ContractLimited Temporary Insurance Agreement • October 6th, 2023 • Separate Account Fp
☐ Equitable Financial Life Insurance Company ☐ Equitable Financial Life Insurance Company of America Mailing Address: PO Box 1047, Charlotte, NC 28201-1047 Section C—Limited Temporary Insurance Agreement and Questionnaire Forming a Part of the Application for Individual Life Insurance Name of Proposed Insured Date of Birth (mm/dd/yyyy) Name of Proposed 2nd Insured Date of Birth (mm/dd/yyyy) If any of the questions below are answered “Yes” or left blank with respect to any Proposed Insured(s), no representative of the Company is authorized to accept money, and NO COVERAGE will take effect under this Agreement with respect to such Proposed Insured(s). 1. The questions below apply to all Proposed Insured(s). a) Is any Proposed Insured less than 15 days or over 70 years of age? ☐ Yes ☐ No b) Within the past 24 months has any Proposed Insured been attended by a care provider or been seen at a medical facility for heart condition or disease, stroke or cancer? ☐ Yes ☐ No c) Within the past 10
