Home Office: 1290 Avenue of the Americas, New York, NY 10104
Cat. No. 162303
X04489_National Series ADV
Equitable Advisors, LLC Page 1 of 10
1. Contract Series and Type
A. Contract Series:
 Series ADV ($25,000 minimum contribution)
B. Contract Type:
 Non-Qualified
C. Total Initial Contribution(s): $ (Estimated Value Required In Case of Transfer or Exchange)
Specify Method(s) of Payment:
Check or Wire (make check payable to: Equitable)
1035 Exchange (NQ)
CD or Mutual Fund Proceeds (NQ)
PLEASE PRINT
REQUIRED
REQUIRED
REQUIRED
2. Account Registration
Please check one
Individual UGMA/UTMA (Child’s SSN )
The Owner types below require additional form(s). See the New Business Form Booklet for more information.
Trust Other Non-Natural Owner
A. Owner
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Owner Name
(First) (Middle Initial) (Last)
Owner Taxpayer Identification Number (Check one) SSN EIN ITIN
U.S. Primary Residential Address only — No P.O. Box City State Zip Code
If your Mailing Address is different from the Primary Residential Address above, please provide your Mailing Address in Section 11.
Fee Based Client Account Number at Your Broker-Dealer
Email Address
(Must be legal resident of U.S. or U.S. Territories)
Regular Mail:
Equitable
Retirement Service Solutions
P.O. Box 1577
Secaucus, NJ 07096-1577
Express Mail:
Equitable
Retirement Service Solutions
500 Plaza Drive, 7th Floor
Secaucus, NJ 07094-3619
Equitable Financial Life Insurance Company
INVESTMENT EDGE ADV
Application for an Individual Annuity
For Assistance,
please call 800-338-3434
www.equitable.com
Equitable Advisors, LLC
X04489_National Investment Edge — Series ADV

Page 2 of 10
B. PATRIOT Act Information
U.S. Citizen Yes No If yes, check one: Valid Driver’s License Passport State Issued ID
If no, check either: U.S. Visa (Complete below) or Permanent Resident (Green Card) (Copy of document required)
Identification/Passport# Exp. Date U .S. Visa Type (if applicable)
Your Employer’s Name Your Occupation
C. Joint Owner
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Taxpayer Identification Number (Check one) SSN ITIN
U.S. Primary Residential Address — No P.O. Box City State Zip Code
Email Address
Joint Owner Form of Identification (Check one) Valid Driver’s License Passport State Issued ID
Identification Number Exp. Date (MM/DD/YYYY)
D. Annuitant
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Name
(First) (Middle Initial) (Last)
Taxpayer Identification Number (Check one) SSN ITIN
U.S. Primary Residential Address only — No P.O. B ox City State Zip Code
Annuity Commencement Date: The Annuity Commencement Date will be the Contract Date Anniversary following the
Annuitant’s 95th Birthday. You may commence payments earlier by submitting a written request to our Processing Office
in accordance with the Contract.
E. Joint Annuitant
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Name
(First) (Middle Initial) (Last)
Taxpayer Identification Number (Check one) SSN ITIN
U.S. Primary Residential Address only — No P.O. B ox City State Zip Code
(If other than Owner.) Annuitant must complete the PATRIOT Act Information section 2B above
if the owner is NOT an individual.
Only complete this section if this is a NQ 1035 Exchange of an existing contract with joint
annuitants who are spouses.
(First) (Middle Initial) (Last)
Name
REQUIRED
Owner must complete this section. If the owner is not an individual, the annuitant
must complete this section.
(Must be legal resident of U.S. or U.S. Territories) NQ Only
X04489_National Investment Edge — Series ADV

Page 3 of 10

3. Beneficiary(ies) (Please use Special Instructions for Additional Beneficiaries.)

Please enter the beneficiaries full name below. Unless otherwise indicated, proceeds will be divided equally.

A. Primary

1. %

Primary Beneficiary Name Relationship to Owner1

SSN EIN ITIN

Date of Birth (MM/DD/YYYY)

Address Phone #

2. %

Primary Beneficiary Name Relationship to Owner1

SSN EIN ITIN

Date of Birth (MM/DD/YYYY)

Address Phone #

B. Contingent

1. %

Contingent Beneficiary Name Relationship to Owner1

SSN EIN ITIN

Date of Birth (MM/DD/YYYY)

Address Phone #

2. %

Contingent Beneficiary Name Relationship to Owner1

SSN EIN ITIN

Date of Birth (MM/DD/YYYY)

Address Phone #

4. Optional Return of Premium Death Benefit Rider Election

This optional rider is purchased for an additional charge and may only be elected at the time of application. You should read

the prospectus, disclosure on page 8 and applicable supplements for more complete information including the limitations,

restrictions, charges and other information that apply to this rider before making an election.

• Please note: This rider will automatically be dropped once you elect Income Edge Series and your election becomes

effective. Unless and until your Income Edge Series election becomes effective, the rider will continue to remain in effect as

will any limitations, restrictions, and/or charges applicable under the rider.

• The age requirement for the benefit is based on the Owner’s age(s) at the time the contract is issued, regardless of the

Owner’s age(s) when the application is signed.

If you do not make an election in this section, the Return of Premium Death Benefit is declined and your contract will

be issued with a Return of Account Value death benefit.

Yes, I wish to elect Return of Premium Death Benefit (Available for Owner issue ages 0-75)

5. General Dollar Cost Averaging (DCA)

• Please select the DCA destination funds in Section 6. The first DCA transfer to these funds will occur upon issuance of

your contract; subsequent DCA transfers will occur monthly over the remaining portion of the time period selected below

including any allocation into Segments. Amounts transferred into Segments will be first transfered into Segment Type

Holding Accounts and then swept on the next Segment Start Date.

• T he remaining portion of your initial contribution not allocated to the DCA destination funds will be allocated to the DCA

EQ/Money Market.

• Your future contributions will be allocated according to the instructions provided in Section 6, unless otherwise instructed

by you.

• The total maximum number of Segments and Investment Options that you can invest in at any time is 160.

Check a box to elect a DCA time period. 3 months 6 months 12 months

1 Enter the relationship to the annuitant when the Owner is not an Individual.

REQUIRED

(Not Available if electing Income Edge Series)

X04489_National Investment Edge — Series ADV

Page 4 of 10
6. Investment Selection
• You must allocate your initial contribution among the Structured Investment Option and the Variable Investment Options
below using the Contribution Allocation % column.
• All future contributions will be allocated according to the percentages below unless otherwise instructed by you.
• If you elected General Dollar Cost Averaging in Section 5, the DCA transfers will be made periodically according to the
allocation instructions provided below.
• If you elect Rebalancing in Section 7, the Rebalancing transfers will only be made among the Variable Investment Options.
See Section 7 for more details.
• If you elect any of the Structured Investment Option Segment Types listed below, once amounts are received, they will be
first placed in a Segment Type Holding Account until your Segment(s) becomes available on the Segment Start Date. At that
time, your funds will be allocated per your selection(s) below provided that all Segment Participation Requirements specified
in the Contract are met.
REQUIRED
Investment Options (Includes Structured Investment Option and Variable Investment Options)
Percentages must be whole numbers and total 100%.
Structured Investment Option
Standard Segment Types
% S&P 500 1 Year -10% Buffer
% Russell 2000 1 Year -10% Buffer
% MSCI EAFE 1 Year -10% Buffer
% NASDAQ 100 1 Year -10% Buffer
% MSCI EM 1 Year -10% Buffer
Step Up Segment Types
% S&P 500 Step Up 1 Yr -10% Buffer
% Russell 2000 Step Up 1 Yr -10% Buffer
% MSCI EAFE Step Up 1 Yr -10% Buffer
Asset Allocation
Risk Based Portfolios
% EQ/Aggressive Allocation
% EQ/All Asset Growth Allocation
% EQ/Conservative Allocation
% EQ/Moderate Allocation
% EQ/Moderate-Plus Allocation
Manager Select Portfolios
% 1290 VT DoubleLine Dynamic Allocation
American Funds Insurance Series®
% Asset Allocation FundSM
% BlackRock Global Allocation V.I. Fund
% EQ/AB Dynamic Moderate Growth
% First Trust/Dow Jones Dividend & Income Allocation Portfolio
% First Trust Multi Income Allocation Portfolio
% Franklin Allocation VIP Fund
% Franklin Income VIP Fund
% Franklin Mutual Shares VIP Fund
% Invesco V.I. Balanced-Risk Allocation Fund
% Janus Henderson Balanced Portfolio
% JPMorgan Insurance Trust Global Allocation Portfolio
% JPMorgan Insurance Trust Income Builder Portfolio
% PIMCO Global Managed Asset Allocation Portfolio
% Putnam VT Global Asset Allocation Fund
Specialty
Alternatives/Specialty
% 1290 VT Convertible Securities
% 1290 VT GAMCO Mergers & Acquisitions
% 1290 VT Multi-Alternative Strategies
% Eaton Vance VT Floating-Rate Income Fund
% PIMCO VIT Emerging Markets Bond Portfolio
% Templeton Global Bond VIP Fund
Commodities
% 1290 VT Natural Resources
% PIMCO VIT CommodityRealReturn® Strategy Portfolio
REITs
% 1290 VT Real Estate
% EQ/Invesco Global Real Estate
Sector
% EQ/MFS Technology
% EQ/MFS® Utilities Series
% EQ/T. Rowe Price Health Sciences
% EQ/Wellington Energy
% Invesco V.I. Health Care Fund
% Multimanager Technology Portfolio
Large Cap Value Stocks
% 1290 VT Equity Income
% AB VPS Growth and Income Portfolio
% EQ/BlackRock Basic Value Equity
% EQ/JPMorgan Value Opportunities
% EQ/Large Cap Value Index
% Janus Henderson U.S. Low Volatility Portfolio
% MFS® Value Series
% T. Rowe Price Equity-Income Portfolio-II

6. Investment Selection (Continued)
Investment Options (Variable Investment Options)
Large Cap Blend Stocks
American Funds Insurance Series®
% Growth-Income FundSM
% ClearBridge Variable Dividend Strategy Portfolio
% EQ/ClearBridge Select Equity Managed Volatility
% EQ/Common Stock Index
% EQ/Equity 500 Index
% EQ/Fidelity Institutional AMSM Large Cap
% EQ/Franklin Rising Dividends
% MFS® Investors Trust Series
% MFS® Research Series
% Putnam VT Research Fund
Large Cap Growth Stocks
% 1290 VT Socially Responsible Portfolio
% ClearBridge Variable Aggressive Growth Portfolio
% EQ/ClearBridge Large Cap Growth
% EQ/Large Cap Growth Index
% EQ/Loomis Sayles Growth
% EQ/T. Rowe Price Growth Stock
Mid Cap Stocks
Mid Cap Value Stocks
% EQ/American Century Mid Cap Value
Mid Cap Blend Stocks
% EQ/Mid Cap Index
% Fidelity® VIP Mid Cap Portfolio
Mid Cap Growth Stocks
% EQ/Janus Enterprise
% Federated Hermes Kaufmann Fund II
Small Cap Stocks
Small Cap Value Stocks
% 1290 VT GAMCO Small Company Value
% 1290 VT Small Cap Value
% AB VPS Small/Mid Cap Value Portfolio
Small Cap Blend Stocks
% 1290 VT Microcap
% EQ/Small Company Index
% Invesco V.I. Small Cap Equity Fund
Small Cap Growth Stocks
% EQ/AB Small Cap Growth
International/Global Stocks
International Stocks
American Funds Insurance Series®
% International Growth and Income FundSM
% EQ/International Equity Index
% EQ/Invesco International Growth
% EQ/MFS International Growth
% EQ/MFS International Intrinsic Value
International/Global Stocks (Continued)
Emerging Market Stocks
% American Funds Insurance Series® New World Fund®
% Delaware VIP® Emerging Markets Series
% EQ/Emerging Markets Equity PLUS
% EQ/Lazard Emerging Markets Equity
Global Stocks
% 1290 VT Low Volatility Global Equity
% 1290 VT SmartBeta Equity
% AB VPS Global Thematic Growth Portfolio
% American Century VP Inflation Protection Fund
American Funds Insurance Series®
% Global Growth FundSM
American Funds Insurance Series®
% Global Small Capitalization FundSM
% EQ/Invesco Global Portfolio
Bonds
Core Bonds
% 1290 VT DoubleLine Opportunistic Bond
% Delaware VIP® Diversified Income Series
% EQ/Core Bond Index
% EQ/Intermediate Government Bond
% EQ/PIMCO Total Return
% Janus Henderson Flexible Bond Portfolio
Inflation-Linked (TIPS)
% EQ/PIMCO Global Real Return Portfolio
Multi-Sector Bond
% Fidelity® VIP Strategic Income Portfolio
% Lord Abbett Bond Debenture
% PIMCO VIT Income Portfolio
% Putnam VT Diversified Income Fund
Short Term Bonds
% Delaware VIP® Limited-Term Diversified Income Series
% EQ/AB Short Duration Government Bond
% EQ/PIMCO Ultra Short Bond
High Yield Bonds
% 1290 VT High Yield Bond
% Federated Hermes High Income Bond Fund II
% Invesco V.I. High Yield Fund
International/Global Bonds
% PIMCO VIT Global Bond Opportunities Portfolio (Unhedged)
Cash/Cash Equivalents
% EQ/Money Market
X04489_National Investment Edge — Series ADV
Page 5 of 10
X04489_National Investment Edge — Series ADV

Page 6 of 10
7. Rebalancing
Your account value attributable to the Variable Investment Options will be automatically reallocated among the Variable
Investment Option Allocation selections in Section 6. The Variable Investment Option percentages will be redetermined based
on the proportionate Variable Investment Option allocations percent in Section 6 if a portion of your allocation is to Structured
Investment Option. If your allocations in Section 6 are 100% allocated to the Structured Investment Option, the
rebalancing program will not be established regardless of your election in this section.
• Rebalancing program excludes amounts in the DCA EQ/Money Market and Structured Investment Option including
Segment Type Holding Accounts and Segments
Please select a frequency.
Quarterly Semi-Annually Annually
8. Broker Transfer Authority Disclosure
Yes. I have granted authority to each of my Financial Professional(s), which are listed below, to act as my agent and
provide to Equitable Investment Option transfer instructions in writing, by telephone or electronically, and I hereby authorize
and direct Equitable to act on such instructions. I understand and acknowledge that Equitable (i) may rely in good faith
on the stated identity of the person(s) 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 will continue to act upon this authorization until such
time as we receive written notification in our Processing Office that broker transfer authority has been terminated. Upon
receipt of such notification, Equitable will terminate the Financial Professional(s’) ability to provide transfer instructions on
your behalf. Equitable may (i) change or terminate telephone or electronic or overnight mail transfer procedures at any time
without prior notice, and (ii) restrict fax, internet, telephone and other electronic transfer services because of disruptive
transfer activity.
9. Current Insurance BOTH questions in the Owner Response and the Financial Professional Response
columns must be completed and match for the contract to be issued.
Replacement Questions
Owner Response Financial
Professional
Response
1. Do you have any other existing life insurance or annuities?
(If yes, a Requirements Questionnaire (which is Equitable’s state replacement
form) is required even if you answer no for question 2)
☐ Yes No ☐ Yes No
2. 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 Contract applied for will be issued on
the life of the Owner?
(If yes, complete the following below and submit a State Requirements
Questionnaire, (which is Equitable’s state replacement form), if required.)
☐ Yes No ☐ Yes No
Please list the contract(s) below that will be used to fund this new Equitable contract
Company T ype of Plan Year Issued Certificate/Contract Number
Company T ype of Plan Year Issued Certificate/Contract Number
Company T ype of Plan Year Issued Certificate/Contract Number
REQUIRED
X04489_National Investment Edge — Series ADV

Page 7 of 10
11. Special Instructions
Attach a separate sheet if additional space is needed. For Owners whose Mailing Address differs from their
Primary Residential Address in Section 2, please complete the following:
Mailing Address — P.O. Box accepted City State Zip Code
12. Electronic Delivery
I authorize Equitable to send all documents regarding my contract to me electronically. This means that my
contract, contract endorsements, annuity statements, confirmation notices, privacy policy, prospectuses and all
other notices regarding my contract will be sent to me electronically.
My email address is1: _________________________________________________________________________
This authorization will continue unless and until revoked and means that Equitable will send an email or notice to me when
documents are available on Equitable’s website. Please logon to equitable.com to update your email address, revoke your
authorization for electronic delivery or request paper copies. Certain types of correspondence may continue to be delivered
by the United States Postal Service for compliance reasons. To receive and view such documents electronically, I understand
I must register (with a user name and password) for online account access with Equitable. Upon issuance of your contract
you will receive an email providing a temporary password and instructions to register for online account access. Through this
online account you can view, download or save statements and other documents to your home computer. If the email provided
is not a valid address, you will receive paper versions of your statements and other contract related documents. When you
agree to do transactions electronically on equitable.com, you agree to the disclosures, terms and requirements pertaining to
electronic transactions set forth on the website.
1 Custodially owned contracts: please provide the annuitant’s email address. Other non-natural owners (such as trusts):
please provide the email address of the authorized signatory.
10. Fraud Warning
Alabama/Arkansas/Louisiana/New Mexico/Rhode Island/West Virginia: 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.
Colorado/District of Columbia/Kentucky/Maine/Tennessee/Washington: WARNING: 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.
Oklahoma: Any person who knowingly and with intent to injure, defraud or deceive an insurer, files a statement of claim
containing any false, incomplete, or misleading information is guilty of a felony.
Kansas: Any person who knowingly and with intent to defraud any insurance company or other person files an
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 may be guilty of insurance fraud as determined by a court of
law.
Ohio: 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 is guilty of insurance fraud.
Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal
offense and subject to penalties under state law.
All other states: Any person who knowingly and with the intent to defraud any insurance company or other person
files an application for insurance or a 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.

13. Signature and Acknowledgements
GENERAL DISCLOSURE. I/WE UNDERSTAND AND ACKNOWLEDGE THAT:
• ACCOUNT VALUE(S) ATTRIBUTABLE TO ALLOCATIONS TO THE VARIABLE INVESTMENT OPTIONS,
STRUCTURED INVESTMENT OPTION AND ANY VARIABLE ANNUITY BENEFIT PAYMENTS I MAY ELECT, MAY
INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
• U nder penalty of perjury, I certify that all the Taxpayer Identification Numbers in Section 2 and 3 are correct.
• All information and statements furnished in this application are true and complete to the best of my knowledge and belief.
• Equitable may accept amendments to this application provided by me or under my authority.
• No Financial Professional has the authority to make or modify any Contract on behalf of Equitable, or to waive or alter any
of Equitable’s rights and regulations. Equitable must agree to any change made to the Contract and benefits applied for, or
to the age at issue, in writing.
• Charges under the Contract generally apply for the duration of the Contract.
• Fees, Charges and Investment Options vary by Series.
• Unless I elect DCA, if I elect any of the Segment Types available, once amount(s) are received, they will be placed in the
applicable Segment Type Holding Account(s) until swept into the Segment Type(s) on the Segment Start Date provided that
all Segment Participation Requirements specified in the Contract are met.
• Each Segment in the Structured Investment Option provides a rate of return tied to the performance of specified index. The
Segments are not index funds and do not invest in underlying mutual funds that hold investments tracked by a specified index.
• The Segment Rate of Return for Segments using one Segment Option may differ from Segments using different Segment
Options even though the Segments have similar durations and/or track similar indices. In addition, because of the way the
Segment Rate of Return is calculated for Step Up Segments, I understand that in certain circumstances a very small difference in
the Index Performance Rate can result in a much larger difference in the Segment Rate of Return for those Segments.
• The prospectus and applicable supplements contain more complete information including the limitations, restrictions and
conditions that apply to the Contract.
• The S&P 500® Price Return Index is a product of S&P Dow Jones Indices LLC (“SPDJI”), and has been licensed for use by
Equitable. The Investment Edge contract is not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P or any
of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices makes no representation or
warranty, express or implied, to the owners of the Investment Edge contract.
• Investment Edge is not sponsored, endorsed, or promoted by MSCI, and MSCI bears no liability with respect to such
product or any index on which such product is based. The prospectus contains a more detailed description of the limited
relationship that MSCI has with Equitable and any related product.
OPTIONAL RETURN OF PREMIUM DEATH BENEFIT DISCLOSURE. I/WE UNDERSTAND AND ACKNOWLEDGE THAT:
• There is an additional charge if the Return of Premium Death Benefit (“ROP DB”) is elected.
• The ROP DB generally cannot be terminated once it is elected.
• The ROP DB does not provide an Annuity Account Value or Cash Value and cannot be withdrawn.
• If I/We elect the ROP DB, the maximum age I/We may make contributions to the Contract will be through age 75 (or first
Contract Date Anniversary if later) of the older of the original Owner or Annuitant.
• Withdrawals under the Contract may reduce my ROP DB.
• The ROP DB may be of limited use if required minimum distributions apply, now or in the future, to my Contract because
withdrawals that are made from this Contract to meet the required amount may significantly reduce the benefit.
Prospectus Information: I acknowledge that I have received the most current prospectus and supplements, for
Investment Edge ADV. After reviewing my financial information and goals with my Financial Professional, I believe
that this Certificate/Contract will meet my financial goals.
X04489_National Investment Edge — Series ADV
Page 8 of 10

13. Signature and Acknowledgements (Continued)
Consent for Delivery of Initial Prospectus on CD-ROM:
Yes. By checking this box and signing the enrollment form/application below, I acknowledge that I received the initial
prospectus on computer readable compact disk ‘‘CD’’, and that my computer has a CD drive and I am able to access the
CD information. In order to retain the prospectus indefinitely, I understand that I must print or download it. I also understand
that I may request a prospectus in paper format at any time by calling Customer Service at 1-800-789-7771, and that all
subsequent prospectus updates and supplements will be provided to me in paper format, unless I enroll in Equitable’s
Electronic Delivery Service.
When you sign this application, you are agreeing to the elections that you have made in this application and acknowledge
that you understand the terms and conditions set forth in this application.
Contract State:
We will issue and deliver a contract to you based upon your state of primary residence. If you sign the enrollment form/
application in a state other than your primary residence state:
I certify that either: I have a second residence where the enrollment form/application was signed (the state of sale) or
I work or maintain a business in the state where the enrollment form/application was signed (the state of sale).
(Please check one)
X
Owner Signature City, State Date (MM/DD/YYYY)
X
Joint Owner Signature City, State Date (MM/DD/YYYY)
X
Annuitant Signature (if different than Owner) City, State Date (MM/DD/YYYY)
X
Joint Annuitant Signature City, State Date (MM/DD/YYYY)
REQUIRED
REQUIRED
X04489_National Investment Edge — Series ADV
Page 9 of 10

14. Financial Professional Section
A. Did you (i) verify the identity by reviewing the driver’s license/passport of the Owner, or in the case
of an entity owner, obtain documentary evidence of entity’s existence (e.g. articles of incorporation,
trust agreement, etc.), and (ii) inquire about the source of the customer’s assets and income? Yes No
B. Is the Proposed Owner/Annuitant, or is their family member or close associate, a government,
political official or foreign military official? Yes No
If “Yes”, please provide explanation of position and relationship
C. Is the Proposed Owner/Annuitant currently an Active Duty* Member of the Armed Forces? Yes No
D. NORTH CAROLINA ONLY: I certify that I have truly and accurately recorded on the application the information
provided by the Proposed Owner.
(If ‘‘Yes’’, you must also submit a complete and signed LIFE INSURANCE/ANNUITY DISCLOSURE TO ACTIVE DUTY
MEMBERS OF THE ARMED FORCES.)
* Active Duty means full-time in the active military service of the United States and includes members of the reserve
component (National Guard and Reserve) while serving under published orders for active duty or full-time training. The term
does not include members of the reserve component who are performing active duty or active duty for training under military
calls or orders specifying periods of less than 31 calendar days.
X ELAS
Primary Financial Professional Signature Social Security Number Agent Code
%
Print Name Phone Number
Email Address Agent Location
X
Financial Professional Signature Social Security Number Agent Code
%
Print Name Phone Number
Cat No. 162303
X04489_National Investment Edge — Series ADV
Page 10 of 10