APPLICATION TO THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Processing Office: Individual Annuity Center, P.O. Box 2996, G.P.O.,
New York, New York 10116
FOR A VARIABLE ANNUITY CONTRACT: EQUITABLE'S NON-QUALIFIED EQUI-VEST CONTRACT
--------------------------------------------------------------------------------
UNIT SECTION (complete only if Salary Allotment is used)
1. EMPLOYER / UNIT NAME
-------------------------------------------------------
2. |_| EXISTING UNIT NO. |_|_|_|_|_|_| - |_|_|_|
|_| NEW UNIT |_|_|_|_|_|_| - |_|_|_|
FORM 983-2357 REQUIRED
--------------------------------------------------------------------------------
PARTICIPANT SECTION
3. PROPOSED PARTICIPANT - Print name to appear on Contract.
----------------------------------------------------------------------------
First Middle Initial Last
a. |_| Mr. |_| Mrs. |_| Miss |_| Ms. Other
---------
b. Date of Birth: Year Month Day
------- ------- --------
c. Age at Nearest Birthday:
-----------------------------
d. State of Residence:
----------------------------------
e. Participant's Mailing Address: 1. |_| Male |_| Female
No. St. |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
State |_|_| Zip Code |_|_|_|_|_| - |_|_|_|_|
g. Social Security Number (Required): |_|_|_| - |_|_| - |_|_|_|_|
h. Are you associated with or employed by a member of National
Association of Securities Dealers, Inc. (NASD)? |_| Yes |_| No
4. RETIREMENT AGE (maximum: 85)
------------------
5. BENEFICIARY--Include FULL NAME and RELATIONSHIP to Participant.
FOR DEATH BENEFIT UPON PARTICIPANT'S DEATH BEFORE RETIREMENT DATE, AND FOR
OWNERSHIP RIGHTS UPON DEATH OF OWNER.
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
6. OWNER--ONLY IF OTHER THAN PARTICIPANT: |_| Individual |_| Executor
|_| Guardian |_| Custodian (SEE #14) |_| Trustee (For natural person)
The following owner types will incur annual tax liability
|_| Corporation |_| Partnership |_| Deferred Compensation
|_| Trustee (NOT for natural person)
Name |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
No. St. |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
State |_|_| Zip Code |_|_|_|_|_| - |_|_|_|_|
Relationship to Participant
---------------------------------
Owner SSN # |_|_|_| - |_|_| - |_|_|_|_|
(IF CUSTODIAN USE PARTICIPANT'S SSN #)
Are you associated with or employed by a member of National
Association of Securities Dealers, Inc. (NASD)? |_| Yes |_| No
ABOVE NAMED OWNER WILL RECEIVE ALL COMMUNICATIONS. SPECIFY ANY CO-OWNERS
IN SPECIAL INSTRUCTIONS (#13)
7. CONTRIBUTION ALLOCATION
Fixed Income Account ______%
Stock Account ______%
Money Market Account ______%
Balanced Account ______%
Aggressive Stock Account ______%
----------------------------
(PERCENTAGES IN WHOLE NUMBERS) Total 100%
8. Will any existing insurance or annuity be replaced or changed (or has it
been), assuming the contract applied for will be issued? |_| Yes |_| No
IF YES, answer the questions below:
a. Year Issued: Plan:
---------- ----------
Company:
----------------------------------------------------------------
b. Contribution Basis: (CHECK ONE ONLY):
|_| pre-August 14, 1982 |_| post-August 13, 1982
(SEPARATE APPLICATION REQUIRED FOR EACH BASIS.)
c. Net Cost: $
-------------------------------------------------------------
(NET COST ILLUSTRATION MUST BE SUBMITTED)
9. CONTRIBUTIONS (COMPLETE ONLY IF CONTRIBUTION BASIS POST-AUGUST 13, 1982 AND
FURTHER CONTRIBUTIONS ANTICIPATED)
a. Reminder Notice (Billing) Required |_| Yes |_| No
IF YES, complete B-C-D
b. Reminder Frequency:
|_| Annual |_| Semi-Annual |_| Quarterly
For Salary Allotment Only:
|_| Monthly |_| Semi-Monthly |_| Bi-Weekly
c. First Reminder Date (IF SALARY ALLOTMENT, MUST AGREE WITH EXISTING UNIT
OR ATTACHED 983-2357 FORM):
Mo. Day
------------- -------------
d. XXXXXXXX XXXXXX $
-------------------------------------------------------
(CONTRIBUTIONS MUST BE AT LEAST $50.)
10. EXPECTED FIRST PARTICIPATION YEAR CONTRIBUTION $
----------------------------
(MUST BE AT LEAST $1,000 OR $600 IF SALARY ALLOTMENT)
FOR SALARY ALLOTMENT ONLY: IF AN ADVANCED PARTICIPATION DATE IS REQUESTED,
COMPLETE #9C AND #13.
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
(FOR PROCESSING OFFICE USE)
Unit Name Cert or App. #
--------------------------- ------------------------
Frequency Reminder Date
--------------------------- -------------------------
Amendment Required Participation Date
------------------ --------------------
----------------------------------------------------------------------------
Receipt Date | Batch # | Inquiry # | Processor
----------------------------------------------------------------------------
--------------------------------------------------------------------------------
983-2356A-PA (8-87) Cat. #121442
--------------------------------------------------------------------------------
11. Did you receive the Separate Accounts Prospectus? |_| Yes |_| No
Date on Prospectus
----------------------------------------------------------
Date of any supplement to Prospectus
----------------------------------------
12. ITEMS (A) THROUGH (G) ARE TO BE ANSWERED COMPLETELY OR NOT AT ALL. If
Participant does not wish to provide information requested, check here |_|.
(Show amounts before this purchase.)
NOTE: In NJ and MD by law item (A) MUST be answered
(a) Sources of Retirement Income (other than Soc. Security)
----------------------------------------------------------------------
----------------------------------------------------------------------
(b) Debts: $
---------------------------------------------------------------
---------------------------------------------------------------
---------------------------------------------------------------
(c) (i) Savings (Checking and Savings accounts)
$
---------------------------------------------------------------
(ii) Securities: $
----------------------------------------------------
(iii) Value of home, less mortgage: $
----------------------------------
(iv) Other Assets (specify sources and amounts):
-----------------------------------------------------------------
-----------------------------------------------------------------
(d) Ages of dependents:
----------------------------------------------------
(e) Amount of Life Insurance: $
--------------------------------------------
(f) Cash available for investment or retirement:
(i) $ annually, or (ii) $ single sum
-------- --------
(g) Annual income including spouse's: $
------------------------------------
13. SPECIAL INSTRUCTIONS
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
14. CUSTODIAN DESIGNATION: (Fill in)
THE OWNER IS
------------------------------------ --------------------------
(name) (Relationship)
as custodian for
------------------------------------------------------------
(participant)
under the Uniform Gifts to Minors Act
----------------
(state)
15. Amount paid with this form: $
-----------------------------------------------
(must be at least $1,000 for other than Salary Allotment)
(If a check is submitted with this request, no advanced participation date
is permitted.) BACKDATING IS NOT PERMITTED.
--------------------------------------------------------------------------------
NOTE: Amount paid will be credited upon receipt at Equitable's Processing
Office, subject to return if the contract is not issued; the Participation Date
of the contract will be the date of receipt by Equitable of all completed
requirements at Equitable's Processing Office. The Normal Form of annuity
benefit is a Life With 10 Years Certain Annuity. At retirement, you will be
given a choice of this form or any of several other available forms.
AGREEMENT
All information and statements furnished in this request are true and complete
to the best of my (our) knowledge and belief. I (We) understand and acknowledge
that no Agent has the authority to make or modify any contract on Equitable's
behalf, or to waive or alter any of Equitable's rights and regulations. Under
the penalties of perjury I (we) certify that the Social Security Number(s) or
Tax Identification Number(s) provided on this form is (are) true, correct, and
complete.
IT IS UNDERSTOOD THAT THE ACCOUNT VALUES ATTRIBUTABLE TO ALLOCATIONS TO THE
SEPARATE ACCOUNTS AND VARIABLE ANNUITY BENEFIT PAYMENTS MAY INCREASE OR DECREASE
AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
Signature of Proposed Participant X
---------------------------------------------
Date City State
------------------- ------------------------------ ------------------
Signature of Owner X
------------------------------------------------------------
(if other than the Proposed Participant)
--------------------------------------------------------------------------------
AGENT SECTION
Will any existing insurance or annuity be replaced or changed (or has it been),
assuming the contract applied for will be issued? |_| Yes |_| No
I (we) certify that a prospectus for the contract applied for has been given to
the proposed Participant and that no written sales materials other than those
approved by The Equitable have been used.
Non-Qualifed Equi-Vest issues must adequately reflect the commission interest of
all Agents on previous certificates or contract.
------------------------------------------------------------------------------------------------------------------------------------
Agents's Name(s) (Print) Initial of Agent Agent Agency District Agent's
(Service Agent first) Last Name Number % Code Manager Code Signature
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
FOR AGENCY COMPLIANCE FILE:
INITIALS OF AGENCY EQS Date District EQS Date
-------- -------- ------ -------------
--------------------------------------------------------------------------------
(FOR ASU USE)
ASU Code and App. No.
-----------------------------------------------------------
ASU Rec'd.
----------------------------------------------------------------------
Date to Proc. Off.
--------------------------------------------------------------
Campaign
------------------------------------------------------------------------
Agent(s) shown above is Equity Qualified and is licensed in the state
where the request is signed.
Above Agent information verified by ASM (Registered Rep)
------------------------
--------------------------------------------------------------------------------
983-2356A-PA (8-87) Cat. #121442
THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Processing Office: Individual Annuity Center, P.O. Box 2996, G.P.O.,
New York, New York 10116
REQUEST FOR ENROLLMENT UNDER EQUITABLE'S NON-QUALIFIED EQUI-VEST CONTRACT
--------------------------------------------------------------------------------
UNIT SECTION
(complete only if Salary Allotment is used)
1. EMPLOYER/UNIT NAME __________________________________________________________
2. |_| Existing Unit No.|_|_|_|_|_|_|-|_|_|_| |_| NEW UNIT |_|_|_|_|_|_|-|_|_|_|
Form 983-2357 Required
--------------------------------------------------------------------------------
PARTICIPANT SECTION
3. PROPOSED PARTICIPANT
a. Print name to appear on Certificate.
______________________________________________________________
First Middle Initial Last
b. |_| Mr. |_| Mrs. |_| Miss |_| Ms. |_| Other ______
x. Xxxx of Birth: Year ____________ Month __________ Day ________
d. Age at Nearest Birthday ______________________________________
e. State of Residence ___________________________________________
f. |_| Male |_| Female
g. Social Security Number |_|_|_|-|_|_|-|_|_|_|_|
h. Are you associated with or employed by a member of National
Association of Securities Dealers, Inc. (NASD)? |_| Yes |_| No
4. RETIREMENT AGE (maximum: 85) ________________
5. BENEFICIARY--Include FULL NAME and RELATIONSHIP to Participant.
(For Death Benefit upon Participant's death before Retirement
Date, and for Ownership Rights upon death of Owner)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
6. OWNER--Specify:
Full Name and Address Relationship to Participant
_____________________________ ________________________________
_____________________________ Social Security or Tax I.D. No.
_____________________________ ________________________________
Above named Owner will receive all communications. Specify any
co-owners or secondary owners in Special Instructions (#12).
7. CONTRIBUTION ALLOCATION
(PERCENTAGES IN WHOLE NUMBERS)
Fixed Income Account _______%
Stock Account (Sep Acct A) _______%
Money Market Acct (Sep Acct E) _______%
Balanced Acct (Sep Acct J) _______%
Aggressive Stock Acct (Sep Acct K _______%
------------------
Total 100 %
8. Will any existing insurance or annuity be replaced or changed
(or has it been), assuming the certificate applied for will be
issued? |_| Yes |_| No
If yes, answer the questions below:
Contribution Basis |_| pre-August 14, 1982
(check one) |_| post-August 13, 1982
Note that a separate enrollment form must be submitted for
each basis.
_______________________________________________________________
Year Issued, Company, and Plan
_______________________________________________________________
Net Cost
(Net Cost Illustration msut be submitted.)
9. CONTRIBUTIONS (complete only if the Contribution Basis is
post-August 13, 1982 and further contributions are
anticipated)
a. Reminder Frequency
If no reminders are desired, check here: |_|
|_| Annual |_| Semi-Annual |_| Quarterly
For Salary Allotment Only:
|_| Monthly |_| Semi-Monthly |_| Bi-Weekly
b. First Reminder Date (if Salary Allotment, must agree with
existing unit or attached 983-2357
form): Mo.____________ Day____________
c. REMINDER AMOUNT $_____________
(contributions must be at least $50.)
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
(FOR
PROCESSING Unit Name ___________________ Cert. or App. # ____________________
OFFICE Frequency ___________________ Reminder Date ______________________
USE) Amendment Required __________ Participation Date _________________
--------------------------------------------------------------------------
Receipt Date Batch# Inquiry # Processor
--------------------------------------------------------------------------
--------------------------------------------------------------------------------
983-2356 CAT.#115075
d. EXPECTED FIRST PARTICIPATION YEAR
CONTRIBUTION $ __________________________________________
(must be at least $1,000, for Individual billing
or $600. for Salary Allotment)
For Salary Allotment only: If an advanced participation date
is requested, complete #9b and #12.
10. Did you receive the Separate Accounts Prospectus?
|_| Yes |_| No
Date on Prospectus __________________________________________
Date of any supplement to Prospectus ________________________
11. Items (a) through (g) are to be answered completely or not at all.
If Participant does not wish to provide information requested,
check here |_|. (Show amounts before this purchase.) Note: In NJ and MD
by law item (a) must be answered.
(a) Sources of Retirement Income (other than Soc. Security)
_______________________________________________________
_______________________________________________________
(b) Debts: $_______________________________________________
_______________________________________________
(c) (i) Savings (Checking and Savings accounts):
$________________________________________________
(ii) Securities: $____________________________________
(iii) Value of home, less mortgage: $__________________
(iv) Other Assets (specify sources and amounts):
_________________________________________________
_________________________________________________
(d) Ages of dependents:____________________________________
(e) Amount of Life Insurance: $____________________________
(f) Cash available for investment or retirement:
(i) $___________________________________ annually, or
(ii) $___________________________________ single sum
(g) Annual income including spouse's: $____________________
12. SPECIAL INSTRUCTIONS
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
13. Amount paid with this form: $______________________________
(must be at least $1,000. for other than Salary Allotment)
(If a check is submitted with this request, no advanced
participation date is permitted.)
Backdating is not permitted.
--------------------------------------------------------------------------------
NOTE: Xxxxxx paid will be credited upon receipt at Equitable's Processing
Office, subject to return if the certificate is not issued; the Participation
Date of the certificate will be the date of receipt by Equitable of all
completed requirements at Equitable's Processing Office. The Normal Form of
annuity benefit is a Life With 10 Years Certain Annuity. At retirement, you will
be given a choice of this form or any of several other available forms.
AGREEMENT
All information and statements furnished in this request are true and complete
to the best of my (our) knowledge and belief. I (We) understand and acknowledge
that no Agent has the authority to make or modify any contract on Equitable's
behalf, or to waive or alter any of Equitable's rights and regulations. Under
the penalties of perjury I (we) certify that the Social Security Number(s) or
Tax Identification Number(s) provided on this form is (are) true, correct, and
complete.
IT IS UNDERSTOOD THAT THE ACCOUNT VALUES ATTRIBUTABLE TO ALLOCATIONS TO THE
SEPARATE ACCOUNTS AND VARIABLE ANNUITY BENEFIT PAYMENTS MAY INCREASE OR DECREASE
AND NOT ARE GUARANTEED AS TO DOLLAR AMOUNT.
Signature of Proposed Participant Date: City State:
-----------------------------------------------
Signature of Owner (if other than the Proposed Participant)
---------------------
--------------------------------------------------------------------------------
AGENT SECTION
Will any existing insurance or annuity be replaced or changed (or has it been),
assuming the certificate applied for will be issued? |_| Yes |_| No
I (We) certify that a prospectus for the certificate applied for has been given
to the proposed Particpant and that no written sales materials other than those
approved by The Equitable have been used.
Non-Qualified Equi-Vest issues must adequately reflect the commission interest
of all Agents on previous contracts or certificates.
___________________________________________________________________________
Agent's Name(s) (Print Initial of Agent Agent Agency District Agent's
(Service Agent first) Last Name Number % Code Manager Code Signature
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
--------------------------------------------------------------------------------
FOR AGENCY COMPLIANCE FILE: INITIALS OF AGENCY EQS__________ Date__________
District EQS_____________ Date_____________
--------------------------------------------------------------------------------
(FOR ASU USE)
ASU Code and App. No.____________ ASU Rec'd._____________ Date to Proc. Off.____
__________________ Campaign |_|
Agent(s)shown above is Equity Qualified and is licensed in the state where the
request is signed.
Above Agent information verified by ASM (Registered Rep)__________________
--------------------------------------------------------------------------------
983-2356 CAT.#115075
APPLICATION TO THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Processing Office: Individual Annuity Center, P.O. Box 2996, G.P.O.,
New York, New York 10116
REQUEST FOR ENROLLMENT UNDER EQUITABLE'S QUALIFIED EQUI-VEST CONTRACT
--------------------------------------------------------------------------------
PLAN/UNIT SECTION
1. TYPE OF PURCHASE Complete One Plan Only
A. |_| TSA Public School (GV-PS 4931)
B. |_| TSA 501(c)(3) Organization (GV-501 4921)
C. |_| TSA University (GV-PS 4931-31)
D. |_| IRA Individual (XX-XXX 4971)
E. |_| IRA Unit Billed (XX-XXX 4971)
F. |_| IRA QUALIFIED PLAN ROLLOVER-Distribution from a Qualified Plan
(XX-XXX 4971-71)
G. |_| PEDC (Public Employee Deferred Compensation) )GV-PEDC 4991)
H. |_| IRC-457 (Tax Exempt Organization) (GV-PEDC 4991-SU-080)
I. |_| SEP (Simplified Employee Pension) (GV-SEP 4981)
J. |_| CORPORATE TRUSTEED (GV-Corp 4941-41)
Type of contributions |_| Required |_| Voluntary (After Tax)
K. |_| XXXXX/HR-10 TRUSTEE (GV HR-10 4911-11) (trustee owned) (9)
Type of contributions |_| Required |_| Voluntary (After Tax)
L. |_| XXXXX/HR-10 (GV - HR-10 4911) (not trustee owned) (9)
Type of contributions |_| Required |_| Voluntary (After Tax)
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
DO NOT COMPLETE THIS SECTION IF BOX 1.D OR 1.F CHECKED ABOVE
2. EMPLOYER / PLAN NAME
-------------------------------------------------------
3. |_| EXISTING UNIT NO. |_|_|_|_|_|_| - |_|_|_|
|_| NEW UNIT |_|_|_|_|_|_| - |_|_|_|
(FOR NEW TRUSTEED OWNER PLAN OR TWO OR MORE LIVES FORM 983-135B REQUIRED)
================================================================================
PARTICIPANT SECTION
4. PROPOSED PARTICIPANT - Print name to appear on Certificate.
----------------------------------------------------------------------------
First Middle Initial Last
A. |_| Mr. |_| Mrs. |_| Miss |_| Ms. Other
---------
B. Date of Birth: Year Month Day
------- ------- --------
C. Age at Nearest Birthday
-----------------------------
D. |_| Male |_| Female
E. Participant's Mailing Address
No., St. |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
State |_|_| Zip Code |_|_|_|_|_| - |_|_|_|_|
F. State of Residence
---------------------------------------
G. Social Security No. (Required) |_|_|_| - |_|_| - |_|_|_|_|
H. Are you associated with or employed by a member of National
Association of Securities Dealers, Inc. (NASD)? |_| Yes |_| No
5. RETIREMENT AGE
------------------
6. BENEFICIARY--Include FULL NAME and RELATIONSHIP to Participant.
(BENEFICIARY MUST BE THE OWNER FOR PEDC/IRC-457 PURCHASES AND FOR MOST
TRUSTEED PLANS.)
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
7. CONTRIBUTION ALLOCATION
(PERCENTAGES IN WHOLE NUMBERS)
Fixed Income Account ______%
Stock Account ______%
Money Market Account ______%
Balanced Account ______%
Aggressive Stock Account ______%
------------------
Total 100%
8. CONTRIBUTIONS (NOT REQUIRED FOR 1.F)
A. Reminder Notice (Billing) Required |_| Yes |_| No
IF YES, complete b-c-d-e
B. REMINDER DATE Required for Individual IRA or otherwise must agree with
existing unit or attached 983-135B
Month Day
------------- -------------
C. REMINDER FREQUENCY
|_| Annual |_| Semi-Annual
|_| Quarterly |_| Monthly
Available for TSA, PEDC/IRC-457 AND UNIT BILLED IRA ONLY:
|_| Semi-Monthly |_| Bi-Weekly
D. REMINDER AMOUNT $
-------------------------------------------------------
E. BILLING MONTHS TO BE EXCLUDED - TSA ONLY
------------------------------------------------------------------------
------------------------------------------------------------------------
9. EXPECTED FIRST PARTICIPATION YEAR CONTRIBUTION $
----------------------------
If an advanced billing and/ or participation date are requested, complete
#8b and #13.
================================================================================
(FOR PROCESSING OFFICE USE)
Unit Name Reminder Date
--------------------------- -------------------------
Cert or App. # Amendment Required
---------------------- ------------------
PEDC Emp. Add. Emp. Fed. ID#
---------------------- ------------------------
Frequency Participation Date
--------------------------- --------------------
----------------------------------------------------------------------------
Receipt Date | Batch # | Inquiry # | Processor
----------------------------------------------------------------------------
================================================================================
983-136D (1-87) Cat. #120764
--------------------------------------------------------------------------------
10. Did you receive the Separate Accounts Prospectus? |_| Yes |_| No
Date shown on Prospectus
----------------------------------------------------
Date of any supplement to Prospectus
----------------------------------------
11. ITEMS (A) THROUGH (G) ARE TO BE ANSWERED COMPLETELY OR NOT AT ALL. If
Annuitant does not wish to provide information requested, check here |_|.
(Show amounts before this purchase.) NOTE: In NJ and MD by law item (A) MUST
be answered.
(a) Sources of Retirement Income (other than Soc. Security)
------------------------------------------------------------------------
------------------------------------------------------------------------
(b) Debts: $
---------------------------------------------------------------
---------------------------------------------------------------
---------------------------------------------------------------
(c) (I) Savings (Checking and Savings accounts)
$
---------------------------------------------------------------
(II) Securities: $
----------------------------------------------------
(III) Value of home, less mortgage: $
----------------------------------
(IV) Other Assets (specify sources and amounts):
-----------------------------------------------------------------
-----------------------------------------------------------------
(d) Ages of dependents:
----------------------------------------------------
(e) Amount of Life Insurance: $
--------------------------------------------
(f) Cash available for investment or retirement:
(I) $ annually, or
----------------------------------------------------
(II) $ single sum
-------------------------------------------------------
(g) Annual income including spouse's: $
------------------------------------
12. Will any existing insurance or annuity be replaced or changed (or has it
been), assuming the certificate applied for will be issued? |_| Yes |_| No
13. SPECIAL INSTRUCTIONS
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
----------------------------------------------------------------------------
14. Amount paid with this form: $
-----------------------------------------------
(If a check is submitted with this request, no advanced participation date
is permitted.) BACKDATING IS NOT PERMITTED.
NOTE: Xxxxxx paid will be credited upon receipt at Equitable's Processing
Office, subject to return if the certificate is not issued; the Participation
Date of the certificate will be the date of receipt by Equitable of all
completed requirements at Equitable's Processing Office.
================================================================================
AGREEMENT
All information and statements furnished in this request are true and complete
to the best of my knowledge and belief. I understand and acknowledge that no
Agent has the authority to make or modify any contract on Equitable's behalf, or
to waive or alter any of Equitable's rights and regulations.
IT IS UNDERSTOOD THAT THE ACCOUNT VALUES ATTRIBUTABLE TO ALLOCATIONS TO THE
SEPARATE ACCOUNTS AND VARIABLE ANNUITY BENEFIT PAYMENTS MAY INCREASE OR DECREASE
AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT.
Signature of Participant X Date City State
------------------------ ------ ----- ------
Signature of Owner (REQUIRED FOR PEDC/IRC 457/HR-10 TRUSTEE/CORP. TRUSTEED)
X
-------------------------------------------------------------------------------
================================================================================
AGENT SECTION
Will any existing insurance or annuity be replaced or changed (or has it been),
assuming the certificate applied for will be issued? |_| Yes |_| No
I (we) certify that a prospectus for the certificate applied for has been given
to the proposed Annuitant and that no written sales materials other than those
approved by The Equitable have been used.
Equi-Vest issues must adequately reflect the commission interest of
all Agents on previous contracts or certificates.
--------------------------------------------------------------------------------
Initial
(Print) of
Agents's Name(s) Last Agent Agent Agency District Agent's
(Service Agent first) Name Number % Code Manager Code Signature
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
================================================================================
FOR AGENCY COMPLIANCE FILE: INITIALS OF AGENCY EQS Date District EQS Date
--- --- -- --
================================================================================
(FOR ASU USE)
ASU Code and App. No.
-----------------------------------------------------------
ASU Rec'd.
----------------------------------------------------------------------
Date to Proc. Off. Campaign |_|
--------------------------------------------------
AGENT(S) SHOWN ABOVE IS EQUITY QUALIFIED AND IS LICENSED IN THE STATE
WHERE THE REQUEST IS SIGNED.
Above Agent information verified by XXX (Registered Rep)
--------------------------------------------------------------------------------
Application reviewed by
--------------------------------------------------------
.===============================================================================
983-136D Cat. #120764
--------------------------------------------------------------------------------
THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
APPLICATION FOR ESTABLISHMENT OF NEW QUALIFIED EQUI-VEST PLAN
--------------------------------------------------------------------------------
1. TYPE OF QUALIFIED PLAN ESTABLISHED:
a) |_| TSA 403(b) (Public School) (3-30)
b) |_| TSA 501 (c) (3) Organization (2-20)
c) |_| TSA University (3-31)
d) |_| IRA Unit Billed (7-70)
e) |_| SEP (Simplified Employee Pension) (8-80)
f) |_| PEDC (Public Employee Deferred Compensation) (9-90)
g) |_| IRC-457 (Tax Exempt Organization) (9-90 SU 080)
h) |_| XXXXX/HR-10 TRUSTEE (1-11)
i) |_| XXXXX/HR-10 (1-10)
j) |_| CORPORATE TRUSTEED (4-41)
2. NAME OF PLAN:
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
3. EFFECTIVE DATE OF PLAN:
Year___________ Month__________ Day___________
4. FISCAL YEAR END (FOR XXXXX, SEP, PEDC/IRC-457):
Month___________________ Day_______________
5. REMINDER NOTICE REQUIRED: |_| YES |_| NO
6. UNIT REMINDER DUE DATE:
Month___________________ Day_______________
7. REMINDER FREQUENCY:
|_| Annual (1) |_| Semi-Annual (2)
|_| Quarterly (3) |_| Monthly (4)
Available for TSA, PEDC/IRC-457 and Unit Billed IRA
only: |_| Semi-Monthly (5) |_| Bi-Weekly (7)
8. ORDER IN WHICH PARTICIPANTS TO APPEAR ON STATEMENT
REMINDER:
|_| Alphabetical (3) |_| Certificate Number (2)
9. EMPLOYER FEDERAL IDENTIFICATION NUMBER:
|_|_|-|_|_|_|_|_|_|_|
10. BILLING NAME:
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Plan Mailing and Billing Address: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
No. & Street: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City or Town: |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
State: |_|_|_|_|_|_|_|_|
Zip Code: |_|_|_|_|_|-|_|_|_|_|
11. TSA UNIVERSITY PLANS ONLY:
(A) Does the University Plan Document AUTHORIZE Participants to make
Loans: |_| Yes |_| No
(B) Maximum % of cash at maturity |_|_|_|%
(C) Surrenders, Withdrawals or Loans (if allowed) will be processed only
with employer approval at the time the request is made.
(D) Please describe any other plan restrictions on reverse of this form.
Acceptance of any other plan provisions or restrictions detailed on
the back is subject to Equitable approval.
12. PEDC/IRC-457, HR-10 TRUSTEE, AND CORPORATE TRUSTEED PLANS ONLY:
A) Should all correspondence (except Billing & Proxies) be sent to
participant? |_| Yes |_| No
B) Does Owner/Employer authorize Participants to make transfers
between accounts and change the allocation percentages for
future allocations? |_| Yes |_| No
13. ERISA INFORMATION STATEMENT SUBMITTED (Required if Box 1(C)(D)(E)(G)(H)
(I) or (J) checked): |_| Yes |_| No
14. IS EQUITABLE ADOPTION STATEMENT BEING SUBMITTED (Answer Required if Box
1(H)(I) or (J) checked): |_| Yes |_| No
--------------------------------------------------------------------------------
UPON ESTABLISHMENT OF PLAN, THE EQUITABLE IS AUTHORIZED TO SOLICIT PROSPECTIVE
APPLICANTS FOR THE PLAN.
X_____________________________________________ Date at _____________ on __ 19 __
Signature and Title of Authorized Officer City State
or Purchaser
--------------------------------------------------------------------------------
Key Agent (Please Print)
___________________________________________ ASU (Alpha) _______ (Numeric) ______
(First) (Middle Initial) (Last) (Code)
Agency__________________________________________________________________________
(Name) (Numeric Code)
Key Agent Signature ___________________________________________
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(PROC. OFFICE USE ONLY) |_|_|_|_|_|_|_|_|_|_|_| Analyst Code |_|_|_|
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983-135B (1-87) Cat. #120755
