SECTION I

PERSONAL FINANCIAL STATEMENT OF THE PROPOSED INSURED(S)

SECTION II (CONT’D ON NEXT TWO PAGES)

OTHER INFORMATION

1. Balance Sheet

Assets Liabilities

Description Amount Description Amount

Cash $ Mortgages $

Stocks, Bonds, Securities $ Loans $

Real Estate (including primary residence) $ Notes $

Retirement Plans $ Other (please specify) $

Business Equity $ Other (please specify) $

Other (please specify) $ Other (please specify) $

Other (please specify) $ Other (please specify) $

Total $ Total $

Net Worth (total assets – total liabilities $

2. Income

‘‘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.

5. Do any of the Parties intend to use or transfer the policy for any type of pre-death financial settlement, such Yes No

as a viatical settlement, senior settlement, life settlement, or for any other settlement in the secondary market?

6. Will any other person or entity (i.e., a person or entity different than the Owner or Beneficiary initially named in Yes No

the policy) provide any funding, financing, or guarantees for any premium payment on the policy, or are any

potential or alternate sources of funding, financing, or guarantees under consideration?

If ‘‘Yes,’’ please submit a copy of all actual or potential funding, financing, or guarantee documents, and a

detailed, third party prepared Personal Financial Statement signed by the preparer. The above documents are not

required if funding is part of a split-dollar arrangement (1) between the employer and the employee or a

corporation and its shareholders, provided that the employment and/or shareholder relationship was not entered

into to establish a premium funding arrangement; or (2) between the Proposed Insured and another family

member (i.e., in either case, there is no third party unaffiliated entity or non-related individual involved). Please

also answer the following questions:

a. State why the premiums will or may be funded or financed, or why other guarantees will or may be provided.

AXA Equitable Life Insurance Company MONY Life Insurance Company of America

SECTION C – FINANCIAL QUESTIONNAIRE FORMING PART OF THE APPLICATION FOR LIFE INSURANCE

Complete SECTION I only if the Proposed Insured is under age 65 and the sum of the Face Amount(s) of all concurrent and/or pending applications

with the Company checked on page 1 above Section A of the Application and/or any other affiliated companies equals $2 million or more.

Complete SECTIONS I and II if the Proposed Insured is age 65 or older and the sum of the Face Amount(s) of all concurrent and/or pending

applications with the Company checked on page 1 above section A of the Application and/or any other affiliated companies equals $2 million or

more.

Provide responses for each Proposed Insured and each Owner(s), as well as each Beneficiary, where applicable. (If additional space is needed,

attach additional sheet(s) of paper, which must be signed and dated by the Proposed Insured, Owner, and Financial Professional(s)).

Name of Proposed Insured Policy # (if known) Date of Birth

(mm/dd/yyyy)

Earned Income Unearned Income

Income Dividends/Interest Rental Income Pension/Social

Sec.

Other (please

specify):

Total

Current Year $ $ $ $ $ $

Last Year $ $ $ $ $ $

3. How was the proposed face amount determined for this Application?

State what formula was used (e.g., estate tax calculation, survivor needs, estimated fair market value or book value of the business,

capitalization of earnings, etc.); if none, state ‘‘None’’

4. Do you expect any changes greater than 15% in income or net worth in the next 12 months? Yes No

If ‘‘Yes,’’ please explain

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SECTION II (CONT’D FROM PREVIOUS PAGE)

OTHER INFORMATION

b. State the name of the other person or entity providing the actual or potential funding, financing, or guarantees

and role (i.e., lender, guarantor, etc).

c. State how the actual or potential funding, financing, or guarantees will be repaid, what collateral will be used,

and whether the lender’s or guarantor’s ability to recover is limited to the value of the policy.

d. Will a letter of credit or personal guarantee be posted? Yes No

If ‘‘Yes,’’ please state the details, including details relating to the assets backing the letter of credit.

7. Will any of the Parties have the right or option to transfer any direct or indirect interest in the policy to another Yes No

person or entity at a predetermined price or other terms?

If ‘‘Yes,’’ please identify the right or the option and submit a copy of all documents providing for that right or

option.

8. a. Will a trust, partnership, or other entity receive or potentially receive any direct or indirect ownership, death Yes No

benefits, or other interests or benefits in the policy?

If ‘‘Yes,’’ please submit a copy of all documents that create the trust, partnership or other entity. The above

documents are not required if funding is part of a split-dollar arrangement (1) between the employer and the

employee or a corporation and its shareholders, provided that the employment and/or shareholder relationship

was not entered into to establish a premium funding arrangement; or (2) between the Proposed Insured and

another family member (i.e., in either case, there is no third party unaffiliated entity or non-related individual

involved).

b. If an employer sponsored split dollar arrangement, please indicate the amount of time the employee or

shareholder has been affiliated with the entity: years

9. Has there been any consideration or any written information provided regarding the sale or transfer or potential Yes No

sale or transfer to another person, partnership, or other entity of (1) any interest in this policy; or (2) any interest

in a trust or other entity that has an interest in this policy?

If ‘‘Yes,’’ please state what has been considered or provided, what action has or may be taken in the future as a

result, and attach the written information provided.

10. Have any of the Parties sold or transferred any life insurance policy or an interest therein, within the last Yes No

five years?

If ‘‘Yes,’’ please state the details of the transaction including name of each company and the number of years the

policy was in effect.

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SECTION II (CONT’D FROM

PREVIOUS PAGE)

11. Has any entity, other than the Company checked on page 1 above section A of the Application, medically Yes No

evaluated the Proposed Insured to determine life expectancy or will such an evaluation occur?

If ‘‘Yes,’’ please state who has conducted or will conduct the examination, and when the examination occurred

or will occur.

REFERENCES

Please complete this References section if:

the Proposed Insured is under age 70 and the sum of the Face Amount(s) of all concurrent and/or pending

applications with the Company checked on page 1 above section A of the Application and/or any other affiliated

companies equals $10 million or more;

or

the Proposed Insured is age 70 or older and the sum of the Face Amount(s) of all concurrent and/or pending

applications with the Company checked on page 1 above section A of the Application and/or any other affiliated

companies equals $5 million or more.

Attorney Accountant

Name, Title Business Address Telephone No.

Has the above-named reference been authorized to release information? Yes No

If ‘‘No,’’ please explain

If you did not provide a reference, please explain

CERTIFICATIONS

State laws prohibit intentional misstatements in connection with any application for insurance. If you make any misstatement

in response to the questions in this Financial Questionnaire (including any intentional misstatement regarding the actual or

potential funding of premiums, or transfer or sale of this policy), you will be subject to those laws and any penalties that may

result.

I (We), as Proposed Insured and Owner, represent that if I (we) enter into any transaction at any time to assign, sell, or otherwise

transfer any interest in the policy or any interest in a trust or other entity owning the policy:

(1) I (we) have not relied on any representations by the Company checked on page 1 above section A of the Application and/or any

other affiliated companies, or its Agents/Insurance Brokers, regarding the benefits and risks of such a transaction; and

(2) there are no guarantees that I (we) will be successful, and I (we) may incur costs or other disadvantages and risks of such a

transaction. The disadvantages and risks of such a transaction include, but are not limited to, the risk of tax consequences, the loss

of death benefits, the loss of insurability, or the loss of other rights or interests that I (we) are not aware of.

If additional sheets of paper are attached to this Financial Questionnaire, please indicate the number of additional pages: pages

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