THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Application and Agreement for Establishment of Plan
Participation in the [Momentum] Program
Group Annuity Contract
Employer:__________________________________________________________
Employer Address:___________________________________________________
Employer Plan:______________________________________________________
I. Plan/Trust Type: The Employer Plan will participate in Equitable's
[Momentum] Program through adoption of the Members Retirement Plan and Trust
by the Employer. The type of plan adopted thereunder is (Check one):
[ ] (a) Standardized Profit Sharing Plan
[ ] (b) Non-standardized Profit Sharing Plan
[ ] (c) Simplified Profit Sharing Plan
[ ] (d) Standardized Defined Contribution Pension Plan
[ ] (e) Non-standardized Defined Contribution Pension Plan
[ ] (f) Simplified Defined Contribution Pension Plan
A duly authorized officer of the Employer has, on behalf of the
Employer, completed and signed the appropriate Participation
Agreement with respect to such plan.
II. Application and Agreement: By signature below of duly authorized person(s),
the Employer hereby:
A. Acknowledges having received and read the Prospectus and Group Annuity
Contract for Equitable's [Momentum] Program, as well as the ERISA
Information Statement;
B. Acknowledges understanding of the fees, charges, and funding arrangements
under the [Momentum] Program;
PF10, 631 PAGE 1
C. Applies for participation in the [Momentum] Program Group Annuity
Contract as funding vehicle for assets of the Employer Plan;
D. Agrees to be bound by the terms and conditions of the Group Annuity
Contract; and
E. Acknowledges understanding that no Agent of Equitable has authority to
make or modify any contract or agreement on Equitable's behalf, or to
waive or alter any of Equitable's rights or requirements.
This Application and Agreement will become effective only upon
acceptance, by signature below, of a duly authorized signatory on
Equitable's behalf.
FOR EMPLOYER:
-------------
_________________________ ____________________ _________________
Print Name of Employer City State
or Officer
By____________________________________________ __________________
Signature & Title of Employer or Officer Date
ACCEPTED FOR EQUITABLE:
-----------------------
_______________________________ By_______________________________
Print Name of Authorized Signatory Signature of Authorized Signatory
EFFECTIVE DATE:_________________________ CLIENT NO.____________
A copy of the Application/Agreement should be retained in Applicant's files and
the original should be given to the Agent for forwarding to the Equitable
Processing Office along with the other installation materials. These documents
will be signed by Equitable and returned to the Applicant after being
underwritten. Initial contributions will be accepted by Equitable only after
installation documents have been approved by the Equitable Processing Office.
PF10, 631 PAGE 2
THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Application and Agreement for Establishment of Plan
Participation in the [Momentum] Program
Group Annuity Contract
Employer:__________________________________________________________
Employer Address:___________________________________________________
Employer Plan:______________________________________________________
Participating Trust:___________________________________________________
__________________________________________________________________
I. Plan/Trust Type: The Employer Plan will participate in Equitable's
[Momentum] Program through adoption of the Pooled Trust for Members
Retirement Plans by the Employer and the Trustee(s) of the Participating
Trust. The Employer Plan is a plan of the following type (Check one):
[ ] (a) Profit Sharing Plan
[ ] (b) Defined Contribution Pension Plan
II. Application and Agreement: By signature below of duly authorized person(s),
the Employer and the Trustee(s) of the Participating Trust, hereby:
A. Acknowledge having received and read the Prospectus and Group Annuity
Contract for Equitable's [Momentum] Program, as well as the ERISA
Information Statement;
B. Acknowledge understanding of the fees, charges, and funding arrangements
under the [Momentum] Program;
C. Apply for participation in the [Momentum] Program Group Annuity Contract
as funding vehicle for some or all of the assets of the Employer Plan;
D. Agree to be bound by the terms and conditions of the Group Annuity
Contract; and
E. Acknowledge understanding that no Agent of Equitable has authority to
make or modify any contract or agreement on Equitable's behalf, or to
waive or alter any of Equitable's rights or requirements.
PF10, 632 PAGE 1
This Application and Agreement will become effective only upon
acceptance, by signature below, of a duly authorized signatory on
Equitable's behalf.
FOR EMPLOYER:
-------------
_________________________ ____________________ _________________
Print Name of Employer City State
or Officer
By____________________________________________ _________________
Signature & Title of Employer or Officer Date
FOR TRUSTEE(S):
_________________________ ____________________ _________________
Print Name of Trustee City State
By_____________________________________________ _________________
Signature of Trustee Date
_________________________ ____________________ _________________
Print Name of Trustee City State
By_____________________________________________ _________________
Signature of Trustee Date
_________________________ ____________________ _________________
Print Name of Trustee City State
By_____________________________________________ _________________
Signature of Trustee Date
PF10,632 Page 2
ACCEPTED FOR EQUITABLE:
-----------------------
_______________________________ By_______________________________
Print Name of Authorized Signatory Signature of Authorized Signatory
EFFECTIVE DATE:_________________________ CLIENT NO.____________
A copy of the Application/Agreement should be retained in Applicant's files and
the original should be given to the Agent for forwarding to the Equitable
Processing Office along with the other installation materials. These documents
will be signed by Equitable and returned to the Applicant after being
underwritten. Initial contributions will be accepted only after installation
documents have been approved by the Equitable Processing Office.
PF10, 632 PAGE 3
