Financial special services request - PrimElite IVSM ... 1 of 6 8265-B (05/17) Fs - B/f Annuities....

of 6 Fs - B/f 8265-B (04/18)

Annuities

Financial special services request - PrimElite IVSM variable annuity Use this form for changing future purchase payment allocations, one-time fund transfers, Dollar Cost Averaging transfers and/or rebalancing transfers.

Things to know before you begin • Please read all instructions carefully and complete the appropriate

section(s) of the form.

You must complete and sign this entire form to prevent a delay in processing your request.

Brighthouse Life Insurance Company • Brighthouse Life Insurance Company of NY

SECTION 1: Contract information AnnuitantFirst name Middle name Last name

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

Contract Owner's phone number (not required) Contract number

of 6 Fs - B/f8265-B (04/18)

SECTION 2: Purchase payment allocation 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 subsequent Purchase Payment Allocation below. However, if you make an additional purchase payment and you have a DCA program in effect, we will allocate your additional payments to the investment portfolios selected under the DCA program, unless you tell us otherwise. If you are selecting a DCA program below, be sure to allocate the portion of your subsequent purchase payment to your choice of source fund (Fixed Account or BlackRock Ultra-Short Term Bond Portfolio) and also complete Section 4 - Dollar Cost Averaging Program. Please note: Allocation selections must be whole percentages and must total 100%. Unless otherwise directed, subsequent purchase payments will also be allocated as shown.

PercentageFixed Account (N/A in NY, OR and WA) %Investment Portfolios American Funds Bond Fund %American Funds Global Growth Fund %

American Funds Global Small Capitalization Fund

%

American Funds Growth-Income Fund %American Funds® Growth Portfolio %BlackRock Bond Income Portfolio %BlackRock High Yield Portfolio %BlackRock Ultra-Short Term Bond Portfolio %Brighthouse/Aberdeen Emerging Markets Equity Portfolio %

Brighthouse/Wellington Core Equity Opportunities Portfolio %Clarion Global Real Estate Portfolio %ClearBridge Variable Aggressive Growth Portfolio

%

ClearBridge Variable Appreciation Portfolio %

ClearBridge Variable Dividend Strategy Portfolio

%

ClearBridge Variable Equity Income Portfolio %ClearBridge Variable Small Cap Growth Portfolio

%

Fidelity VIP Contrafund® Portfolio %Fidelity VIP Mid Cap Portfolio %Franklin Income VIP Fund %

PercentageFranklin Mutual Shares VIP Fund %Franklin Small Cap Value VIP Fund %Harris Oakmark International Portfolio %Invesco Comstock Portfolio %Invesco Small Cap Growth Portfolio %Invesco V.I. Equity and Income Fund %Invesco V.I. International Growth Fund %Loomis Sayles Global Markets Portfolio %MFS® Research International Portfolio %Morgan Stanley Mid Cap Growth Portfolio %Oppenheimer Main Street Small Cap Fund®/VA %

Pioneer Mid Cap Value VCT Portfolio %T. Rowe Price Large Cap Value Portfolio %Templeton Global Bond Securities Fund %Variable Conservative Growth %Variable Growth %Victory Sycamore Mid Cap Value Portfolio %Western Asset Management Strategic Bond Opportunities Portfolio %Western Asset Management U.S. Government Portfolio %Western Asset Variable Global High Yield Bond Portfolio %

Total 100 %

of 6 Fs - B/f8265-B (04/18)

SECTION 3: One-time fund transferI/We authorize a transfer of the following whole percentages or dollar amounts. Twelve 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. Check one:

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

Transfer based on the following percentages (Please note, total percentages in the “To” column must equal 100%).

From ToFixed Account (N/A in NY, OR and WA)

Investment Portfolios American Funds Bond FundAmerican Funds Global Growth Fund American Funds Global Small Capitalization FundAmerican Funds Growth Fund - Class 2 N/AAmerican Funds Growth-Income Fund

American Funds® Growth Portfolio - Class CBlackRock Bond Income PortfolioBlackRock Capital Appreciation Portfolio N/ABlackRock High Yield Portfolio

BlackRock Ultra-Short Term Bond Portfolio - Class E N/A

BlackRock Ultra-Short Term Bond Portfolio - Class B

Brighthouse/Aberdeen Emerging Markets Equity Portfolio

Brighthouse/Wellington Core Equity Opportunities Portfolio

Clarion Global Real Estate PortfolioClearBridge Aggressive Growth PortfolioClearBridge Variable Aggressive Growth Portfolio

ClearBridge Variable Appreciation Portfolio


ClearBridge Variable Small Cap Growth Portfolio

Fidelity VIP Contrafund® Portfolio - Service Class 1

N/A

From ToFidelity VIP Contrafund® Portfolio - Service Class 2

Fidelity VIP Mid Cap Portfolio

Franklin Income VIP Fund

Franklin Mutual Shares VIP Fund

Franklin Small Cap Value VIP FundHarris Oakmark International Portfolio

Invesco Comstock Portfolio

Invesco Small Cap Growth PortfolioInvesco V.I. Equity and Income FundInvesco V.I. International Growth FundJennison Growth Portfolio N/ALoomis Sayles Global Markets PortfolioMFS® Research International PortfolioMorgan Stanley Mid Cap Growth Portfolio Oppenheimer Global Equity Portfolio N/A

Oppenheimer Main Street Small Cap Fund®/VAPioneer Mid Cap Value VCT PortfolioT. Rowe Price Large Cap Value PortfolioTempleton Global Bond Securities Fund

Variable Conservative GrowthVariable Growth

Victory Sycamore Mid Cap Value Portfolio

Western Asset Management Strategic Bond Opportunities Portfolio

Western Asset Management U.S. Government Portfolio

Western Asset Variable Global High Yield Bond Portfolio

Total N/A 100

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SECTION 4: Dollar cost averaging program When checked below, I/We authorize a portion of the Purchase Payment or Account Value to be allocated under the dollar cost averaging program elected below. Only one program may be elected at a time.

Standard Dollar Cost Averaging Program (DCA)The DCA Transfers will be made from: (check one)

Fixed Account (N/A in NY, OR or WA) BlackRock Ultra-Short Term Bond Portfolio

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

per month until the account is depleted

per month for:

12 Months 24 Months 36 Months 48 Months 60 Months MonthsPlease note: Allocation selections must be whole percentages and must total 100%. Unless otherwise directed, subsequent purchase payments will also be allocated as shown.

Destination: (Indicate below, the percentage each destination portfolio is to receive.)Investment Portfolios American Funds Bond Fund %

American Funds Global Growth Fund %


%

American Funds Growth-Income Fund %

American Funds® Growth Portfolio %BlackRock Bond Income Portfolio %BlackRock High Yield Portfolio %BlackRock Ultra-Short Term Bond Portfolio %Brighthouse/Aberdeen Emerging Markets Equity Portfolio %


%



%


%

Fidelity VIP Contrafund® Portfolio %Fidelity VIP Mid Cap Portfolio %Franklin Income VIP Fund %Franklin Mutual Shares VIP Fund %Franklin Small Cap Value VIP Fund %

Harris Oakmark International Portfolio %Invesco Comstock Portfolio %Invesco Small Cap Growth Portfolio %Invesco V.I. Equity and Income Fund %Invesco V.I. International Growth Fund %Loomis Sayles Global Markets Portfolio %MFS® Research International Portfolio %Morgan Stanley Mid Cap Growth Portfolio %Oppenheimer Main Street Small Cap Fund®/VA

%

Pioneer Mid Cap Value VCT Portfolio %T. Rowe Price Large Cap Value Portfolio %Templeton Global Bond Securities Fund %Variable Conservative Growth %Variable Growth %Victory Sycamore Mid Cap Value Portfolio %Western Asset Management Strategic Bond Opportunities Portfolio %

Western Asset Management U.S. Government Portfolio %

Western Asset Variable Global High Yield Bond Portfolio %

Total 100%

of 6 Fs - B/f8265-B (04/18)

SECTION 5: Rebalancing transfers I/We authorize Rebalancing Transfers to be made at the contract anniversary as follows:

Monthly Quarterly Semi-Annual AnnualCheck one:

In the applicable percentages shown in Section 2 - Purchase Payment Allocation.

In the following percentages: (Must be whole percentages with a minimum of 10% to any Portfolio. Applies only to Rebalancing Transfers. Not applicable to Purchase Payment Allocation.)

Please note: If the rebalancing transfer date is the 29th, 30th, or 31st of a month, 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. DCA transfers and Rebalancing transfers are available simultaneously if the DCA source is the Fixed Account. If a DCA program is elected, rebalancing shall be based on the transfer allocations selected for such program. You should understand that unless this program is terminated, subsequent purchase payment allocations and transfers will be rebalanced under this program to the percentages selected. Termination or modification of this program must be by written notice to us. Investment Portfolios American Funds Bond Fund %American Funds Global Growth Fund %


%

American Funds Growth-Income Fund %American Funds® Growth Portfolio %BlackRock Bond Income Portfolio %BlackRock High Yield Portfolio %BlackRock Ultra-Short Term Bond Portfolio %Brighthouse/Aberdeen Emerging Markets Equity Portfolio

%


%



%


%

Fidelity VIP Contrafund® Portfolio %Fidelity VIP Mid Cap Portfolio %Franklin Income VIP Fund %Franklin Mutual Shares VIP Fund %Franklin Small Cap Value VIP Fund %

Harris Oakmark International Portfolio %Invesco Comstock Portfolio %Invesco Small Cap Growth Portfolio %Invesco V.I. Equity and Income Fund %Invesco V.I. International Growth Fund %Loomis Sayles Global Markets Portfolio %MFS® Research International Portfolio %Morgan Stanley Mid Cap Growth Portfolio %Oppenheimer Main Street Small Cap Fund®/VA

%

Pioneer Mid Cap Value VCT Portfolio %T. Rowe Price Large Cap Value Portfolio %Templeton Global Bond Securities Fund %Variable Conservative Growth %Variable Growth %Victory Sycamore Mid Cap Value Portfolio %Western Asset Management Strategic Bond Opportunities Portfolio %Western Asset Management U.S. Government Portfolio %Western Asset Variable Global High Yield Bond Portfolio %

Total 100%

Sign on the following page

of 6 Fs - B/f8265-B (04/18)

SECTION 6: SignaturesOwner’s signature and title, if applicable* Date (mm/dd/yyyy)

Joint Owner’s signature and title, if applicable* Date (mm/dd/yyyy)

Contract number

*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.

SECTION 7: How to submit this formMail: Brighthouse Financial PO Box 10426 Des Moines, IA 50306-0426

Overnight mail only: Brighthouse Financial 4700 Westown Parkway, Suite 100 West Des Moines, IA 50266

Fax: 877-549-5850

We're here to help Please don't hesitate to contact us if you have any questions. You can reach us at 1-888-556-5412, Monday through Friday, 8:00 a.m. to 11:00 p.m. Eastern time.

PrimElite IVSM is a service mark of Primerica, Inc. Brighthouse Life Insurance Company and Brighthouse Life Insurance Company of NY use this mark pursuant to a license agreement. Securities offered by PFS Investments Inc.

Financial special services request - PrimElite IVSM ... 1 of 6 8265-B (05/17) Fs - B/f Annuities....

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