AXA Equitable Life Insurance Company

RETIREMENT CORNERSTONE® SERIES E

Application for an Individual Annuity

Regular AXA Equitable Mail:

Retirement P.O. Box 1577 Service Solutions Secaucus, NJ 07096-1577

Express AXA Equitable Mail: For Assistance, please call 888-517-9900 www.axa.com

500 Retirement Plaza Drive Service Solutions 6th Secaucus, Floor NJ 07094-3619

PLEASE PRINT

A. Contract Series

☑Series E ($25,000 minimum contribution)

B. Choose a Contract Type.

Non-Qualified Traditional IRA Roth IRA

Qualified Plan Defined Contribution (QPDC) Qualified Plan Defined Benefit (QPDB)

C. Total Initial Contribution(s): $ (Estimated Value Required In Case of Transfer)

Specify Method(s) of Payment:

Check or Wire (make check payable to: AXA EQUITABLE) 1035 Exchange (NQ) Direct Transfer (IRA, Roth IRA) Rollover (IRA, Roth IRA)

R E Q U I R E D

Home Office: 1290 Avenue of the Americas, New York, NY 10104

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AXA Distributor, LLC

Cat. No.160116

Series E

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(Must be legal resident of U.S. or U.S. territories)

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 ualified Plan Trust (DC/DB) Other Non-Natural Owner Custodian (IRA/ROTH)

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 9. Email Address

Annuity Commencement Date: The Annuity Commencement Date will be the Contract Date Anniversary following the Annuitant’s 95th birthday. If GMIB is elected, the Annuity Commencement Date will be the Contract Date Anniversary following the Owner’s 95th birthday. You may commence Annuity payments earlier by submitting a written request to our Processing Office in accordance with the Contract.

B. PATRIOT Act Information: Owner annuitant must must complete complete this this section section . If the . owner is not an individual, the

U.S. Citizen Yes No

If no, check either: U.S. Visa (Complete below) or Permanent Resident (Green Card) (Copy of document required)

U.S. Visa Type (if applicable)

C. Joint Owner (Must be legal resident of U.S. or U.S. territories) NQ only If GMIB elected, both owners must be ages 50-80.

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 — No P.O. Box City State Zip Code

Email Address

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D. Annuitant (Required if other than Owner) Annuitant must complete the PATRIOT Act Information section 2B on the previous page if the owner is NOT an individual.

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. Box City State Zip Code

E. Joint Annuitant Only complete this section if this is a NQ 1035 Exchange of an existing contract with joint annuitants who are spouses.

If GMIB elected, both annuitants must be ages 50-80.

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. Box City State Zip Code

(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 #

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

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R E Q U I R E D

4. Optional Guaranteed Benefit Rider Elections

These optional riders are purchased for an additional charge. You should read the disclosure on page 8, the prospectus and applicable supplements for more complete information including the limitations, restrictions, charges and other information that apply to these features before making a selection.

The death benefit, if any, in connection with the Investment Account Value is equal to amounts in the Investment Account Investment Options.

• The for these benefit riders, riders unless are optional otherwise and noted may .only be chosen at the time of the application. There are additional charges

• If you opt out of the GMIB at issue by declining it below in section 4A or 4C, you will not be able to add it later.

• Benefits under these riders apply only to amounts allocated to the Protected Benefit Account Investment Options.

• You subject may to allocate the terms amounts and limitations to the Protected of the contract Benefit. Account Investment Options immediately or at a future date, • under If you do your not Contract allocate until amounts you allocate to the Protected amounts at Benefit a future Account date. Investment Options, these rider(s) will have no value

• The the Owner’s age requirements age(s) when for the all benefits application are is based signed on. the Owner’s age(s) at the time the contract is issued, regardless of

4A: Guaranteed Minimum Income Benefit (GMIB)

• Eligible contracts will be automatically issued with the GMIB combined with the Return of Principal death benefit 1 unless you elect otherwise in section 4A, 4B or 4C.

• For single owned contracts the owner must be ages 20 ages 50-80. -80.For joint owned contracts both owners must be • The Automatic Reset program will be automatically included with the GMIB unless you opt-out in Section 4D.

To opt out of the GMIB, please check the box below.

I decline the GMIB (Please go to section 4C to select GMDB only)

4B: Guaranteed Minimum Death Benefit (GMDB) with GMIB

To elect a GMDB other than the Return of Principal death benefit1 with GMIB, please make an election below: single Yes, owner I wish to ages elect 20 Greater -65. For of joint Annual owners Roll both up or owners Highest must Anniversary be ages 50 Value -65.) death benefit (Available only for For Yes, joint I wish owners to elect both Highest owners Anniversary must be ages Value 50-75 death .) benefit (Available only for single owner ages 20-75.

4C: GMDB Only (without GMIB)

Yes, I wish to elect RMD Wealth Guard GMDB2 without GMIB (Available only for owners age 20 to 683)

Yes, I wish to elect Highest Anniversary Value death benefit without GMIB (Available only for owners age 0 to 75)

4D: Annual Reset Election

• If your contract is issued with GMIB, it will automatically include the Automatic Reset program.

• The Automatic Reset program resets the GMIB and if elected the “Greater of” GMDB each year that you are eligible. If you accept the Automatic Reset program, resets will occur automatically unless such automatic resets are or have been terminated. The reset will result in a new waiting period to exercise the GMIB of up to the later of 10 years or the original exercise date, but not later than age 95.

To opt out of the Automatic Reset Program, please check the box below.

I decline the Automatic Reset Program.

Or to elect a Customized Reset Program, check the box below.

Customized Reset Program Reset my GMIB and if elected “Greater of” GMDB each year up to and including the contract anniversary date in the year only. I understand that resets will only occur during this time period if I am eligible. (YYYY)

1 There is no additional charge for the Return of Principal death benefit.

2 Available for Traditional IRA and QPDC only.

3 The charge for this rider is based on the Owner’s age at the time the contract is issued, regardless of the Owner’s age when the application is signed. The charge is higher for Owner issue ages 65-68.

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R E Q U I R E D

5. Investment Selection

• in You Section must allocate 5B. 100% of your initial contributions to either the Investment Options in Section 5A OR any Special DCA

• All future allocations will be apportioned according to the percentages below unless instructed otherwise by you.

• Contributions Account Investment received Options after the and Special the Protected DCA program Benefit terminates Account Investment will be allocated Options to according the Investment to the instructions below.

• value If you under do not your allocate contract amounts until you to the allocate Protected amounts Benefit at Account a future date. Investment Options, the guaranteed benefits will have no

PROTECTED BENEFIT ACCOUNT Investment INVESTMENT Options ACCOUNT Investment Options

Total Allocation to Protected Benefit Account Total Allocation to Investment

Investment Options % (percent must be a Account Investment Options % whole number) (percent must be a whole number)

If your contract is issued with GMIB and you are younger Please see the Investment Account Investment Option than age 50, you may not allocate amounts to the Protected section on page 6 to select your allocations.

Benefit Account until you attain age 50.

Please see the Protected Benefit Account Investment Options section at the bottom of page 5 to select your allocations.

Total Investment Account Investment Options percentage plus Protected Benefit Account Investment Options percentage must equal 100%.

Choose either 5A or 5B below.

5A: Immediate Allocation

Allocate 100% immediately to the Investment Account Investment Options and/or the Protected Benefit Account Investment Options.

5B: Special Dollar Cost Averaging Programs

Allocate 100% immediately to the Special Dollar Cost Averaging Program selected below.

Check box for one time period.

3 months 6 months 12 months

• You may designate either or both the Investment Account Investment Options and the Protected Benefit Account Investment Options as the destination Option for DCA.

• If you select the Protected Benefit Account Investment Options, your funds will be considered invested in the Protected Benefit Account from the date of contribution. The destination cannot be changed to the Investment Account Investment Options at a later date.

PROTECTED BENEFIT ACCOUNT Investment Options

If you allocated 100% to the Investment Account Investment Options proceed to page 6 to enter your allocation instructions.

If your contract is issued to the with Protected GMIB and Benefit you Account are younger until than you age attain 50, age you 50. may not allocate amounts

Percentages must be whole numbers

Allocation %

% EQ/AB Dynamic Aggressive Growth GB

% EQ/AB Dynamic Growth GB

% EQ/Aggressive Growth Strategy GB

% EQ/Goldman Sachs Growth Allocation GB

% EQ/Growth Strategy GB

% EQ/JPMorgan Growth Allocation GB

% EQ/Legg Mason Growth Allocation GB

% EQ/Conservative Growth Strategy GB

% EQ/Conservative Strategy GB

Allocation %

% 1290 VT Moderate Growth Allocation GB

% EQ/AB Dynamic Moderate Growth GB

% EQ/American Century Moderate Growth Allocation GB

% EQ/AXA Investment Managers Moderate Allocation GB

% EQ/Balanced Strategy GB

% EQ/First Trust Moderate Growth Allocation GB

% EQ/Goldman Sachs Moderate Growth Allocation GB

% EQ/Invesco Moderate Allocation GB

% EQ/Invesco Moderate Growth Allocation GB

% EQ/Legg Mason Moderate Allocation GB

% EQ/Moderate Growth Strategy GB

100% Protected Benefit Account Investment Options*

* This in the amount Protected represents Benefit Account 100% of Investment the percentage Options shown section. above

R E Q U I R E D

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INVESTMENT ACCOUNT Investment Options

Percentages must be whole numbers

Allocation %

% 1290 VT DoubleLine Dynamic Allocation

% 1290 VT Moderate Growth Allocation

% BlackRock Global Allocation V.I. Fund

% All Asset Growth — Alt 20

% CharterSM Moderate

% CharterSM Moderate Growth

% EQ/AB Dynamic Aggressive Growth

% EQ/AB Dynamic Growth

% EQ/AB Dynamic Moderate Growth

% % EQ/American EQ/Aggressive Century Growth Moderate Strategy Growth Allocation

% EQ/AXA Investment Managers Moderate Allocation

% EQ/Balanced Strategy

% EQ/Conservative Growth Strategy % % EQ/First EQ/Conservative Trust Moderate Strategy Growth Allocation % % EQ/Goldman EQ/Goldman Sachs Sachs Growth Moderate Allocation Growth Allocation % % EQ/Invesco EQ/Growth Strategy Moderate Allocation % % EQ/JPMorgan EQ/Invesco Moderate Growth Growth Allocation Allocation % % EQ/Legg EQ/Legg Mason Mason Growth Moderate Allocation Allocation

% EQ/Moderate Allocation

% % First EQ/Moderate Trust Multi Growth Income Strategy Allocation Portfolio

% % First Franklin Trust/Dow Founding Jones Funds Dividend Allocation & Income VIP Fund Allocation Portfolio % % Invesco Franklin V. Income I. Equity VIP and Fund Income Fund

% QS Legg Mason Dynamic Multi-Strategy VIT Portfolio

% ClearBridge Variable Appreciation Portfolio % % ClearBridge EQ/ClearBridge Variable Select Dividend Equity Managed Strategy Volatility Portfolio % % EQ/Equity EQ/Common 500 Stock Index Index

% EQ/Fidelity Institutional AM® Large Cap

% EQ/Franklin Rising Dividends

% MFS® Investors Trust Series

% BlackRock Large Cap Focus Growth V.I. Fund

% ClearBridge Variable Aggressive Growth Portfolio % % EQ/ClearBridge EQ/Large Cap Growth Large Cap Index Growth % % EQ/T. EQ/Loomis Rowe Sayles Price Growth Growth Stock

% Hartford Growth Opportunities HLS Fund

% MFS® Massachusetts Investors Growth Stock Portfolio

% Multimanager Aggressive Equity

% % 1290 EQ/BlackRock VT Equity Basic Income Value Equity % % EQ/Invesco EQ/JPMorgan Comstock Value Opportunities

% EQ/Large Cap Value Index

% % EQ/Large Invesco V. I. Cap Diversified Value Managed Dividend Volatility Fund

% ClearBridge Variable Mid Cap Portfolio % % EQ/American EQ/Goldman Sachs Century Mid Mid Cap Cap Value Value

% EQ/Ivy Mid Cap Growth % % EQ/Janus EQ/Mid Cap Enterprise Index

% EQ/Mid Cap Value Managed Volatility

% Fidelity® VIP Mid Cap Portfolio % % Multimanager Invesco V.I. Mid Mid Cap Cap Core Growth Equity Fund

% Multimanager Mid Cap Value

Allocation %

% % 1290 1290 VT VT GAMCO Microcap Small Company Value

% 1290 VT Small Cap Value

% CharterSM Small Cap Value % % EQ/AB EQ/Small Small Company Cap Growth Index

% Invesco V.I. Small Cap Equity Fund

% % 1290 1290 VT VT Low SmartBeta Volatility Equity Global Equity

% American Funds Insurance Series® Global Small Capitalization FundSM

% American Funds Insurance Series® New World Fund®

% EQ/Emerging Markets Equity PLUS

% % EQ/International EQ/International Equity Core Managed Index Volatility % % EQ/Invesco EQ/Lazard Emerging International Markets Growth Equity % % EQ/MFS EQ/MFS International International Growth Value % % Neuberger EQ/Oppenheimer Berman Global International Equity Portfolio

% Templeton Developing Markets VIP Fund

% % 1290 1290 VT VT Natural GAMCO Resources Mergers & Acquisitions % % 1290 EQ/Invesco VT Real Global Estate Real Estate % % EQ/Ivy EQ/Ivy Science Energy and Technology % % EQ/MFS EQ/MFS Technology Utilities Series % % EQ/T. Multimanager Rowe Price Technology Health Sciences

% Neuberger Berman U.S. Equity Index PutWrite Strategy Portfolio

% PIMCO VIT CommodityRealReturn® Strategy Portfolio

% ProFund VP Biotechnology

% % Templeton EQ/PIMCO Global Global Bond Real VIP Return Fund

% % 1290 Invesco VT V. High I. High Yield Yield Bond Fund % % Lord Ivy VIP Abbett High Bond Income Debenture

% 1290 VT DoubleLine Opportunistic Bond

% American Funds Insurance Series® Bond FundSM

% % EQ/Core Eaton Vance Bond VT Index Floating-Rate Income Fund % % EQ/Franklin EQ/Intermediate Strategic Government Income Bond % % EQ/PIMCO EQ/PIMCO Total Real Return Return

% EQ/PIMCO Ultra Short Bond

% Fidelity® VIP Strategic Income Portfolio % % Putnam PIMCO VIT VT Diversified Income Portfolio Income Fund

% % Guaranteed EQ/Money Market Interest Option (GIO) (maximum 25%) 100% Investment Account Investment Options*

TOTAL%

* This amount represents 100% of the percentage is shown above in the Investment Account Investment Option section.

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agent Yes. and I have provide granted to AXA authority Equitable to each Investment of my Registered Option transfer Representative(s), instructions in which writing, are by listed telephone below, to or act electronically, as my and Equitable I hereby (i) may authorize rely in and good direct faith AXA on the Equitable stated identity to act on of such the person(s) instructions. placing I understand such instructions, and acknowledge and (ii) will that have AXA no will liability continue for to any act claim, upon loss, this authorization liability, or expense until such that time may as arise we in receive connection written with notification such instructions. in our Processing AXA Equitable Office Registered that broker Representative’s(s’) transfer authority has ability been to terminated. provide transfer Upon receipt instructions of such on notification, your behalf. AXA AXA Equitable Equitable will may terminate (i) change the or fax, terminate internet, telephone telephone or electronic and other or electronic overnight transfer mail transfer services procedures because of at disruptive any time without transfer prior activity. notice, and (ii) restrict

BOTH questions in the Owner Response and the Registered Representative Response columns must be completed and match for the contract to be issued.

Replacement Questions Owner Response Representative Registered Response

1. Do you have any other existing life insurance or annuities? Yes No Yes No

(If yes, a State Requirements Questionnaire may be required)

2. surrendered, Will any existing withdrawn life insurance from, loaned or annuity against, be (or changed has it been) or otherwise Yes No Yes No assuming reduced in the value, Certificate/Contract or replaced in connection applied for with will this be issued transaction on the life of the Owner?

(If yes, complete the following below and submit a State Requirements Questionnaire, if required.)

Please list the contract(s) below that will be used to fund this new AXA Equitable contract

Company Type of Plan Year Issued Certificate/Contract Number

Company Type of Plan Year Issued Certificate/Contract Number

Company Type of Plan Year Issued Certificate/Contract Number

of Any a criminal person who offense knowingly and subject presents to penalties a false statement under state in an law. application for insurance may be guilty

Primary Attach a Residential separate sheet Address if additional in Section space 2A, is please needed. complete For Owners the following: whose Mailing Address differs from their

Mailing Address — P.O. Box accepted City State Zip Code

contract, I authorize contract AXA endorsements, Equitable to send annuity all documents statements, regarding confirmation my contract notices, to privacy me electronically. policy, prospectuses This means and that all my other notices regarding my contract will be sent to me electronically.

My email address is1: me This when authorization documents will are continue available unless on AXA and Equitable’s until revoked website. and means Please that logon AXA to Equitable axa.com will to update send an your email email or notice address, to revoke to be delivered your authorization by the United for electronic States Postal delivery Service or request for compliance paper copies. reasons. Certain types of correspondence may continue To for receive online account and view access such documents with AXA Equitable. electronically, Upon I issuance understand of your I must contract register you (with will a receive user name an email and password) providing view, a temporary download password or save and statements instructions and to other register documents for online to your account home access. computer. Through If the this email online provided account is not you a can valid address, do transactions you will electronically receive paper on versions axa.com, of you your agree statements to the disclosures, and other contract terms and related requirements documents. pertaining When you to agree electronic to transactions set forth on the website.

1 Non-natural owners (such as trusts): please provide the email address of the authorized signatory.

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R E Q U I R E D

11. Signature and Acknowledgements

GENERAL DISCLOSURE. BY SIGNING BELOW, I/WE UNDERSTAND AND ACKNOWLEDGE THAT:

• payments Account value(s) I may elect, attributable may increase to allocations or decrease to the and investment are not guaranteed options, and as any to dollar variable amount. annuity benefit

• application In the case of I acknowledge IRAs and qualified that I am plans buying that provide the Contract tax deferral for its features under the and Internal benefits Revenue other than Code, tax by deferral, signing as this the tax deferral feature of the Contract does not provide additional benefits.

• information Under penalty in Section of perjury, 2 are I certify correct. that all the Taxpayer Identification Numbers citizenship and owner status • belief. All information and statements furnished in this application are true and complete to the best of my knowledge and

• AXA Equitable may accept amendments to this application provided by me or under my authority.

• waive No Registered or alter any Representative of AXA Equitable’s has the rights authority and regulations. to make or modify AXA Equitable any Contract must on agree behalf to any of AXA change Equitable, made to or the to Contract and benefits applied for, or to the age at issue, in writing signed by an officer of the company.

• Charges under the Contract generally apply for the duration of the Contract.

• and The prospectus conditions that and applies applicable to the supplements Contract and contain any optional more complete benefit riders. information including the limitations, restrictions

OPTIONAL GUARANTEED BENEFIT DISCLOSURE. I/WE UNDERSTAND AND ACKNOWLEDGE THAT:

• There are additional charges for the elected optional benefit riders, unless otherwise noted in this application.

• Options To receive either the benefits immediately under or the at a rider(s), future date, I/we must subject allocate to the amounts terms and to limitations the Protected of the Benefit Contract. Account I understand Investment that the allocating Contract, amounts on a future to the Contract Protected Date Benefit Anniversary Account maximizes either immediately the benefit or, of subject the roll to up the feature. terms and If AXA conditions Equitable of be discontinues able to create transfers or add and to contributions the benefit base. to the Protected Benefit Account Investment Options, I/we will thereafter not • am Contributions between the and ages transfers of 43 and to the 49 GMIB on my and Contract “Greater Date, of” the GMDB applicable (if elected) Initial are Lock-in only permitted Deferral Rollup starting Rate at age and 50. Initial If I first Lock-in seven Annual Contract Rollup Years. Rate If will I am only age apply 42 or after younger I attain on age my Contract 50, and then Date, only the for Initial the Lock-in amount Deferral of time remaining Rollup Rate of and my Ten Initial Year Lock-in Treasuries Annual Formula Rollup Rate Rate will according never apply to the to terms my Contract of the Contract. and my benefit(s) will rollup based on the applicable • my The Account rollup rate Value used or for Cash the Value. rollup The benefit rollup bases rates under that apply GMIB to and my GMDB contract (if elected) are specified does not in the represent Rate Sheet a guarantee of Supplement to the Prospectus.

• with The benefit a divorce. base does not represent an Account Value or Cash Value. The benefit base cannot be split in connection

• Automatic Unless otherwise Reset program declined, resets contracts my GMIB with the and GMIB if elected will automatically “Greater of” GMDB issue with Rollup the Benefit Automatic Base Reset each program. year that The I am reset eligible. will result Resets in a new will occur wait period automatically to exercise unless the such GMIB, automatic of up to the rests later are of or 10 have years been or the terminated. original exercise The annual date and if (but elected not later “Greater than of” age GMDB 95) which Rollup may Benefit be started Base beginning is reset. If on my each Annuity Contract Account Date Value Anniversary does not that exceed the GMIB my GMIB completed benefit reset base cancellation on any Contract request. Anniversary, Any such request no reset must will occur. be received To cancel at AXA my Equitable’s reset I must processing submit a signed office and at least after this 1 business window day will prior apply to the the following Contract year. Date I Anniversary am not able to to which cancel the a reset cancellation once it has applies. occurred. Requests For jointly received owned Contracts, eligibility to reset the benefit base is based on the age of the older owner.

• Guard AXA Equitable GMDB Riders, reserves up the to the right maximum to change charges the charges stated for in the the GMIB, Contract the and “Greater prospectus of” GMDB, at any and time. the I RMD will have Wealth the option fee increase to exercise is imposed the GMIB by submitting or terminate a written the GMIB, request “Greater to AXA of” Equitable’s GMDB or the Processing “RMD Wealth Office. Guard” GMDB Riders if a

• Withdrawals under the Contract may reduce my optional benefit.

• of An limited optional use benefit, if required with minimum the exception distributions of the RMD apply, Wealth now Guard or in the GMDB future, Rider to my after Contract the first because contract withdrawals anniversary, that may are be made or “Greater from this of” Contract GMDB and to meet also elect the required the Automatic amount RMD may significantly Withdrawal Service, reduce the withdrawals benefit. However, of my required if I elect minimum the GMIB distributions GMDB the GMDB made Rollup through benefit the automatic base during RMD the Withdrawal GMDB Rollup Service Period. will not reduce my GMIB or for the “Greater of”

Prospectus Information: I acknowledge that I have received the most current prospectus and supplements, for Retirement Cornerstone® Series E. After reviewing my financial information and goals with my Registered Representative, I believe that this Certificate/Contract will meet my financial goals.

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11. 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 800-789-7771, and that all subsequent prospectus updates and supplements will be provided to me in paper format, unless I enroll in AXA Equitable’s Electronic Delivery Service.

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).

(Check one)

When you sign this application, you are agreeing to the elections that you have made in this application and acknowledge that you have read and understand the information.

X Owner Signature City, State Date (MM/DD/YYYY) X Joint Owner Signature City, State Date (MM/DD/YYYY) X Annuitant Signature (if other than Owner) City, State Date (MM/DD/YYYY) X Joint Annuitant Signature (if other than Owner) City, State Date (MM/DD/YYYY)

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12. Registered Representative Information

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

(If Yes, you must also submit a completed and signed LIFE INSURANCE/ANNUITY DISCLOSURE TO ACTIVE DUTY MEMBERS OF THE ARMED FORCES).

*Active Duty means full-time duty in 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. It 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 Primary Registered Representative Signature Social Security Number Rep Code

% Print Name Phone Number

Client Account Number Email Address Rep Location

X Registered Representative Signature Social Security Number Rep Code

% Print Name Phone Number

Registered Representative Use Only. Contact your home office for program information.

Once selected, program cannot be changed. ☑ Option I

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Retirement Cornerstone — Series E

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