EQUITABLE LIFE INSURANCE VARIABLE ANNUITY APPLICATION
COMPANY OF IOWA
______________________________________________________________________________
Annuity plan applied for: _________________________
Maturity Date (Date on which benefit payments are to begin.) __/__/__
Purchase Payment $____________
Future Payment(s) $___________ [ ] Monthly [ ] Qrtly [ ] Semi-Annl [ ] Annual
______________________________________________________________________________
TYPE OF PLAN [ ] Non-Qualified [ ] 1035 Exchange [ ] IRA [ ] SEP-IRA Rollover
[ ] IRA Transfer [ ] SEP-IRA [ ] IRA Rollover from Qualified Plan
[ ] OTHER ____________________ [ ] 403(b) [ ] 403(b) TSA Rollover
I acknowledge that I understand the withdrawal restrictions under Internal
Revenue Code Section 403(b)(11) on contributions and earnings and have
received a prospectus explaining the restrictions. I understand the other
investment alternatives available under the employer's 403(b) arrangement to
which I may elect to transfer my contract value.
______________________________________________________________________________
ANNUITANT INFORMATION
Full Name______________________________ Social Security Number________________
Address________________________________ [ ] Male [ ] Female
________________________________ Date of Birth __/__/__
City___________________________________ State_____________________ Zip________
______________________________________________________________________________
OWNER INFORMATION JOINT OWNER INFORMATION
(If different from Annuitant)
Full Name_____________________________ Full Name______________________________
Address_______________________________ Address________________________________
City____________State________Zip______ City_____________State________Zip______
Social Security Number________________ Social Security Number_________________
[ ] Male [ ] Female [ ] Male [ ] Female
Date of Birth ___/___/___ Date of Birth ___/___/___
______________________________________________________________________________
PRIMARY BENEFICIARY(IES) (Show % each is to receive.) Relationship Soc. Sec. #
______________________________________________________________________________
______________________________________________________________________________
(Add separate sheet for contingent beneficiary information)
______________________________________________________________________________
PURCHASE PAYMENT ALLOCATION Subaccount Percent(%)
_____________ _____________
Enter desired Subaccount number and _____________ _____________
indicate percent of Purchase Payment _____________ _____________
allocation. Use whole percentages only. _____________ _____________
If more room is needed, use back of _____________ _____________
application. _____________ _____________
_____________ _____________
Fixed Account
_____________ _____________
Total Percent 100%
ALLOCATION DURING RIGHT TO EXAMINE PERIOD
Under certain circumstances, as described in the accompanying Prospectus, the
initial purchase payment will be allocated to the XXX Money Market Portfolio
until the expiration of the Right to Examine Period. Thereafter, the purchase
payments will be allocated as directed in the Purchase Payment Allocation
Section.
______________________________________________________________________________
Is the policy applied for to replace or change any existing Life Insurance or
Annuity contract? [ ] Yes [ ] No
______________________________________________________________________________
It is understood and agreed that:
(1) The statements made shall form the exclusive basis of any Annuity Contract
or Certificate issued hereon;
(2) Only the President or Secretary can make, modify, discharge, or waive any
of the Company's rights;
(3) The Annuity Contracts or Certificates are not effective until the initial
purchase payment is received by the Company;
(4) CHECKS MUST BE MADE PAYABLE TO THE COMPANY. CHECKS ARE NOT TO BE MADE
PAYABLE TO THE AGENT. THE CANCELLED CHECK IS YOUR RECEIPT;
(5) THERE IS A SUBSTANTIAL PENALTY FOR EARLY SURRENDER.
______________________________________________________________________________
I agree that the above information contained in the application is true and
correct to the best of my knowledge and belief and is made as the basis for my
application. I UNDERSTAND THAT ANNUITY PAYMENTS AND TOTAL WITHDRAWAL VALUES
(IF ANY) PROVIDED BY THIS CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF
A SEPARATE ACCOUNT ARE VARIABLE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR
AMOUNT. HOWEVER, FIXED ACCOUNT VALUES ARE GUARANTEED AS TO A FIXED DOLLAR
AMOUNT. RECEIPT OF A CURRENT VARIABLE ANNUITY PROSPECTUS IS HEREBY
ACKNOWLEDGED. Under penalty of perjury, I certify that my social security
number listed above is correct and that I am not currently subject to backup
withholding. Application made at:
City____________________ State___________ this ___ day of _____________, 19___
_________________________________ ___________________________________________
Annuitant's Signature Owner's Signature (if other than Annuitant)
______________________________________________________________________________
AGENT'S REPORT To the best of your knowledge, does the policy applied for
involve replacement or modification of any existing Life Insurance or Annuity
contract? [ ] Yes [ ] No
If Yes, Indicate which cost basis and submit required replacement forms.
[ ] Life Insurance [ ] Annuity [ ] Cost Basis $_____________
Agent Name_____________________________ Tel. (___)___-____ Agent No. _____
Address_______________________________________________________________________
City___________________________________ State___________________ Zip__________
Signature of Agent____________________________________ Date Signed ___/___/___
______________________________________________________________________________
General Agent______________________________ Branch Office Location____________
City_____________________ State_________ Zip________ Telephone________________
______________________________________________________________________________
SEND APPLICATION AND CHECK TO: P.O. BOX 9271, DES MOINES, IA 50306-9271
