EX-99.5A 3 file004.txt FORM OF ENROLLMENT FORM/APPLICATION equitable ACCUMULATOR SELECT II(SM) combination variable and fixed deferred annuity Enrollment Form under Group Annuity Contract No. AC6725 (Non-Qualified), No. AC6727 (Qualified) and Application for Individual Contract MAILING INSTRUCTIONS: EXPRESS MAIL: Equitable Accumulator Select c/o Bank One, N.A. 300 Harmon Meadow Boulevard, 3rd Floor Attn: Box 13014, Secaucus, NJ 07094 REGULAR MAIL: Equitable Accumulator Select P.O. Box 13014, Newark, NJ 07188-0014 [EQUITABLE LOGO] EDI FOR ASSISTANCE CALL 888-517-9900 1. TYPE OF CONTRACT [ ] Non-Qualified (NQ) [ ] Rollover IRA [ ] Roth Conversion IRA [ ] Qualified Plan - Defined Contribution (DC) [ ] Qualified Plan - Defined Benefit (DB) [ ] ERISA Tax-Sheltered Annuity (Rollover TSA) [ ] Non-ERISA Tax-Sheltered Annuity (Rollover TSA) All of the above are subject to state availability. 2. OWNER PLEASE PRINT [ ] Individual [ ] Qualified Plan Trustee - DC [ ] Trustee (for an Individual) [ ] Qualified Plan Trustee - DB [ ] UGMA/UTMA* [ ] Custodian (IRA) [ ] Male [ ] Female _______________________________________________________________________________ Name (First, Middle, Last) _______________________________________________________________________________ Address (Street) _______________________________________________________________________________ City State ZIP Code _______________________________________________________________________________ Home Phone Office Phone _______________________________________________________________________________ Social Security No./TIN Date of Birth (M/D/Y) *As a Custodian under the __________ (state) Uniform Gifts to Minors Act (UGMA) or Uniform Transfer to Minors Act (UTMA). See instructions for additional information. 3. JOINT OWNER PLEASE PRINT OPTIONAL. (NQ certificates/contracts only) [ ] Male [ ] Female |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Address (Street) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State ZIP Code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Home Phone Office Phone |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Social Security No. Date of Birth (M/D/Y) 4. SUCCESSOR OWNER PLEASE PRINT OPTIONAL. (NQ certificates/contracts only) Available only if owner and annuitant are different persons. [ ] Male [ ] Female |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Address (Street) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State ZIP Code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Social Security No. Date of Birth (M/D/Y) 5. ANNUITANT PLEASE PRINT If other than owner. [ ] Male [ ] Female |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Address (Street) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State ZIP Code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Social Security No./TIN Date of Birth (M/D/Y) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Relationship to Owner 6. BENEFICIARY(IES) PLEASE PRINT If more than one - indicate %. Total must equal 100%. If additional space is needed, please use Section 15. PRIMARY |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Relationship to Annuitant % |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Relationship to Annuitant % CONTINGENT |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Relationship to Annuitant % |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name (First, Middle, Last) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Relationship to Annuitant % Accum App 02 e3298 The Equitable Life Assurance Society of the United States 7. INITIAL CONTRIBUTION REFER TO INSTRUCTIONS FOR MINIMUM AMOUNTS Specify Amount $__________________ 8. METHOD OF PAYMENT PLEASE REFER TO INSTRUCTIONS BEFORE COMPLETING NON-QUALIFIED: [ ] Check payable to Equitable Life [ ] Wire [ ] 1035 Exchange QUALIFIED PLAN: [ ] Check payable to Equitable Life [ ] Wire ROLLOVER IRA: [ ] Rollover from traditional IRA [ ] Direct rollover from qualified plan or TSA [ ] Direct transfer from other traditional IRA ROTH CONVERSION IRA: [ ] Conversion rollover from traditional IRA [ ] Direct transfer from other Roth IRA [ ] Rollover from Roth IRA ROLLOVER TSA: [ ] Direct 90-24 transfer from another carrier [ ] Rollover by check [ ] Direct rollover from other carrier 9. GUARANTEED BENEFIT ELECTION A. CHOOSE ONE OPTION ONLY. [ ] baseBUILDER(R) which includes Guaranteed Minimum Death Benefit- 5% roll up to age 80 [ ] baseBUILDER(R) which includes Guaranteed Minimum Death Benefit- annual ratchet to age 80 [ ] Guaranteed Minimum Death Benefit only-5% roll up to age 80 [ ] Guaranteed Minimum Death Benefit only-annual ratchet to age 80 * B. I WISH TO ELECT THE OPTIONAL PROTECTION PLUS DEATH BENEFIT RIDER. [ ] Yes [ ] No See instructions for additional information. *SUBJECT TO STATE AVAILABILITY. 10. PRINCIPAL ASSURANCE A. Under Principal Assurance, an amount is allocated to a fixed maturity option so that its maturity value will equal your initial contribution in the year you select below. [ ] 2008 [ ] 2009 [ ] 2010 [ ] 2011 B. The remaining portion of your initial contribution will be allocated to "(2) Variable Investment Options" as you indicate in Section 11 (complete variable investment options section only). The total must equal 100%. 11. ALLOCATION AMONG INVESTMENT OPTIONS CHOOSE A OR B. ALLOCATION AMOUNTS MUST BE IN WHOLE PERCENTAGES. PLEASE REFER TO ENROLLMENT FORM/APPLICATION INSTRUCTIONS BEFORE COMPLETING. A. [ ] SELF-DIRECTED ALLOCATION Allocate initial contribution between "(1) Fixed Maturity Options" and "(2) Variable Investment Options." The total of (1) and (2) must equal 100%. B. [ ] Principal Assurance: if elected, you MUST complete Section 10. IMMEDIATE ALLOCATION TO INVESTMENT (1) FIXED MATURITY OPTIONS OPTIONS ------------------------------------------------------------------------------- (502) February 15, 2002..................................... ________ % (503) February 15, 2003..................................... ________ % (504) February 15, 2004..................................... ________ % (505) February 15, 2005..................................... ________ % (506) February 15, 2006..................................... ________ % (507) February 15, 2007..................................... ________ % (508) February 15, 2008..................................... ________ % (509) February 15, 2009..................................... ________ % (510) February 15, 2010..................................... ________ % (511) February 15, 2011..................................... ________ % (2) VARIABLE INVESTMENT OPTIONS (096) EQ/Aggressive Stock................................... ________ % (094) EQ/Alliance Common Stock.............................. ________ % (092) EQ/Alliance High Yield................................ ________ % (097) EQ/Alliance Money Market.............................. ________ % (645) EQ/Alliance Premier Growth............................ ________ % (093) EQ/Alliance Small Cap Growth.......................... ________ % (780) EQ/Alliance Technology................................ ________ % (291) EQ/Bernstein Diversified Value........................ ________ % (646) EQ/Capital Guardian International..................... ________ % (647) EQ/Capital Guardian Research.......................... ________ % (648) EQ/Capital Guardian U.S. Equity....................... ________ % (824) EQ/Equity 500 Index................................... ________ % (811) EQ/FI Mid Cap......................................... ________ % (810) EQ/FI Small/Mid Cap Value............................. ________ % (296) EQ/International Equity Index......................... ________ % (812) EQ/Janus Large Cap Growth............................. ________ % (293) EQ/J.P. Morgan Core Bond.............................. ________ % (292) EQ/Lazard Small Cap Value............................. ________ % (287) EQ/MFS Emerging Growth Companies...................... ________ % (299) EQ/MFS Investors Trust................................ ________ % (286) EQ/MFS Research....................................... ________ % (290) EQ/Morgan Stanley Emerging Markets Equity............. ________ % (281) EQ/Putnam Growth & Income Value....................... ________ % (285) EQ/Putnam International Equity........................ ________ % (282) EQ/Putnam Investors Growth............................ ________ % (295) EQ/Small Company Index................................ ________ % TOTAL 100% TOTAL MUST EQUAL 100%. Accum App 02 Accumulator Select II page 2 12. SYSTEMATIC WITHDRAWALS OPTIONAL. (NQ and IRA certificates/contracts) For IRA certificates/contracts, available only if you are age 59 1/2 to 70 1/2. Other withdrawal options are available for IRA and Rollover TSA certificates/contracts. FREQUENCY: [ ] Monthly [ ] Quarterly [ ] Annually (Max 1.2% of (Max 3.6% of (Max 15% of Account Value) Account Value) Account Value) START DATE: ______________ (Month, Day) AMOUNT OF WITHDRAWAL: $_________or_________% (Minimum $250.00) WITHHOLDING ELECTION INFORMATION (Please read application instructions.) [ ] A. I do not want to have Federal income tax withheld. (U.S. residence address and Social Security No./TIN required) [ ] B. I want to have Federal income tax withheld from each payment. 13. GENERAL DOLLAR COST AVERAGING PLEASE PRINT OPTIONAL. You must have a minimum account value of $5,000 in the EQ/Alliance Money Market option. A. TRANSFER AMOUNT (minimum of $250) $______ or ______% [ ] Monthly [ ] Quarterly [ ] Annually B. VARIABLE INVESTMENT OPTIONS ___________________________ $______ or ______% ___________________________ $______ or ______% ___________________________ $______ or ______% ___________________________ $______ or ______% ___________________________ $______ or ______% ___________________________ $______ or ______% Total must equal transfer amount in A. above or 100%. If additional space is needed, please use Section 15. 14. AUTOMATIC INVESTMENT PROGRAM PLEASE PRINT OPTIONAL. (NQ certificates/contracts only.) Attach a VOID check (not a deposit slip) and complete the following information. See instructions for additional information. A. Amount to be allocated to the investment options (as indicated in section 11) $_______________ B. Day of the month: _____________ (no later than the 28th) C. The amount indicated above will be deducted from the following bank/financial institution account (check one) [ ] Bank Checking [ ] Bank Money Market [ ] Credit Union Checking |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Account Name Account Number |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Name of Bank/Financial Institution |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Bank/Financial Institution Address (Street) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State ZIP Code 15. SPECIAL INSTRUCTIONS PLEASE PRINT Attach a separate sheet if additional space is needed. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 16. FUND REBALANCING OPTIONAL. This option is not available if you have elected the general dollar cost averaging program. Your account value in the variable investment options will be readjusted quarterly, semi-annually, or annually on a contract year basis according to the percentages indicated in Section 11 of this enrollment form/application. Rebalancing will be on the same day of the month as the contract date. SELECT REBALANCING FREQUENCY: (Choose one) [ ] Quarterly [ ] Semi Annually [ ] Annually See instructions for additional information. 17. BROKER TRANSFER AUTHORIZATION OPTIONAL. "I designate ________________to act as my agent in giving transfer instructions by telephone or electronically, and I authorize Equitable Life to act on such instructions. I understand that Equitable Life (i) may rely in good faith on the stated identity of a person placing such instructions, and (ii) will have no liability for any claim, loss, liability or expense that may arise in connection with such instructions. Equitable Life will continue to act upon this authorization until such time as it receives my written notification of a change at its processing office. Equitable Life may (i) change or terminate telephone or electronic transfer procedures at any time without prior notice, and (ii) block telephone or electronic transfers that it determines are being used for market timing activities." 18. SUITABILITY PLEASE PRINT A. Did you receive the Equitable Accumulator Select II prospectus? [ ] YES [ ] NO Date of prospectus _________________________________________ Date of any supplement(s) to prospectus ___________________________ In the case of IRAs, Qualified Plans and TSAs that provide tax deferral under the Internal Revenue Code, by signing this enrollment form/application you acknowledge that you are buying the certificate/contract for its features and benefits other than tax deferral, as the tax deferral feature of the certificate/contract does not provide additional benefits. B. Do you believe this purchase transaction is in accordance with your investment objectives? [ ] YES [ ] NO C. 1. Do you have any other existing life insurance or annuities? [ ] YES [ ] NO 2. Have you purchased another Equitable annuity contract in the last year? [ ] YES [ ] NO If YES, provide name of product _____________________________ and contract number _____________________________. D. Will any existing life insurance or annuity be (or has it been) surrendered, withdrawn from, loaned against, changed or otherwise reduced in value, or replaced in connection with this transaction assuming the certificate/contract applied for will be issued? [ ] YES [ ] NO If YES, complete the following: _______________________________________________________________________________ Year Issued Type of Plan _______________________________________________________________________________ Company Certificate/Contract Number E. Are you applying for this certificate/contract in a state other than your state of residence? [ ] YES [ ] NO If YES, please provide reason: _______________________________________________________________________________ _______________________________________________________________________________ Accum App 02 Accumulator Select II page 3 19. AGREEMENT All information and statements furnished in this enrollment form/application are true and complete to the best of my knowledge and belief. I understand and acknowledge that no registered representative has the authority to make or modify any certificate/contract on behalf of Equitable Life, or to waive or alter any of Equitable Life's rights and regulations. I understand that the account value attributable to allocations to the variable investment options and variable annuity benefit payments, if a variable settlement option has been elected, may increase or decrease and are not guaranteed as to dollar amount. I understand that my market adjusted amount may increase or decrease in accordance with a market value adjustment until the expiration date. IF I HAVE ELECTED THE baseBUILDER, I UNDERSTAND THAT (1) THE INTEREST RATE USED FOR baseBUILDER DOES NOT REPRESENT A GUARANTEE OF MY ACCOUNT VALUE OR CASH VALUE, AND (2) IF I SUBSEQUENTLY EXERCISE THE baseBUILDER GUARANTEED MINIMUM INCOME BENEFIT, IT MUST BE IN THE FORM OF A LIFETIME INCOME. Equitable Life may accept amendments to this enrollment form/application provided by me or under my authority. I understand that any change in benefits applied for or age at issue must be agreed to in writing on an amendment. ARKANSAS/KENTUCKY/NEW MEXICO: Any person who knowingly and with intent to defraud any insurance company or other person files an enrollment form/application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a contract owner or claimant for the purpose of defrauding or attempting to defraud the contract owner or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FLORIDA: Any person who knowingly and with intent to injure, defraud or deceive an insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Equitable Life is a subsidiary of AXA Financial, Inc. AXA is the majority shareholder of AXA Financial, Inc. Neither AXA Financial, Inc. nor AXA has any responsibility for the insurance obligations of Equitable Life. DISTRICT OF COLUMBIA/LOUISIANA/MAINE: 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 a denial of insurance benefits. NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an enrollment form/application or files a claim containing a false or deceptive statement is guilty of insurance fraud. ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company files an enrollment form/application or statement of claim containing any materially false, misleading or incomplete information is guilty of a crime which may be punishable under state or Federal law. X______________________________________________________________________________ Proposed Annuitant's Signature Signed at: City, State Date X______________________________________________________________________________ Proposed Owner's Signature Signed at: City, State Date (if other than annuitant) X______________________________________________________________________________ Proposed Joint Owner's Signature Signed at: City, State Date (if other than annuitant) REGISTERED REPRESENTATIVE SECTION ------------------------------------------------------------------------------- DO YOU HAVE REASON TO BELIEVE THAT ANY EXISTING LIFE INSURANCE OR ANNUITY HAS BEEN OR WILL BE SURRENDERED, WITHDRAWN FROM, LOANED AGAINST, CHANGED OR OTHERWISE REDUCED IN VALUE, OR REPLACED IN CONNECTION WITH THIS TRANSACTION, ASSUMING THE CERTIFICATE/CONTRACT APPLIED FOR WILL BE ISSUED ON THE LIFE OF THE ANNUITANT? [ ] YES [ ] NO ------------------------------------------------------------------------------- _______________________________________________________________________________ Registered Print Name & No. Rep Phone No Representative Signature of Registered Representative _______________________________________________________________________________ Broker-Dealer/Branch Client Account No. Registered Representative Soc. Sec. No./TIN Florida License ID# _____________________ E-Mail Address:_____________________ ------------------------------------------------------------------------------- FOR REGISTERED REPRESENTATIVE USE ONLY. Contact your home office for program information. [ ] Option I [ ] Option II Accum App 02 Accumulator Select II page 4