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Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company
The Company indicated in this section is referred to as "the Company."
Policy loan request
Use this form to request a loan on your policy.
Things to know before you begin
Please complete this form in its entirety to avoid any delays in
If you need assistance completing this form, please call your
representative, sales office, or the appropriate number listed under
How to submit this form.
A loan will affect the cash value of your policy and may have
Please refer to your policy or
prospectus for important
information (including minimum
loan amounts).
SECTION 1: About the Owner
Policy number
Type of Owner:
Trust/Business entity
If Individual or Co-owner:
First name Middle name Last name
Phone number Social Security number E-Mail address
Co-owner - First name Middle name Last name
Phone number Social Security number E-Mail address
If Trust/Business entity owner:
Name of Trust Date executed (mm/dd/yyyy)
Name of Business entity Tax ID number of Trust/Business entity
Trust/Business entity contact person:
First name Middle name Last name
Contact phone number E-Mail address
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Please provide the address where your proceeds should be sent:
Number and street/Post office box City State ZIP
Should we use this address for all future correspondence?
Yes No
SECTION 2: About the Insured
First name Middle name Last name
SECTION 3: About the loan request
Not all policies allow the borrowing of dividends or contain the paid-up additions/premiums additions/variable
additional insurance rider. Please review your policy or prospectus to determine if these options are available.
Loan Request:
Maximum amount available Specific amount $
*If there is not sufficient value to meet the specific dollar amount, a loan for the largest
amount available will be granted. If the loan includes dividends and/or riders, the
amount(s) should be
Payment options: Please select one of the following methods of payment:
A. Pay by check.
B. Apply loan to pay premiums as detailed below:
Policy 1 Policy 2
Policy number
Number of premiums to pay
Due date of first premium
Additional funds submitted to be applied
If loan value exceeds amount to be applied, the excess will be sent by check. If the available loan value is
insufficient, this request could result in the need to make additional out of pocket premium payments.
Special instructions:
SECTION 4: About income tax witholding
Under current federal income tax law, we are required to withhold 10% of the taxable portion of the loan value
and pay it to the IRS unless you tell us in writing not to withhold tax. Certain states also require us to withhold
state income tax if we withhold federal tax.
You are responsible for paying income tax on the taxable portion of the payment even if we do no withholding.
In making your decision about withholding, you should consider that penalties under the estimated income tax
rules may apply if your withholding and estimated income tax payments are not sufficient.
Check here if you do not want us to withhold federal and state income tax
(This choice is void if we do not have your social security or Tax ID number.).
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SECTION 5: Certification and signatures
Under the penalties of perjury I certify:
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, e.g. IRS Form W-8BEN for
individuals, which can be found on the IRS website).
The Internal Revenue Service does not require your consent to any provision of this document other
than the certifications required to avoid backup withholding.
Signature requirements
All Owners must sign this form. Any Irrevocable Beneficiary or Collateral Assignee must sign this form.
Please sign as shown below:
A Partnership The full name of the firm should be printed with the signature of all general partners
(not limited partners).
A Sole Proprietorship The full name of the business should be printed with the signature of the owner
followed by the word “owner.”
A Trust Signatures, followed by the word "Trustee," of all required Trustees. Also submit a
Trust Certification, which is available from your representative, sales office, or the
appropriate number listed under How to Submit This Form.
A Corporation The signature and title of one officer (other than the insured).
An Individual acting on The full name of the Owner's fiduciary or agent and the legal documentation of the
behalf of the Owner authority to act (e.g., power of attorney, guardianship papers, etc.).
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Signature of Owner Date (mm/dd/yyyy)
Title (If you are acting in a representative capacity)
Print name of individual signing - First name Middle name Last name
Signed at city State
Signature of Co-owner
Date (mm/dd/yyyy)
Title (If you are acting in a representative capacity)
Print name of individual signing - First name Middle name Last name
Signed at city State
For sales office use only
Sales office/Agency number/Representative ID Date (mm/dd/yyyy)
Sales representative - First name Middle name Last name
SECTION 6: How to submit this form
Return pages 1 through 4 of the completed form to the address or fax number listed below for the company that
issued the policy. If policies are issued by more than one company, return the completed form to any company
that issued at least one of the policies.
Variable Universal Life Policies
P.O. Box 390
Warwick, RI 02887-0390
Whole Life,Term,Universal Life Policies
P.O. Box 391
Warwick, RI 02887-0391
Phone :
Fax :