Premium Allocation Form - MetLife Alico OMAN

Premium Allocation Form
(Fund Allocation)
American Life Insurance Company
WILMINGTON, DELAWARE, U.S.A., INCORPORATED 1921
ADMINISTRATIVE OFFICE
P.O. Box 371916, Dubai, United Arab Emirate
Tel +971 4 415 4555 Fax +971 4 415 4445
Country
Agent Code
Agent Name
Agency Code
Agency Name
1. Policy Details (Enter Policy Number and specify type)
Policy No. Policy Type VISION IGP 2000 GEMSTONE MAXIMISA
2. Personal Details (Enter your name as shown in identification document)
Gender Male Female
First Name Middle Name Last Name
3. Contact Details
Mobile (1) Include Country Code E-mail (1)
Mobile (2) Include Country Code E-mail (2)
Has your Address been changed Yes No If yes, provide new address
4. Allocation of Premium: Please allocate all premiums received as of the date of this request to the following sub account(s)
Strategies Subaccounts Funds currently used Allocation
• Guaranteed Return Account (GRA) N/A %
Conservative
• US Government Bond VG US Government Bond Fund %
• Global Bond Pine Bridge Global Bond Fund %
• Money Market USD US Dollar Cash Fund A-ACC-USD %
• Sukuk Global Emirates Global Sukuk Fund %
• Bond Global Templeton Global Bond Fund Class A (Acc) USD %
• Global Asset Allocation Pine Bridge Balanced World Fund %
Balanced
• Multicurrencies Index Sub-Account Multicurrencies Index Sub-Account %
• Mixed Asset USD Bal - Global Templeton Global Balanced Fund Class A (Acc) USD %
International Opps Fds Asian Bond A %
• Absolute Return Julius Baer BF Absolute Return Plus-USD B %
• Equity Emerging Mkts Latin Am Templeton Latin America Fund Class A(Acc) %
• Equity Sector Real Est Global Franklin Global Real Estate (USD) Fund Class A (Acc) %
• Equity Emerging Mkts Europe Templeton Eastern Europe A (ACC) %
Aggressive
• Equity Emerging Mkts Far East Prudential - INTERNATIONAL OPP-DRAGON P-A %
• Bond Emerging Markets Global INVESCO Emerging Local Currencies Debt Fund %
• Equity Sector Natural Resource Invesco Energy A %
International Opps Fds Asian Equity A %
• Equity Emerging Mkts Other Fidelity Funds - Em Eur Mdl East and Afr A Acc USD %

• Equity India International Opps Fds India Equity A %
• Equity Sector Gold & Prec Metals BGF World Gold Fund A2 USD %
• Equity North America Franklin Mutual Beacon Fund Class A (Acc) USD %
• Equity Emerging Mkts Global Aberdeen Global - Emerging Markets Equity A2 Acc %
• Equity Global Franklin Global Growth A (acc) USD %
• Global Index VG Global Stock Index Fund %
• Global Equity Pine Bridge Global Equity Fund %
• US Index VG US 500 Stock Index Fund %
• Pine Bridge Global Funds Pine Bridge American Equity Fund %
• European Index VG Europe Global Stock Index Fund %
• European Equity FT European Fund %
• Islamic** Equity BNP-Paribas Islamic Equity Optimizer %
• BRIC* Equity FT Bric Fund %
• China Equity FT China Fund %
• India Equity PF Indian Equities %
• Global Small Cap Equity FT Global Smaller Companies Fund %
TOTAL 100 %
5. DECLARATIONS
a) I understand that MetLife Alico makes investments in line with the strategies I have chosen, and my Policy Account Values will reflect
the performance of the strategies I select. With the exception of the Guaranteed Rate Account (GRA), the Investment Account earnings
will fluctuate up or down and principal and investment returns are not guaranteed and are likely to change depending on the actual
performance of the Investment Strategies. I also declare that the allocation of my contributions to the Policy’s Investment Strategies is
based on my own selection and risk tolerance.
b) I understand that future contributions and future transfers in and out of the GRA are subject to MetLife Alico’s prior approval.
c) I understand that, all future contributions will be allocated as indicated above unless MetLife Alico is notified in writing otherwise and
that future contributions are subject to a minimum and maximum amounts as determined by MetLife Alico from time to time.
d) I understand that the Investment Strategies and Investment Subaccounts offered are subject to MetLife Alico’s ability to invest, in
international mutual funds or investment companies’ shares or any other non-local currency denominated investment vehicles. I further
understand that MetLife Alico may from time to time make other Subaccounts available and has the right to change, add or delete
designated investment companies, to add or remove Subaccounts, and to combine any two or more Subaccounts. In the event that I
fail to respond, within the stipulated time, to MetLife Alico’s notice of any modification, discontinuance or unavailability of particular
investment Strategies or Subaccount, I hereby authorize MetLife Alico, at its sole discretion, to re-allocate the value of the discontinued
or unavailable Subaccounts into an available Subaccount under the lower Risk Strategy as determined by MetLife Alico at the time and
to maintain my allocation in any modified Subaccount.
e) I hereby acknowledge that MetLife Alico may be required by applicable laws to withhold income tax on behalf of the Owner and/
or behalf of the Beneficiary (ies) in relation to any returns realized on any of the underlying investments of the selected Investment
Subaccount(s) and/or in relation to any payments due to the Owner and/ or to the Beneficiary (ies) under the Policy.
f) I understand that all contributions to the Policy are subject to any applicable anti-money laundering rules and regulations that are in
force at the time the contributions are received by MetLife Alico.
g) I fully understand that with respect to the first contribution into the Investment Strategies, if applicable, the number of investment
units and their respective value will be allocated within 15 days from the date the signed Policy Receipt, confirming my acceptance of the
Policy as processed, is received at MetLife Alico Administrative Office and the full contribution is duly received and cleared by MetLife Alico.

In applying for insurance coverage as indicated in the initial Application, and in signing this Request Form, I certify that:
• I am not a United States (“U.S.”) Person as defined below.
• Any Beneficiary I have designated IS NOT U.S. Person(s) as defined below.
• I agree to inform the Company within Thirty (30) days of the date I become aware that any designated Beneficiary or I become a U.S.
Person as defined below or of the date the policy is assigned to a U.S. Person as defined below.
• I understand for purposes of this statement, a U.S. Person is a citizen or resident of the United States (including a U.S. Permanent
Resident residing outside the U.S.), U.S. partnership and any trust that is controlled by one or more U.S. persons and is subject to the
supervision of a U.S. Court.
• I understand that this statement is for both U.S. Securities Exchange Control and U.S. Federal Income Tax purposes and that a false
statement or a misrepresentation of tax status by a U.S. Person could lead to penalties under U.S. Law.
Disclaimer: Your relationship is with MetLife Alico. In turn, MetLife Alico makes investments in line with the strategies you have chosen,
and your Policy Account Values will reflect the performance of the strategies you select. The Investment Account earnings will fluctuate up
or down and principal and investment returns are not guaranteed, except under Guaranteed Rate Account (GRA). In order to continue
to best serve its clients, or in the event of change in applicable legislation, MetLife Alico may add, combine, or delete sub-accounts and/
or funds, which back the three investment strategies without notice to its clients. As the clients’ investments are made with MetLife Alico,
in the VUL Insurance plan, rest assured that MetLife Alico’s obligations to its individual clients under their VUL Insurance plans will not be
altered or amended by any such change. The investment Strategies and Investment Sub-accounts offered are subject to the Company’s
ability to invest in international mutual funds or investment companies’ shares or in any other non-local currency denominated investment
vehicles.
Neither MetLife Alico nor any of its affiliates, agents or representatives is giving investment advice in relation to any of the investment
Strategies and/or in connection with the underlying Funds used to achieve the investment goals selected by the Policyholder. Neither MetLife
Alico nor any of its affiliates, agents or representatives is giving any professional advice regarding the compatibility of the underlying Funds
with any set of religious precepts or guidelines.
Important: Before signing this Form, make sure all the information is correct and all Declarations and Statements made
above are fully understood.
Signatures
Signed at Place City/Country on this D D day of M M Year
Name of Proposed Insured
in his/her own handwriting
Signature x
Name of Irrevocable Beneficiary
or Assignee
Name of Witness Agent
in his/her own handwriting
in his/her own handwriting
Signature x
Signature x
Name of Policy Owner
in his/her own handwriting
Signature x

Metropolitan Life Insurance Company (MetLife) is a subsidiary of MetLife, Inc. (NYSE: MET), a leading global provider of insurance, annuities
Qatar and the United Arab Emirates, MetLife Alico offers life, accident and health insurance along with retirement and savings products to
individuals and corporations.
For more information, visit www.metlife.com
Alico is a MetLife, Inc. Company
American Life Insurance Company
WILMINGTON, DELAWARE, U.S.A.
INCORPORATED 1921
www.metlifealico-gulf.com
MA/UND/02-PA-FRM/11-13
© 2010 MetLife Alico