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Annuity Application FieldNet MassMutual

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                                                                                 MassMutual RetireEaseSM
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                                                   Mail completed applications to:           Contact Numbers:
Application                                        Regular Mail:                              Broker/Dealers –
Package                                            MassMutual Retirement Income Center Hub    (800) 262-1626
Annuity New Business                               P.O. Box 9067                              M-F 8am to 6pm EST
                                                   Springfield, MA 01102-9067
Application package
                                                   Overnight Address:                         MassMutual Agent (CAS) –
                                                   MassMutual Retirement Income Center Hub    (800)-234-5606
                                                   1295 State Street                          M-F 8am to 6pm EST
                                                   Springfield, MA 01111-0001
                                                                                 BROKER DEALER
MASSMUTUAL AGENCY # _________________                                            FIRM NAME    ____________________________

                                                            PLEASE REVIEW THE FOLLOWING INSTRUCTIONS:
ADDITIONAL INFORMATION                                         Sales Quote (Must be included)
SUBMITTED:
                                                               Check in the amount of $__________
(Check all that apply)
                                                               Company to Company Transfer of Assets Form (F6628)
                                                               State Replacement Form
                                                               Other: ______________________________
                                                               Other: ______________________________
                                                               Other: ______________________________

                                                            The following are guidelines for completing this package:
IMPORTANT REMINDERS:
                                                               All applications must be accompanied by a Sales Quote, and the initial
                                                               quote must match the application.
                                                               Evidence of age is required for “Single Life” or “Joint Life” annuity options,
                                                               including “Life with Period Certain.”
                                                               If a joint owner is designated and tax withholding is elected, only the
                                                               primary Owner will be taxed.
                                                               Make checks payable to MassMutual.
                                                               When a replacement is involved or if your state has adopted the NAIC
                                                               Model Replacement Regulation, the appropriate state required
                                                               replacement form must be signed and dated on, or prior to, the
                                                               Application Date.
                                                               If your state has adopted the NAIC Suitability in Annuity Transactions
                                                               Model Regulation, complete the Fixed Annuity Investor Account form
                                                               – F9726S.

SPECIAL INSTRUCTIONS:
Please include any special handling or
processing instructions here.




     Massachusetts Mutual Life Insurance Company
     and affiliates, Springfield, MA 01111-0001

      www.massmutual.com

                                                                                                                                  FR1097 (0812)
                                                                                                                                                               Individual Immediate
     (LOGO)                                                                                                                                                     Annuity Application
                                                                                                                                                               Contract No.                                   .
                                                                                                                                                                              (For Home Office Use Only.)

 A. Contract Owner(s)                                                                                                               Complete this section for all cases.
     Contract Owner
Contract Owner must be the same as the Annuitant for all types of IRAs, except Custodial IRAs, and 403(b) plans. If Contract Owner is a corporation,
we require a copy of the corporate resolution. If the Contract Owner or Beneficiary is a trust, we require a Certification of Trust Agreement (F6734).

                                                                                                                                   9.   Legal Address – PO Box not allowed (Street, Apt., City, State, Zip)
1.    Name                                                                                                                 .
                (Individual – First, Middle, Last, Suffix / Corporation / Trust)                                                                                                                         .
                                                                                                                                                                                                         .
2.    Contact Name                                                                                                     .                                                                                 .
                                  (Corporate Officer / Trustee)
                                                                                                                                   10. Mailing Address (if different)
3.    DOB / Date of Trust Agreement                                  /            /                                        .                                                                             .
                                                       (month)           (Day)                (Year)
                                                                                                                                                                                                         .
                                                                                                                                                                                                         .
4. Social Security No./Tax ID No.                                                                                  .
                                                                                                                                   11. Legal Status of Contract Owner (check one and complete applicable
                                                                                                                                       fill-in):
5.    State of Residence                           .
                                                                                                                                            I am a U.S. person (U.S. Citizen or resident alien) and the
                                                                                                                                            Taxpayer Identification Number provided is my correct number
6.    Gender:          Male            Female
                                                                                                                                            and the Internal Revenue service has NOT notified me that I am
                                                                                                                                            subject to backup withholding.
7.    Daytime Contact Number (                               )                        -                            .                        I am NOT a U.S. person. I am a resident of:
                                                                                                                                            (country)                                                 .

8.    E-mail                                                                                                   .                            This Contract will be owned by a U.S. Legal Entity (e.g.
                                             (Optional)                                                                                     Corporation/Partnership/LLC/Trust); Business/Purpose of Entity:
                                                                                                                                            __________________________________.


     Joint Contract Owner
 Joint Contract Owners are not allowed on qualified contracts. Both Contract Owners’ signatures will be required for transactions.

 12. Name                                                                                                              .           20. Mailing Address (if different)
                                       (First, Middle, Last, Suffix)
                                                                                                                                                                                                         .
 13. DOB                      /                        /                                        .                                                                                                        .
                 (Month)              (Day)                              (Year)
                                                                                                                                                                                                         .
 14. Social Security No./Tax ID No.                                                                        .
                                                                                                                                        Complete Items 21-22 for all Joint Contract Owners.
 15. State of Residence                                .
                                                                                                                                   21. Relationship to Contract Owner:         Spouse          Non-Spouse
 16. Gender:               Male               Female
                                                                                                                                   22. Legal Status of Joint Contract Owner (check one and complete
         Complete Items 17-20 only if different than                                                                                    applicable fill-in):
                Primary Contract Owner.
 17. Daytime Contact Number (                                    )                        -                            .                    I am a U.S. person (U.S. Citizen or resident alien) and the
                                                                                                                                            Taxpayer Identification Number provided is my correct number
                                                                                                                                            and the Internal Revenue service has NOT notified me that I
 18. E-mail                                                                                            .
                                            (Optional)                                                                                      am subject to backup withholding.
                                                                                                                                            I am NOT a U.S. person. I am a resident of:
 19. Legal Address – PO Box not allowed (Street, Apt., City, State, Zip)                                                                    (country)                                                   .
                                                                                                                   .                        This Contract will be owned by a U.S. Legal Entity (e.q.
                                                                                                                   .                        Corporation/Partnership/LLC/Trust); Business/Purpose of
                                                                                                                   .                        Entity:_____________________                            ____



                                                                                                IIIIII IIIIIIIII IIIIIII

     APPIMM08                                                                                                                  1                                                          FR1097 (0812)
                         Thank you for choosing MassMutual for your Annuity needs. We value your business.
                                                                                                                 Complete this section only if Annuitant is different than Contract
B. Annuitant                                                                                                     Owner.

      Annuitant Information
                                                                                                                5. Legal Address – PO Box not allowed (Street, Apt., City, State, Zip)
1. Name                                                                                                 .                                                                           .
                                          (First, Middle, Last, Suffix)
                                                                                                                                                                                    .
2. DOB                        /                        /                                   .                                                                                        .
                (Month)              (Day)                                (Year)
                                                                                                                6. Mailing Address (if different)
3. Social Security No./Tax ID No.                                                                   .
                                                                                                                                                                                    .
4. Gender:                Male                    Female                                                                                                                            .
                                                                                                                                                                                    .



                                                                                                                 Complete this section when applicable AND if Joint Annuitant is
C. Joint Annuitant                                                                                               different than Joint Contract Owner.

      Joint Annuitant Information
Joint Annuitants may not be named if the Period Certain Only or Single Life annuity options are elected or if the Inherited IRA Plan Type is selected.
                                                                             12. Residential Address – No PO No. (Street, Apt., City, State, Zip)
7. Name                                                                 .
                                          (First, Middle, Last, Suffix)                                                                                                             .
8.    DOB                 /                   /                                .                                                                                                    .
                (Month)           (Day)                    (Year)
                                                                                                                                                                                    .
9.    Social Security No. /Tax ID No.                                                           .               13. Mailing Address (if different)
10. Gender:               Male                    Female                                                                                                                            .
                                                                                                                                                                                    .
11. Relationship to Annuitant:                          Spouse                     Non-Spouse
                                                                                                                                                                                    .




D. Purchase Payment                                                                                              Complete this section for all cases.

      Purchase Payment Submitted With Application

                                                                                                                     Transfers:
                                                                                                                         • Please estimate for transfers.
                                                                                                                         • All transfer amounts must be included.
      Amount Submitted with Application                                                                                  • Complete Form F6628 for each transfer.

            $                                                                          .                                  Estimated Amount of Transfers, if any:

                                                                                                                          $                                         .




     APPIMM08                                                                                               2                                                           FR1097 (0812)
                          Thank you for choosing MassMutual for your Annuity needs. We value your business.
E. Beneficiary Information                                                    Complete this section for all cases.


        In the event no Beneficiary designation is on record with the Company, death proceeds will be paid to the default Beneficiary under the terms
         of the Contract.
        For the “% of Proceeds” column:
              You may write in “In Equal Shares” as an alternative to using percentages.
              If you do not write in percentages or “In Equal Shares,” any death benefit proceeds will be distributed equally among the beneficiaries.
        If Joint Annuitants are designated under a qualified Contract, the surviving Annuitant must be the sole Primary Beneficiary.
        If a Beneficiary predeceases the last surviving Annuitant, unless you instruct differently in writing, the Beneficiary’s share will be distributed
          pro-rata among the remaining Beneficiaries in the same category (i.e., Primary or Contingent) as the deceased Beneficiary.
        If the Contract is jointly owned:
               In the event of a death of a Joint Contract Owner any surviving Joint Contract Owner will be treated as the Primary Beneficiary.
               To designate someone other than the Joint Contract Owner as Primary Beneficiary, a Change of Beneficiary form (F6455) must be
               submitted to the Company.
        For Custodial IRA Contracts, the Custodian Account must be designated as the sole Primary Beneficiary.
        To change the Beneficiary, a Contract Change form (F6455) must be submitted to the Company.

                      If the Beneficiary is a trust, we require a Certification of Trust Agreement (F6734).


The following beneficiary designations are irrevocable.                         Yes           No (Default if neither box is checked)
Note: Any changes to an irrevocable beneficiary designation will require the signature of the irrevocable beneficiary.

       Primary Beneficiary Name              Gender           Date of Birth /             Social Security No. /          Relationship to           % of
                                                M/F      Date of Trust Agreement              Tax ID No.                 Contract Owner          Proceeds
      Surviving Contract Owner if
                                                                                                                                                   100%
            Jointly Owned




                                                              Date of Birth /             Social Security No. /          Relationship to           % of
     Contingent Beneficiary Name
                                                         Date of Trust Agreement              Tax ID No.                 Contract Owner          Proceeds




  APPIMM08                                                                   3                                                           FR1097 (0812)
                   Thank you for choosing MassMutual for your Annuity needs. We value your business.
F. Miscellaneous Instructions / Comments




G. Company Disclosures

    The Application. This is an application for an annuity Contract. The Application includes any amendments to it. The Application and any
    amendments to it become part of the Contract.
    Changes and Corrections. Any material change or correction of the Application may be shown on an Amendment of Application attached to
    the Contract. Acceptance of any contract issued shall, with the authorization of the Contract Owner, be an acceptance of any change or
    correction of the Application made by the Company.
    Authority of Producers. No producer can change the terms of this Application or any Contract issued by the Company. No producer can
    waive any of the Company’s rights or requirements or extend the time for any payment.
    Customer Identification. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all
    financial institutions to obtain, verify, and record information that identifies each person who purchases a financial product. Therefore, this
    application asks 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. Similarly, we may ask for identifying information and/or documents for applications taken on
    behalf of an entity, rather than an individual (e.g., trusts, corporations). If you cannot provide the information or documentation we require, we
    may not be able to issue the contract for which you are applying.

    Non-Guaranteed. I understand that the Contract is not a bank or credit union deposit or obligation and is not FDIC or NCUA insured. I also
    understand that the Contract is not insured by any federal government agency and is not guaranteed by any bank or credit union.

    For Variable Annuity applicants.
        • The Company will generally issue the contract and apply the purchase payment within 2 business days of receiving it at our Retirement
            Income Service Center or lockbox if the information you have provided is complete. If we do not receive all the information needed to
            issue the contract within 5 business days, we must either return your money or obtain your permission to keep it until we receive all of
            the necessary information.
        • The Company reserves the right, upon 30 days advance notice to the Contract Owner, to limit allocations of Net Purchase Payments to
            the Fixed Account(s). Transfers from the Separate Account to the Fixed Account(s) may also be limited. The right to discontinue
            access to the Fixed Account(s) will only be exercised when the yield on investments will not support the statutory minimum interest rate,
            and will not be exercised in an unfairly discriminatory manner. Please refer to the prospectus for details of any limitations currently in
            effect.
        • I understand that the annuity payments, any withdrawal value, and any death benefit that may be provided by the Contract, when based
            on the investment experience of the Separate Account, are variable and are not guaranteed as to dollar amount.
        • By signing the application, I acknowledge that I have received a current prospectus for the Contract and I understand that the
            prospectus contains more detailed information about the Contract’s provisions.

   Rollover. By signing the application, I acknowledge that I have read the information pertaining to my right to make a direct rollover of eligible
   rollover distributions which I may receive and I waive my right to receive a reasonable time (at least 30 days’ notice) to consider my rollover
   distribution options.




  APPIMM08                                                                  4                                                          FR1097 (0812)
                   Thank you for choosing MassMutual for your Annuity needs. We value your business.
     MassMutual RetireEaseSM Immediate Fixed Annuity
     Issued by Massachusetts Mutual Life Insurance Company
     1295 State Street, Springfield, Massachusetts 01111-0001



H. New Contract Plan Type                                                       Complete this section for all cases.

       Qualified

           Traditional IRA                                                                 Custodial IRA (Submit form F6935)
           Roth IRA*                                                                       Beneficiary/Inherited IRA
           SEP IRA
     *In order to purchase a RetireEase contract as a Roth IRA you must
     have reached age 59½ or be disabled and such disability will continue
     until you reach age 59½.


       Non-Qualified
         Non-Qualified


                                                                                Complete this section for all cases.
I.     Source of Purchase Payment                                               Check all options that apply.

                                                 Submit form F6628 for Company to Company Transfer
                                                                or Rollover of Assets.



           Personal Savings / Checking Account / Cash                                          Governmental 457 Deferred Compensation
           Traditional IRA                                                                     Non-Qualified Deferred Compensation
           Custodial IRA                                                                       Qualified Employer Plan
           Roth IRA (date established: __ __/ __ __ / __ __ __ __)*                            • 401(k)
           SEP IRA                                                                             • Money Purchase Pension Plan
           SIMPLE IRA (date established: __ __/ __ __ / __ __ __ __)                           • Pension Plan
           Spousal IRA                                                                         • Profit Sharing Plan
           Non-Qualified Contract                                                              • Target Benefit Plan
           CD                                                                                  Trust Funds
           Mutual Fund                                                                         Other                                  .
           TSA
       *In order to purchase a RetireEase contract as a Roth IRA you must
       have already met the 5 year holding period and may only purchase with
       funds from a qualified Roth IRA.


J. MassMutual Inflation ProtectorSM Feature                                     Optional Selection

        The following optional feature may only be selected at the time of
        application and may not be changed once the Contract is issued.             • Not available for Installment Refund Annuity Option.

         Select one:      1%       2%       3%       4%




                                                                               4a                                                   FR1097 (08/12)
                       Thank you for choosing MassMutual for your Annuity needs. We value your business.
K. Annuity Options
                                                                                         Complete this section for all cases.

Select one of the following options:
                                                                                      ∗ Proof of Age is required for any Single Life or Joint Life annuity
      Period Certain Only                   Years,                Months                option including Life with Period Certain. No Contract will be
                        (Minimum 5 years)                                               issued unless satisfactory proof of the date of birth of the
      Single Life* with (select one):                                                   Proposed Annuitant(s) is received with the application.
                     Years Period Certain
                                                                                      • The maximum Issue Age for a “Period Certain Only” Annuity Option
             Cash Refund                                                                is 100.
             Installment Refund
             No Refund                                                                • The maximum Issue Age for a “Single Life” or “Joint Life” Annuity
                                                                                        Option is 90, and the Minimum Issue age is 18.
      Joint Life* with (select one):
                      Years Period Certain
              Cash Refund
              Installment Refund
              No Refund

  If you select the Joint Life annuity option, you must
  also select one of the following:
    No Reduction (Default if no box is checked)
    Annuity Reducing at Death of Either (Joint) Annuitant to:                 *
    (select one)    3/4          2/3          1/2
  Annuity Reducing at Death of (Primary) Annuitant to: *
    (select one)     3/4         2/3         ½

    * Not applicable if Joint Life with Cash Refund is selected


L. Payment Date and Frequency                                                            Complete this section for all cases.

                                                                                      • The payment frequency and first annuity payment date cannot be changed
        Monthly
                                                                                        once the Contract is issued. If the payment date selected is later than the
        Quarterly                                                                       28th of the month, the automatic default will be to the next business day
        Semi-Annual                                                                     after the last day of the month.
        Annual                                                                        • The Annuity Payment Date determines the tax-year reporting of the
                                                                                        payment. Please allow an additional three (3) business days for direct
    First annuity payment date:                  /                 /              .
                                       Month         Day (1-28)        Year             deposit and five (5) days for a mailed check.




                                                                                        4b                                                 FR1097 (08/12)
                  Thank you for choosing MassMutual for your Annuity needs. We value your business.
MassMutual RetireEaseSM (continued)


M. Payment Method                                                                                    Complete this section for all cases.

     Contract Owner                       % or $                                 .
       Check (default)       OR                     Direct Deposit                                   • If Direct Deposit is selected, complete Bank Information on page 4d.

     Joint Contract Owner                      % or $                                    .           • Only one direct deposit request per Tax Payer ID can be processed.
        Check (default)   OR                     Direct Deposit
                                                                                                     • If the Contract Owner and Payee are different, the Contract Owner will
                                                                                                       be tax reported.
     Alternate Payee #1                      % or $                                      .
        Check (default)      OR                 Direct Deposit                                       • If more than 2 alternate payees are requested, write in the appropriate
                                                                                                       information for the additional payees in the Miscellaneous
     Alternate Payee #2                       % or $                                     .             Instructions/Comments section F.
        Check (default)      OR                 Direct Deposit

     Alternate Payee(s) Information
Alternate Payee #1                                                                                   Alternate Payee #2
Name                                                                                 .                Name                                                                          .
                             First, Middle, Last, Suffix                                                                          First, Middle, Last, Suffix


Address                                                                                      .       Address                                                                            .
                                   No., Street, Apartment #                                                                           No., Street, Apartment #


                              ,                                          -                       .                                ,                                         -               .
               City               State                       Zip Code                                              City           State                         Zip Code

Social Security No./Tax ID No.                                               .                       Social Security No./Tax ID No.                                             .




N. Liability of Company                                                                              Please read carefully.

By signing this application you are certifying that you understand the following:

If a No Refund Annuity is purchased and the death of all Annuitants occurs after payments begin, there will be no liability on the part of the
Company to refund the Single Purchase Payment or any part thereof and all liability of the Company will cease.




                                                                                                     4c                                                               FR1097 (08/12)
                      Thank you for choosing MassMutual for your Annuity needs. We value your business.
   Tax Withholding
                                                                                   Complete this section for all cases.
 Payments qualifying as eligible rollover distributions, which you receive from tax-qualified contracts, are subject to mandatory 20% Federal income
 tax withholding. The Internal Revenue Code requires you receive a reasonable time (at least 30 days) to consider making a direct rollover of your
 tax-qualified assets to an eligible retirement plan rather than receiving an eligible rollover distribution subject to mandatory withholding. You may
 elect to waive the right to this required time period.
 Other payments you receive from Massachusetts Mutual Life Insurance Company ("MassMutual") are subject to Federal income tax withholding
 unless you elect not to have withholding apply. Withholding will only apply to the portion of your payment that is already included in your income
 subject to Federal income tax and will be like wage withholding. There will be no withholding on the return of your own nondeductible contributions to
 the contract. Any election you make will remain in effect until you revoke it by returning to us a signed and dated revocation of election. If no withholding
 election is affirmatively made, withholding will be performed based on a filing status of married with three exemptions as required by the Internal
 Revenue Code.
 If you elect not to have withholding apply to your other payments, or if you do not have enough Federal income tax withheld from these payments,
 you may be responsible for the payment of estimated tax and/or be subject to estimated tax penalties. A distribution taken before 59½ may be
 subject to a 10% penalty.
 State income tax withholding may also apply. State income tax withholding requirements vary by state. If required under the laws of the state in
 which you live, state income tax withholding will also apply. For more information on the withholding requirements in your state, please see State
 Income Tax Withholding Disclosure.
 You should consult with a professional tax advisor before you begin receiving payments or before changing your election. Please check the
 appropriate box below to make your withholding election for payments other than eligible rollover distributions:
 A.        I elect to have no income tax withheld from my annuity payments (do not complete B or C).
 B.        I want my federal withholding from each annuity payment to be figured using the default assumption of married claiming three exemptions
           unless another election of allowances and marital status is shown below (you may also designate an additional amount in item C).
           ______ Allowances       Single    Married              Married, but withhold at a higher single rate
 C.        Withhold the following additional amount from each annuity payment (you must complete B) $                             .
                                                                                   Complete this section only if you elect Direct Deposit.
   Bank Information
                                                                                               You MUST include voided check(s).

 I hereby authorize MassMutual to make all periodic payments due to me under this Contract by Electronic Direct Deposit to the bank account
 designated below. I also authorize MassMutual to initiate debits to that bank account for overpayments made to me and the bank named below to
 debit my account and refund any such overpayments to MassMutual. Payments made under this agreement shall fully satisfy MassMutual’s
 obligation to make payments to me.
 I also agree that to cancel this agreement, I must give at least one months written notice to the MassMutual Home Office. Upon my death, my
 executors or administrators shall pay to MassMutual from my estate the amount of any payments collected by the bank, which were not payable
 because they were issued after my death.

                                                                          .                                                                            .
 Owner Signature (If direct deposit has been elected)                                     Joint Owner Signature (If applicable)

                                                                          .                                                                            .
 Bank Account Holder Signature (If different from Owner)                                  Bank Account Holder Signature (If applicable)
Payee/Bank Account Holder Name
                                                                                   Type of Account:            Checking               Savings
Bank Name                                                                          Branch Telephone Number

Bank Address (Street/P.O. Box)                                                     Bank ACH Transit Routing Number (9-digit number)

Bank Address (City, State, Zip)                                                    Bank Account Number (Copy of voided check required)

Payee/Bank Account Holder Name
                                                                                   Type of Account:            Checking               Savings
Bank Name                                                                          Branch Telephone Number

Bank Address (Street/P.O. Box)                                                     Bank ACH Transit Routing Number (9-digit number)

Bank Address (City, State, Zip)                                                    Bank Account Number (Copy of voided check required)


                                                                              4d                                                          FR1097 (08/12)
                      Thank you for choosing MassMutual for your Annuity needs. We value your business.
 Agreements and Signatures
                                                                                   Complete this section for all cases.

By signing below:
       I acknowledge that I understand how this annuity Contract fits within my overall financial needs and plan.
       I agree that: (a) the Company can hold my purchase payment until all requirements are met and the contract applied for is issued; (b) I
         understand that my money will be held in a non-interest bearing cash suspense account, and (c) I understand that if the contract applied for is
         not issued within 30 calendar days from the date the initial payment is received by the Company, my application will be withdrawn and the
         purchase payment will be returned to its original source.
Contract Owner’s Replacement Questions
       Do you have any existing life insurance policies or annuity contracts?                                                          Yes        No
       Are you considering discontinuing making premium payments, replacing, surrendering, forfeiting, assigning to the
         insurer, or otherwise terminating your existing policy or contract?                                                           Yes        No
       Are you considering using funds from your existing policies or contracts to pay premiums due on the new policy or
         contract? (This includes taking withdrawals or loans and using these funds to pay premium(s) on a new policy or               Yes        No
         contract.)
       Required replacement forms and information must be signed and submitted with this Application.
Producer’s Replacement Questions
       Does the Contract Owner have any existing life insurance policies or annuity contracts?                                         Yes        No
       Does the Contract Owner intend to replace, surrender, borrow against, sell or use any portion of an existing life
         insurance policy or annuity contract to finance any portion of the policy being applied for?                                  Yes        No
       Required replacement forms and information must be signed and submitted with this Application.
Fraud Notice:
        CT, GA, NE, TX & VT: Any person who, with 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 be guilty of insurance fraud.
        DC: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
        person. Penalties include imprisonment and / or fines. In addition, an insurer may deny insurance benefits if false information materially
        related to a claim was provided by the applicant.
        KY: Any person who knowingly and with 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.
        LA: 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.
        ME: 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 denial of insurance benefit(s).
        OK: 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.
        WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the
        company. Penalties include imprisonment, fines, and denial of insurance benefits.
        All other states: Any person who, with the intent to defraud or knowing that s/he is facilitating a fraud against an insurer, submits an
        application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

I hereby represent that the information contained in this application is correct and true to the best of my knowledge and belief.
If this is a trust owned contract, the trustee should sign as Contract Owner and include “Trustee” following his/her signature.

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

X                                                                                         X
Signature of Contract Owner                                                               Signature of Joint Contract Owner (required if there is a Joint Contract Owner)


X                                                                                         X
Signature of Soliciting Producer                              Agency/Firm                 Signature of Annuitant (only if different than Contract Owner)
The following information must be completed for us to process this application:
                                                                                          X
                                                                                          Signature of Joint Annuitant (required if there is a Joint Annuitant)
City and State where signed by applicant                     Date Signed




    APPIMM08                                                                      5                                                                 FR1097 (08/12)
                      Thank you for choosing MassMutual for your Annuity needs. We value your business.
 Producer’s Statement
                                                                                  Must be completed by Soliciting Producer for all cases.


 Broker/Dealer’s Firm Name:                                                                                                                                         .

 Broker/Dealer’s Firm Address:                                                                                                                                      .
                                                                (MMLISI Reps Use Agency number)

      Compensation Information
     1.    If your Broker/Dealer is NOT MMLISI, should your commission be paid under the terms of your individual
           fixed selling agreement if applicable?                                                                                                 Yes           N/A

     2.    Please complete the following information:
                                                                                                                                                             % of
                                                 Printed Name                   Agency or Entity #   MassMutual ID #, Social Security #, or Tax ID #
                                                                                                                                                          Commission
1    Soliciting Producer
2         Producer
3         Producer
4         Producer
5         Producer
6         Producer
                                                                                                                                                          Total 100%

     3. Only the Soliciting (Servicing) Producer will receive copies of the Quarterly Statements and other mailings
        related to this contract.
     4. Linking/brokerage number (if applicable):
     5. Team number/identifier (if applicable):

                                              Please select one of the following commission options:
                                                Option A     Option B       Option C
                           RetireEase                  *
                                                * Default Option

      Certification and Signature
      By signing below, I certify that:
      • To the best of my knowledge and belief: (a) The statements in this Producer Statement are true and correct; (b) Each
            question in the Application was asked of the proposed Owner(s) and Annuitant(s) and accurately recorded; and (c) The
            Contract applied for is consistent with the financial needs of the Owner(s) and/or Annuitant(s).
      • To the best of my knowledge, information and belief, I am not aware of any suspicious or unusual activities, including but
            not limited to anti-money laundering (AML) “red flags” as described in my AML training or other materials, arising out of
            or in connection with the sale of this Contract.
      •    I believe this investment is suitable for the Owner’s objectives. I have completed a separate suitability review and
            discussed all the features of the product being purchased with the Owner. If the application was taken for a variable
            annuity, I have provided a prospectus to the Owner.
      •    I am licensed to sell annuity contracts in the state where this Application is written and delivered,
      • I have provided the Owner(s) with a quote, and
      • If this Application was taken for a variable annuity, I certify that I am a Registered Representative.

X                                                                                Telephone # (                  )                                               .
Signature of Soliciting Producer                                Date Signed
                                                                                 Fax Number (                  )                                                .
 Print Name
                                                                                 E-mail                                                                         .
Registered Principal’s ID # (if applicable)




                                                                                                                                                       FR1097 (0812)
                       Thank you for choosing MassMutual for your Annuity needs. We value your business.

				
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