AXA Equitable Life Insurance Company MONY Life Insurance Company of America

SECTION C – OWNER QUESTIONNAIRE FORMING PART OF THE APPLICATION FOR LIFE INSURANCE – Complete if other than Proposed Insured

Name of Proposed Insured Date of Birth (mm/dd/yyyy)

COMPLETE FOR

ALL OWNER TYPES

For Joint Owners provide name, residential address, Social Security #, date of birth, driver’s license #, state of issue and expiration date, occupation and employer’s name in Remarks Section on the Application.

1. Owner Type Individually Owned Partnership Corporation Trust LLC Sole Proprietorship

2. Owner’s name

3. Relationship to Proposed Insured

4. SSN EIN ITIN 5. Email address

6. Address

City State Zip Code Phone Number

If P.O. Box, put residential address in Remarks Section.

Complete if Owner Type is Partnership, Corporation, Trust, LLC, Sole Proprietorship

7. Person(s) authorized to act on behalf of Owner Name Title

Name Title

COMPLETE IF INDIVIDUALLY OWNED

8. Do you have a driver’s license? Yes No If ‘‘Yes,’’ provide license #, state and expiration date

Number State Expiration Date (mm/dd/yyyy)

If no driver’s license, do you have a government issued ID? Yes No

If ‘‘Yes,’’ to government issued ID, type of ID Government ID #

9. Date of birth (mm/dd/yyyy) 10. Currently employed? Yes No Retired (If ‘‘Yes,’’ complete question 11)

11. Occupation Employer name

12. Income

Gross Earned Annual Income

(salary, commissions, bonuses)

Gross Unearned Annual Income

(dividends, pensions, interest, real estate income, etc.)

Gross Annual Income

(Household)

Total Net Worth

(Household)

$

$

$

$

13. Are you a member of the armed forces, including the reserves? Yes No

(reserves includes active duty or full-time training of 31 days or more per year)

(If ‘‘Yes,’’ you must also submit a completed and signed Life Insurance/Annuity Disclosure to Active Duty Members of the Armed Forces.)

14. Are you a U.S. citizen? Yes No (If ‘‘No,’’ please complete ‘‘a’’ and ‘‘b’’ or ‘‘c,’’ where applicable.)

a. Country of Citizenship Date of Entry into the U.S. (mm/dd/yyyy)

b. Residents with legal permanent status (Resident) in U.S. only

Green Card/Visa Type Expiration Date (mm/dd/yyyy)

c. Residents residing in the U.S. temporarily (Non-Resident) with valid Visa only

Visa # Visa Type Expiration Date (mm/dd/yyyy)

Form I-94 Expiration Date (mm/ddd/yyyy) Passport #

Complete Question 15 for all non-resident (foreign) Owners. If the Owner is not a U.S. Person (U.S. Citizen or U.S. Corporation, Partnership or Trust established or organized under the laws of a state of the United States), then he, she or it may have to provide additional documentation, including IRS form W-8 BEN. Any foreign Owner (Individual, Trust, Corporation, Partnership, Other Entity) must have a US bank account.

15. U.S. bank name Account #

OTHER INSURANCE

16. Including any policies and riders with AXA Equitable, its affiliates and any other life insurance company:

a. Do you have any life insurance/annuities currently in force, including any policy that has been sold, settled

or assigned to or with a settlement or viatical company or any other person or entity? Yes No

b. Will the coverage applied for replace, change, or affect any existing policy(ies) or contract(s)? Yes No

Complete as appropriate if any of questions 16a and b is ‘‘Yes’’

Name of Company

Total Amount

(Face Plus Riders)

Year

Issued

Policy/

Contract #

P-Personal

G-Group

B-Business

A-Annuity

To Be

Replaced

Changed or Affected

1035

Exchange P B G A Yes

No Yes

No P B G A Yes

No Yes

No

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COMPLETE IF TRUST OWNED

17a. Situs of Trust: The Trust is subject to the laws of the state of b. Date of Trust (mm/dd/yyyy)

18. Name(s) of Grantor(s)

19. Name(s) and title(s) of current Trustee(s)

20a. How long has the Trustee known the Proposed Insured?

b. What is the nature of the relationship between the Proposed Insured and the Trustee?

c. Is the Trust? Revocable Irrevocable (Check appropriate box)

d. Can interests in the Trust be sold without changing the terms of the Trust? Yes No

21. Did the Proposed Insured and/or the Owner retain an attorney to prepare the Trust documents? Yes No

If ‘‘Yes,’’ provide name and address of attorney. If ‘‘No,’’ provide the name and address of the person or entity that did prepare the Trust documents.

Please provide the relationship of the preparer of the Trust to the Proposed Insured

Name Relationship to the Proposed Insured

Address

22. Name(s) of current Beneficiary(ies) of the Trust

23. What is the nature of the relationship between the Grantor(s) and Beneficiary(ies)?

24. Is there a Trust Protector? Yes No (If ‘‘Yes,’’ answer 25a and 25b.)

A Trust Protector is a third party appointed by the Grantor to provide direction and guidance to the Trustee.

25a. How long has the Trustee known the Trust Protector?

b. What is the nature of the relationship between the Proposed Insured and the Trust Protector?

PURPOSE OF INSURANCE

26. Complete For Personal Insurance

Income Replacement Mortgage/Debt Repayment Estate Planning Charitable/Gifting Other

27. Complete for Business Insurance

Key Person Buy-Sell Deferred Comp Other (please explain)

Loan indemnification/Amount of loan $ Duration

Interest charged on loan Collateral pledged to secure loan

a. Type: Sole Proprietorship Partnership Corporation Limited Liability Corporation

b. Name of Business Nature of Business

c. How long has the business been in operation? Years d. Fair market value of the business $

e. % of business owned by Proposed Owner, if other than the Proposed Insured %

f. Are all members of the business being similarly insured? Yes No

If ‘‘Yes,’’ provide details of business coverage issued or applied for on other members (use separate sheet if necessary)

Name and Title

% of Business Owned

Amount In Force or Applied For

g. Has the business filed for bankruptcy and/or reorganization in the past 5 years? Yes No

If ‘‘Yes,’’ explain

h. Business/Corporation finances: (Complete chart below for the past 2 years)

Year

Assets

Liabilities

Gross Sales

Net Profit

$

$

$

$

$

$

$

$

For employer owned life insurance there are notice and consent requirements, established in the Tax Code, that must be met before issuance of the contract, as well as tax limitations on those who can be insured. When purchasing insurance on employees or directors, you should consult your tax advisor to avoid adverse tax consequences.

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SOURCE OF FUNDS

“Parties” refers to the following: the Proposed Insured, the Owner or Beneficiary, the Beneficiary of any Trust owning the policy, and/or the Owner of any legal entity owning the policy.

28. Do you intend to finance any of the premium required to pay for this policy through a financing or loan agreement?

Yes No

If “Yes,” with whom are you financing

29. Indicate the source of funds used to purchase this insurance.

Income

Investments/Savings

Loans

Gifts / Inheritance

Settled Contracts-give details

Other (specify)

30. Have any of the Parties been offered or promised any incentive (financial or otherwise) as an inducement to apply for or purchase the proposed policy, such as (but not limited to), zero cost or no cost life insurance or cash payments?

31. Has any compensation or other inducement (including cash, offers or discussions of free insurance, any forgiveness or potential forgiveness of any debt, or other benefits) been discussed or offered directly or indirectly to any of the following in connection with the application for the purchase of this policy: the Proposed Insured, the Owner or Beneficiary, the Beneficiary of any Trust owning the policy, and/or the owner of any legal entity owning the policy, or is there any expectation of receiving any such compensation or inducement?

If “Yes,” please state the compensation or inducement that will be received or could be received and by whom.

Yes

No

Yes

No