Variable Life Product Dollar Cost Averaging Request Not for use with VUL Guard SM and SVUL Guard SM policies
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- Harry Atkins
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1 Not for use with Guard SM and S Guard SM policies Instructions for this form: (IMPORTANT INFORMATION BELOW) You MAY NOT elect the Dollar Cost Averaging (DCA) option if Portfolio Rebalancing is in effect for your policy. 1. Print the (or application number) and the Name of Insured(s) in the space provided at the top of the form. 2. the frequency, DCA start date, and DCA end date, or the number of transfers after which the DCA should end. The day of your DCA start date will be your specified DCA transfer day. The DCA transfer day can not occur within 66 days of the policy s Issue Date. Therefore, DCA will begin on the next following DCA transfer day after the 66-day period expires. For Variable Life policies: If, on a specified DCA transfer day, the value of the From division is less than the specified Transfer Amount, the remaining value in that division will be transferred on a pro-rata basis to the designated divisions and the GPA. The DCA will then automatically terminate, and future DCA transfers will not occur. You must submit another DCA request to restart the DCA program. For / / I/ S / S policies: If, on a specified DCA transfer day, the value of the From division is less than the specified Transfer Amount, the DCA will not occur. DCA will occur on the next designated DCA transfer day as long as the amount you designated to be transferred is available. 3. Enter the total amount of the transfer in the Transfer Amount (From) field. To be eligible for DCA on your / / I/ S / S policy, your Transfer Amount (From) initial account value must be at least $1,000. To be eligible for DCA on your Variable Life policy, your Transfer Amount (From) initial account value must be at least $5,000. The minimum amount that may be transferred from the Transfer Amount From field on your / / I/ S / S policy is $ The minimum amount that may be transferred from the Transfer Amount From field on your Variable Life policy is $ Enter the name of the division from which the values will be deducted in the Division Name (From) field. You may select only one division. The division name specified in the Division Name (From) field cannot be specified as a Transfer To division. The GPA is not a division of the Separate Account and is not eligible as a From division in our Dollar Cost Averaging program. 5. Print the amount to be transferred in the Transfer To space provided. The amount must be entered in whole dollar amounts and the sum of the dollar amounts must equal the Total Amount of Transfer. There is no minimum for the Transfer To field. If a DCA election is made while an earlier DCA election is currently in effect for the policy, the new election will supersede the current one as of the new effective date. Only one DCA election is allowed for a given Valuation Date. Customer Service A form is required. If you have reviewed and completed this form, please return pages 2-5 for processing. You may submit your DCA requests by mail, or fax to: MassMutual PO Box 1865 Springfield, MA Lifefax@massmutual.com For additional information regarding your policy, please use the following resources: Internet Service Connection Fax Number(s) MassMutual Customer Service Center Monday through Friday, 8 a.m. 8 p.m. Eastern Time We will only accept responsibility for forms that are mailed, ed or faxed as indicated. A copy of this document transmitted by facsimile shall have the same effect as an original. Massachusetts Mutual Life Insurance Company (MassMutual), 1295 State Street, Springfield, MA and its subsidiaries: C.M. Life Insurance Company and MML Bay State Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, Connecticut Page 1 of 5 Client retains this page
2 Please complete the entire form and print. Variable Life Product Not for use with Guard SM and S Guard SM policies The DCA transfer day can not occur within 66 days of the policy s Issue Date. Therefore, Dollar Cost Averaging will begin on the next following DCA transfer day after the 66-day period expires. DCA will not assure you a profit and does not protect against loss in declining markets. Since a DCA program anticipates continued investment during periods of fluctuating prices, you should consider your ability to assume the financial risks of continuing DCA through periods of low price levels. A DCA Start Date must be indicated below. However, the 29 th, 30 th, and 31 st days of the month cannot be selected as the DCA Start Date. To ensure proper performance of the DCA function, it is imperative that sufficient funds are maintained in the Transfer From fund. This form cannot be used to transfer amounts from one division of the Separate Account to another (use Form FR1237 for transfers) nor can it be used to request a change in allocation of future premiums (use Form FR1237 for future net premium allocations). Frequency Monthly Quarterly Semi-Annual Annual DCA Start Date / / DCA End Date / / OR end after number of transfers Transfer Amount (From) $ Division Name (From) Refer to your prospectus for additional information about the divisions of the Separate Account and Information regarding Dollar Cost Averaging. Transfer To Whole Numbers) Available Investment Options by Product Specialty Invesco V.I. Global Health Care $ Invesco V.I. Technology $ MML Managed Volatility $ PIMCO CommodityRealReturn Strategy $ VY Clarion Global Real Estate $ International/Global Janus Henderson Global Research 1 $ MML Foreign $ MML Global $ Oppenheimer Global $ Oppenheimer International Growth $ Templeton Foreign VIP $ Small/Mid-Cap Growth MFS New Discovery $ MML Mid Cap Growth $ MML Small Cap Growth Equity $ I S S Page 2 of 5
3 Not for use with Guard SM and S Guard SM policies Transfer To Whole Numbers Available Investment Option by Product Small/ Mid-Cap Growth (cont d) Oppenheimer Discovery Mid Cap Growth $ T. Rowe Price Mid-Cap Growth 2 $ Small/Mid-Cap Blend Deutsche Small Cap Index $ MML Small Cap Equity $ Small/Mid-Cap Value Franklin Small Cap Value VIP $ MML Mid Cap Value $ MML Small/Mid Cap Value $ Large Cap Growth Goldman Sachs Strategic Growth $ Janus Henderson Forty 3 $ MML Blue Chip Growth $ Oppenheimer Capital Appreciation $ T. Rowe Price Blue Chip Growth $ Large Cap Blend American Funds Growth-Income $ Fidelity VIP Contrafund $ Invesco V.I. Diversified Dividend $ MFS Investors Trust $ MML Equity Index $ MML Growth & Income $ Oppenheimer Main Street $ I S S Page 3 of 5 Client retains this page
4 Not for use with Guard SM and S Guard SM policies Transfer to Whole Numbers ) Available Investment Option by Product Large Cap Value American Century VP Income & Growth $ American Century VP Value $ MML Equity $ MML Equity Income $ MML Income & Growth $ T. Rowe Price Equity Income $ Asset Allocation MML Aggressive Allocation $ MML Balanced Allocation $ MML Conservative Allocation $ MML Growth Allocation $ MML Moderate Allocation $ Balanced American Funds Asset Allocation $ Janus Henderson Balanced 4 $ MML Blend $ Fixed Income MML Inflation-Protected and Income $ MML Managed Bond $ Oppenheimer Total Return Bond 5 $ Oppenheimer Global Strategic Income $ Money Market MML U.S. Government Money Market $ I S S Guaranteed Principal Account (GPA) $ 1 Formerly known as Janus Aspen Global Research 2 T. Rowe Price Mid-Cap Growth division is not available as an investment option for policies issued on May 1, 2004 or later. 3 Formerly known as Janus Aspen Forty 4 Formerly known as Janus Aspen Balanced 5 Formerly known as Oppenheimer Core Bond Page 4 of 5
5 Not for use with Guard SM and S Guard SM policies : Individual, Joint or Multiple Owners Signature Section (All owners must sign.) Printed Name of Owner (1) Signature of Owner Date Signed Printed Name of Additional Owner Signature of Additional Owner Date Signed Printed Name of Additional Owner Signature of Additional Owner Date Signed Residency Address of Owner (1) (Apt/House Number & Street Name, City State Zip) Corporate, Partnership or Trust Owned Signature Section Printed Name of Corporation, Partnership or Trust Date of Trust Date Signed Signature of Corporate Officer or Trustee Title I am the sole officer of the corporation listed Date Signed Signature of Corporate Officer or Trustee Title Date Signed Assignee Signature Section Printed Name of Assignee Signature & Title Date Signed Page 5 of 5
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