A7A850FBE63F

For use in the State of:

New York

Life Insurance Application and Forms Package
Table of Contents and Instructions
Form Name

Form Number

Instructions/Notes

Application for Life Insurance

ENB-7-07-NY

Application for Individual Life Insurance for all MetLife
affiliated companies.
Signatures RequiredAuthorization

EAUTH-07-NY

Proposed Insured’s authorization for release of
information to comply with the requirements of the
Health Insurance Portability and Accountability Act
(HIPAA).
Signatures Required

New York Informed Consent Form for
Blood and Urine Testing for the AIDS Virus
and Other Conditions

EHIV-04-NY

Notice and Consent Authorization form for HIV related
testing. Note: Usethe applicable form for each
Proposed Insured's state of residence.
Signatures Required

Producer Identification & Certification

EPID-54-07-NY

This is to be completed by the Producer attesting to
completion of the application and certification of
Owner identity.
Signatures Required - Producer and
Agency Management

Definition of Replacement

EREPLDIS-NY-DEF Completion requiredwhether Replacement is involved
or not.
Signatures Required

Personal Financial Information

EFIN-05-NY

To be completed when the amount of coverage is
$1,000,000 or over. Used to obtain information about
income and assets/liabilities of the Proposed Insured(s).

Medical Supplement

EMED-48-07-NY

This form is to be completed by the Proposed Insured
regarding his/her health forunderwriting purposes.
Note: Completion is optional if a full Paramedical/
Medical Exam is required. Best practice is to answer all
medical questions to enable the underwriter to
promptly begin the underwriting process.

What Customers Should Know
IDENTITY VERIFICATION:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financialinstitutions to obtain, verify, and record information that identifies each person who applies for life insurance.
WHAT THIS MEANS FOR YOU:
When you apply for a policy, we will ask for your name, address, date of birth, and other information that will allow us to
identify you. We may also ask to see your driver's license or other identifying documents.
APP-PACK-IDG-NY (02/11)

PEANUTS © UnitedFeature Syndicate, Inc.

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DocuSign Envelope ID: 7A8AEB9B-BFF7-419C-9E5E-A7A850FBE63F

What Producers Should Know
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Incomplete Applications may delay processing.

n Complete

all required sections and obtain all signatures and titles (where required).

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Do not use pencil to complete this application or use “white out” to make changes. If a change is made to
an answer, therespondent must initial the change.

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When a replacement is involved or if the policy state has adopted a replacement regulation, the appropriate state required
replacement form(s) must be signed and dated on, or prior to, the Application date.

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The NAIC Replacement Notice (EREPLDIS-NAIC) must be completed and signed in certain states if either the Proposed
Insured or the Owner hasany existing life insurance policies or annuity contracts even if they are not replacing
this coverage.

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While completion of the Medical Supplement (EMED-48-07) is not required if the Proposed Insured is being examined,
answering all medical questions (including the full name, address and phone number for each physician consulted) is
good field underwriting practice and will enable theunderwriter to promptly begin the underwriting process.

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Complete and sign the Producer Identification & Certification form.

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Social Security number of the Beneficiary is an optional field. However, this information is valuable in helping us locate
Beneficiaries at time of claim.

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Complete all Supplements and Questionnaires indicated by the applicant's selection in this...