Financial special services request – Class/Series VA/C/L ... · Financial special services...

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Annuities

Financial special services request – Class/Series VA/C/L/XC/XTRA/XTRA 6 Use this form for changing future Purchase Payments and/or Enhanced Dollar Cost Averaging (EDCA) allocations, one time fund transfers, Dollar Cost Averaging (DCA) transfers and/or rebalancing transfers.

Brighthouse Life Insurance Company Brighthouse Life Insurance Company of NY ("Brighthouse Financial")

Things to know before you begin Important: This form is to be used for Class/Series VA/C/L/XC/XTRA/XTRA 6 variable annuity contracts that contain one of the following: • Pre-2008 version of the Guaranteed Minimum Income Benefit Plus (GMIB Plus) or Lifetime Withdrawal

Guarantee (LWG) riders that have investment restrictions • Guaranteed Minimum Accumulation Benefit (GMAB) rider with investment restrictions • Living benefit riders without investment restrictions: Guaranteed Minimum Income Benefit (GMIB) and

Guaranteed Withdrawal Benefit (GWB) • No Living Benefit Riders • Contracts with the following riders must use Financial Special Services Request Form 7175-B: Guaranteed

Minimum Income Benefit Plus (GMIB Plus (2008), (III), (IV)), Lifetime Withdrawal Guarantee (LWG (2008)), or the Enhanced Death Benefit (EDB I, EDB II, EDB III) riders

• Contracts with the GMIB Max and/or EDB Max, or GWB v1 riders must use Financial Special Services Request Form 7175-MAX-B.

• Contracts with FlexChoice should use form FLEX-FSSR-B. • For contracts with FlexChoice Access Level or FlexChoice Access Expedite, use Financial Special Services

Request Form FLEXACC-FSSR-B.

SECTION 1: Contract informationContract number

Annuitant - First name Middle name Last name

Contract Owner - First name (if different than Annuitant) Middle name Last name

Contract Owner - Phone number (not required)

Joint Owner - First name (if applicable) Middle name Last name

Joint Owner - Phone number (not required)

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* If GMIB Plus or LWG is elected, you may only choose portfolios indicated with an asterisk (*) ‡ If GMAB is elected, you may only allocate 100% into one and only one of the portfolios indicated with a (‡)

PercentageBrighthouse/Eaton Vance Floating Rate Portfolio %Brighthouse/Franklin Low Duration Total Return Portfolio %Brighthouse/Wellington Core Equity Opportunities Portfolio %

Brighthouse Small Cap Value Portfolio %Clarion Global Real Estate Portfolio %ClearBridge Aggressive Growth Portfolio %Fidelity Institutional Asset Management® Government Income Portfolio* %

Frontier Mid Cap Growth Portfolio %Harris Oakmark International Portfolio %Invesco Comstock Portfolio %Invesco Small Cap Growth Portfolio %Jennison Growth Portfolio %JPMorgan Core Bond Portfolio %Loomis Sayles Global Markets Portfolio %MetLife Aggregate Bond Index Portfolio* %MetLife Mid Cap Stock Index Portfolio %MetLife MSCI EAFE® Index Portfolio %MetLife Russell 2000® Index Portfolio %MetLife Stock Index Portfolio %MFS® Research International Portfolio %MFS® Value Portfolio %Neuberger Berman Genesis Portfolio %PIMCO Inflation Protected Bond Portfolio %PIMCO Total Return Portfolio %T. Rowe Price Large Cap Growth Portfolio %T. Rowe Price Large Cap Value Portfolio %T. Rowe Price Mid Cap Growth Portfolio %Victory Sycamore Mid Cap Value Portfolio %Wells Capital Management Mid Cap Value Portfolio %Western Asset Management Strategic Bond Opportunities Portfolio %

Western Asset Management U.S. Government Portfolio %

Total of both columns must equal 100% 100%

Investment Portfolios PercentageEnhanced Dollar Cost Averaging (EDCA)*‡ (Not available in OR or for Class/Series C) %

Fixed Account* (Not available in NY, OR, WA, Class/Series C, or Class/Series L Three Year) %

Asset Allocation Portfolios American Funds Balanced Allocation Portfolio* %American Funds Growth Allocation Portfolio* %American Funds Moderate Allocation Portfolio* %Brighthouse Asset Allocation 20 Portfolio* %Brighthouse Asset Allocation 40 Portfolio*‡ %Brighthouse Asset Allocation 60 Portfolio*‡ %Brighthouse Asset Allocation 80 Portfolio*‡ %Brighthouse Asset Allocation 100 Portfolio‡ %SSGA Growth and Income ETF Portfolio * %SSGA Growth ETF Portfolio * %Risk Managed Global Multi-Asset PortfoliosAB Global Dynamic Allocation Portfolio* %AQR Global Risk Balanced Portfolio* %BlackRock Global Tactical Strategies Portfolio* %Brighthouse Balanced Plus Portfolio* %Invesco Balanced-Risk Allocation Portfolio* %JPMorgan Global Active Allocation Portfolio* %MetLife Multi-Index Targeted Risk Portfolio* %PanAgora Global Diversified Risk Portfolio %Schroders Global Multi-Asset Portfolio* %Additional Variable Investment Options American Funds Growth Portfolio %Baillie Gifford International Stock Portfolio %BlackRock High Yield Portfolio %BlackRock Ultra-Short Term Bond Portfolio* %Brighthouse/Aberdeen Emerging Markets Equity Portfolio %

Brighthouse/Artisan Mid Cap Value Portfolio %Brighthouse/Dimensional International Small Company Portfolio %

Complete below for your Future Purchase Payment Allocation. Indicate the whole percentages each portfolio should receive. If you make additional Purchase Payments, we will allocate them in the same way as your Contract's first Purchase Payment unless you tell us otherwise by indicating a future Purchase Payment allocation in this section. However, if you make an additional Purchase Payment and you have an EDCA or DCA program in effect, we will allocate your additional payments to the investment portfolios selected under the EDCA or DCA program, unless you tell us otherwise. If you are selecting a DCA program complete Section 4 and be sure to allocate the portion of your future Purchase Payment to your choice of source fund (EDCA Account, Fixed Account or BlackRock Ultra-Short Term Bond Portfolio). Note: Please review the footnotes at the bottom of this section prior to making your fund selections.

SECTION 2: Purchase Payment allocation

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*If GMIB Plus or LWG is elected, you may only choose portfolios indicated with an asterisk (*) ‡ If GMAB is elected, you may only allocate 100% into one and only one of the portfolios indicated with a (‡)

From ToInvestment Portfolios Fixed Income* (Not available in NY, OR, WA, Class/Series C, or Class/Series L Three Year) % %

Asset Allocation PortfoliosAmerican Funds Balanced Allocation Portfolio* % %

American Funds Growth Allocation Portfolio* % %American Funds Moderate Allocation Portfolio* % %

Brighthouse Asset Allocation 20 Portfolio* % %Brighthouse Asset Allocation 40 Portfolio*‡ % %Brighthouse Asset Allocation 60 Portfolio*‡ % %Brighthouse Asset Allocation 80 Portfolio* % %Brighthouse Asset Allocation 100 Portfolio % %SSGA Growth and Income ETF Portfolio* % %SSGA Growth ETF Portfolio* % %Risk Managed Global Multi-Asset PortfoliosAB Global Dynamic Allocation Portfolio* % %AQR Global Risk Balanced Portfolio* % %BlackRock Global Tactical Strategies Portfolio* % %

Brighthouse Balanced Plus Portfolio* % %Invesco Balanced-Risk Allocation Portfolio* % %JPMorgan Global Active Allocation Portfolio* % %MetLife Multi-Index Targeted Risk Portfolio* % %PanAgora Global Diversified Risk Portfolio % %Schroders Global Multi-Asset Portfolio* % %Additional Variable Investment Options American Funds Growth Portfolio % %Baillie Gifford International Stock Portfolio Portfolio % %

BlackRock High Yield Portfolio % %BlackRock Ultra-Short Term Bond Portfolio* % %Brighthouse/Aberdeen Emerging Markets Equity Portfolio % %

Brighthouse/Artisan Mid Cap Value Portfolio % %Brighthouse/Dimensional International Small Company Portfolio

% %

Brighthouse/Eaton Vance Floating Rate Portfolio % %

From ToBrighthouse/Franklin Low Duration Total Return Portfolio % %

Brighthouse/Wellington Core Equity Opportunities Portfolio % %

Brighthouse Small Cap Value Portfolio % %Clarion Global Real Estate Portfolio % %ClearBridge Aggressive Growth Portfolio % %Fidelity Institutional Asset Management® Government Income Portfolio* % %

Frontier Mid Cap Growth Portfolio % %Harris Oakmark International Portfolio % %Invesco Comstock Portfolio % %Invesco Small Cap Growth Portfolio % %Jennison Growth Portfolio % %JPMorgan Core Bond Portfolio % %Loomis Sayles Global Markets Portfolio % %MetLife Aggregate Bond Index Portfolio* % %MetLife Mid Cap Stock Index Portfolio % %MetLife MSCI® EAFE Index Portfolio % %MetLife Russell® 2000 Index PortfolioMetLife Stock Index Portfolio % %MFS® Research International Portfolio % %MFS® Value Portfolio % %Neuberger Berman Genesis Portfolio % %PIMCO Inflation Protected Bond Portfolio % %PIMCO Total Return Portfolio % %T. Rowe Price Large Cap Growth Portfolio % %

T. Rowe Price Large Cap Value Portfolio % %T. Rowe Price Mid Cap Growth Portfolio % %Victory Sycamore Mid Cap Value Portfolio % %Wells Capital Management Mid Cap Value Portfolio % %

Western Asset Management Strategic Bond Opportunities Portfolio % %

Western Asset Management U.S. Government Portfolio % %

Total “To” Column must equal 100% N/A 100%

SECTION 3: One-time fund transferTwelve transfers per year are allowed without charge. A minimum of $500 or the entire interest in an account or portfolio, if less, must be transferred.

Transfer based on the following percentages (Please note, total percentages in the “To” column must equal 100%). Transfer based on the following dollar amounts (Please note, total “From” amounts and total “To” allocations must be equal).

Note: Please review the footnotes at the bottom of this section prior to making your fund selections.

Programs: Select one of the following programs: EDCA (Not available for Class/Series C Contracts; check for state availability) The designated portion of the Purchase Payment will be allocated to the EDCA Account and periodic transfers will be made to the investment portfolios in the proportions selected in the table below. (Please note: The Fixed Account is not available as a target allocation for the EDCA program.)

You may make future Purchase Payments while you have an active EDCA Account; however, no portion of this Purchase Payment will be allocated to the EDCA Account without your express direction.

Transfer Period (check one): The terms of this program will be governed by the Enhanced Dollar Cost Averaging Rider or the Three Month Market Entry Rider issued with your contract. Future Purchase Payments may be allocated to your EDCA account. However, such allocation will have the effect of increasing the monthly transfer amount, thereby accelerating the time period over which transfers are made. DCA (Important: The Standard DCA Program is not available if your contract contains the Guaranteed Minimum Income Benefit Plus (GMIB Plus) Rider.)

The DCA Transfers will be made from: (check one)

Periodic transfers from the above account will be made to the investment portfolios in the proportions selected below.Transfer Period and Amount:

Note: Please review the footnotes at the bottom of this section prior to making your fund selections.

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SECTION 4: Dollar cost averaging programs

3 Month Market Entry 6 months 12 months

Fixed Account (Not available for Class/Series C Contracts; check for state availability)BlackRock Ultra-Short Term Bond Portfolio

per month until the account is depleted$ per month for:$

12 Months 24 Months 36 Months 48 Months 60 Months Months

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Asset Allocation Portfolio %American Funds Balanced Allocation Portfolio* %American Funds Growth Allocation Portfolio* %American Funds Moderate Allocation Portfolio* %Brighthouse Asset Allocation 20 Portfolio* %Brighthouse Asset Allocation 40 Portfolio*‡ %Brighthouse Asset Allocation 60 Portfolio*‡ %Brighthouse Asset Allocation 80 Portfolio*‡ %Brighthouse Asset Allocation 100 Portfolio‡ %SSGA Growth and Income ETF Portfolio* %SSGA Growth ETF Portfolio* %Risk Managed Global Multi-Asset PortfoliosAB Global Dynamic Allocation Portfolio* %AQR Global Risk Balanced Portfolio* %BlackRock Global Tactical Strategies Portfolio* %Brighthouse Balanced Plus Portfolio* %Invesco Balanced-Risk Allocation Portfolio* %JPMorgan Global Active Allocation Portfolio* %MetLife Multi-Index Targeted Risk Portfolio* %PanAgora Global Diversified Risk Portfolio %Schroders Global Multi-Asset Portfolio* %Additional Variable Investment OptionsAmerican Funds Growth Portfolio %Baillie Gifford International Stock Portfolio %BlackRock High Yield Portfolio %BlackRock Ultra-Short Term Bond Portfolio* %Brighthouse/Aberdeen Emerging Markets Equity Portfolio %


Brighthouse/Eaton Vance Floating Rate Portfolio %Brighthouse/Franklin Low Duration Total Return Portfolio %

Brighthouse/Wellington Core Equity Opportunities Portfolio %




Total must equal 100% 100%

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SECTION 5: Rebalancing transfersNote: The Rebalancing Program is only available if MORE THAN ONE portfolio is elected.

Indicate Frequency:

If the rebalancing transfer date is the 29th, 30th, or 31st, transfers will occur on the first day of the next month. If the transfer date falls on a weekend or holiday, the transfer will occur on the next business day. If an EDCA or DCA program is elected, rebalancing shall be based on the transfer allocations selected for such program. You should understand that, unless the program is terminated, subsequent Purchase Payment allocations and transfers will be rebalanced under this program to the percentages selected. Please indicate your Rebalancing allocation by writing in the desired percentage. Note: Please review the footnotes at the bottom of this section prior to making your fund selections.

Monthly Quarterly Semi-Annually Annually

Asset Allocation Portfolio %American Funds Balanced Allocation Portfolio* %American Funds Growth Allocation Portfolio* %American Funds Moderate Allocation Portfolio* %Brighthouse Asset Allocation 20 Portfolio* %Brighthouse Asset Allocation 40 Portfolio*‡ %Brighthouse Asset Allocation 60 Portfolio*‡ %Brighthouse Asset Allocation 80 Portfolio*‡ %Brighthouse Asset Allocation 100 Portfolio‡ %SSGA Growth and Income ETF Portfolio* %SSGA Growth ETF Portfolio* %Risk Managed Global Multi-Asset PortfoliosAB Global Dynamic Allocation Portfolio* %AQR Global Risk Balanced Portfolio* %BlackRock Global Tactical Strategies Portfolio* %Brighthouse Balanced Plus Portfolio* %Invesco Balanced-Risk Allocation Portfolio* %JPMorgan Global Active Allocation Portfolio* %MetLife Multi-Index Targeted Risk Portfolio* %PanAgora Global Diversified Risk Portfolio %Schroders Global Multi-Asset Portfolio* %Additional Variable Investment OptionsAmerican Funds Growth Portfolio %Baillie Gifford International Stock Portfolio %BlackRock High Yield Portfolio %BlackRock Ultra-Short Term Bond Portfolio* %Brighthouse/Aberdeen Emerging Markets Equity Portfolio %


Brighthouse/Eaton Vance Floating Rate Portfolio %Brighthouse/Franklin Low Duration Total Return Portfolio %

Brighthouse/Wellington Core Equity Opportunities Portfolio %




Total must equal 100% 100%

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SECTION 7: Please submit this entire form by mail or faxRegular mail: Brighthouse Financial PO Box 10366 Des Moines, IA 50306-0366

Overnight mail only: Brighthouse Financial 4700 Westown Parkway, Suite 200 West Des Moines, IA 50266

Fax: 877-547-9666

We’re here to help Please don’t hesitate to contact us if you have any questions. You can reach us at (800)-343-8496.

SECTION 6: Required signatures

Signature of Owner and title, if applicable* Date (mm/dd/yyyy)

Signature of Joint Owner and title, if applicable* Date (mm/dd/yyyy)

*If you are signing on behalf of another individual or entity, please indicate your title or position (e.g., Trustee, Guardian, Conservator, Executor, etc.) following your signature on the line above.

Contract number

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