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AXA Equitable Life Insurance Company Application for Individual

1290 Avenue of the Americas, New York, NY 10104 MONY Life Insurance Company of America Life Insurance - Part 1

‘‘AXA Equitable’’ is the brand name of AXA Equitable Financial Services, LLC and its family of companies, including the AXA Equitable Life Insurance Company and MONY Life Insurance Company of America.

SECTION A-PROPOSED INSURED INFORMATION

Plan Name Face Amount

1. Name First Middle Last

2. SSN 3. Sex Male Female

4. Is the Proposed Insured the Owner? Yes No (If ‘‘No,’’ complete Owner Questionnaire or see Survivorship Product Questionnaire if applicable)

5. Primary residential address Bldg/Apt/Suite

City/Municipality County/Parish* State Zip

* County/Parish only required in AL, FL, GA, KY, LA, SC

INSURED 6. Are you a U.S. citizen? Yes No (If ‘‘No,’’ complete Foreign Residence and Travel Questionnaire)

7a. Phone # Daytime Cell Evening b. Best time to call AM P M

8. Date of birth (mm/dd/yyyy) 9. Place of birth (Country/State) PROPOSED 10. Email address 11. Do you have a driver’s license? Yes No If ‘‘Yes,’’ provide license number, state and expiration date Number State Expiration Date (mm/dd/yyyy) If no driver’s license, do you have a government issued ID? Yes No If ‘‘Yes’’ to government issued ID, type of ID Government ID number 12. Currently employed? Yes No Retired Other

If ‘‘Yes,’’ to question 12, complete questions 13-15

13. Current occupation(s) a. Title b. Years at current job** **If less than one year at current job, give previous occupation information in remarks section c. Duties EMPLOYMENT 14. Employer name 15. Work site address City State Zip Code 16. Income (If minor, complete for Parent/Guardian)

Gross Unearned Annual Income

DETAILS Gross Earned Annual Income (dividends, pensions, interest real Gross Annual Income Total Net Worth

(salary, commissions, bonuses) estate income, etc) (Household) (Household)

$ $ $ $ 17. In the last 5 years, have you ?led for bankruptcy? Yes No

FINANCIAL If ‘‘Yes,’’ Chapter Date opened (mm/dd/yyyy) Date Closed (mm/dd/yyyy) 18. If or no (2) contingent if the Proposed bene?ciary Insured is has named, no surviving the contingent children, bene?ciary the contingent will be: bene?ciary (1) the Proposed will be the Insured’s Proposed surviving Insured’s children, estate. if Total any, percentage in equal shares; must equal 100% for each category of bene?ciary. If percentage shares are left blank, the shares will be deemed equal. If bene?ciary is a Trust other than Owner, include full name and date of Trust. Please use the Remarks section if you need to include additional bene?ciaries in either category.

1. Relationship to Insured Percentage (%) Full Name Address, City, State, Zip

Phone Number SSN or ITIN or EIN Date of Birth (mm/dd/yyyy) BENEFICIARY Bene?ciary Type: Primary Contingent Email address

2. Relationship to Insured Percentage (%)

Full Name

Address, City, State, Zip

Phone Number SSN or ITIN or EIN Date of Birth (mm/dd/yyyy) Bene?ciary Type: Primary Contingent Email address

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Complete questions 19 and 20 only if Proposed Insured and Owner are same. If Owner is different from Proposed Insured(s) and completing Owner’s Questionnaire, do not complete this section.

19. Complete For Personal Insurance

Income Replacement Mortgage/Debt Repayment Estate Planning Charitable/Gifting Other 20. Complete for Business Insurance Key Person Buy-Sell Deferred Comp Other (please specify) Loan indemnification (Security for Loan) Amount of loan $ Duration Interest charged on loan Collateral pledged to secure loan a. Type Sole Proprietorship Partnership Corporation Limited Liability Corp. b. Name of business Nature of business c. How long has the business been in operation? Years d. % of business owned by Proposed Insured % INSURANCE e. Fair market value of the business: $ OF f. Are all members of the business being similarly insured? Yes No

If ‘‘Yes,’’ provide details of business coverage issued or applied for on other members. (Use remarks section if additional space is needed)

PURPOSE Name and Title % of Business Owned Amount In Force or Applied For g. Has the business ?led for bankruptcy and/or reorganization in the past 5 years? Yes No If ‘‘Yes,’’ explain h. Business/Corporation ?nances: (Complete chart below for the past 2 years) Year Assets Liabilities Gross Sales Net Pro?t $ $ $ $ $ $ $ $

If questions 21a, b or c are answered ‘‘Yes,’’ please provide details in charts below. (Use remarks section if additional space is needed)

21. Including any policies and riders with the Company checked on page 1 above section A of the Application its af?liates and any other life insurance company: a. Do you have any life insurance/annuities currently in force, including any policy that has been sold, settled or assigned to or with a settlement or viatical company or any other person or entity? Yes No b. Will the coverage applied for replace, change, or affect any existing policy(ies) or contract(s)? Yes No c. Do you have any other formal life insurance applications pending? Yes No d. Including this application, what is the total amount of life insurance coverage pending (base policy face amount plus amounts attributable to additional bene?ts and riders) that you plan to accept on the Proposed Insured?

Chart for questions 21a and b

Total Amount G-Group P-Personal Replaced To Be

INSURANCE Name of Company (Face Riders) Plus Year Issued Policy/ Contract # B-Business A-Annuity Changed or Affected 1035 Exchange

P B

OTHER G A Yes No Yes No P B

G A Yes No Yes No P B

G A Yes No Yes No Chart for question 21c

Name of Company Total Amount Competitive or Additional (Face Plus Riders) $ Competitive Additional $ Competitive Additional

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22. Have you ever had a driver’s license suspended, revoked or restricted? Yes No 23. Have you in the last 5 years, been convicted of, or pled guilty or no contest to reckless or negligent driving, any moving violations or driving under the in?uence of alcohol or drugs? Yes No 24. Have you in the last 2 years been disabled for 2 or more weeks? Yes No

Complete if any answer to question(s) 22 through 24 is ‘‘Yes.’’ (Use remarks section if additional space is needed)

Question # Date (mm/dd/yyyy) Description of Event

25. Do you engage in regular exercise? (For example, running, walking, strength training, tennis) Yes No If ‘‘Yes,’’ give details of type, frequency and length of time

26. Have you ever had an application for life or health insurance declined, postponed, required an extra premium, offered with a reduced face amount or other modi?cation or had a life or health policy or contract that was cancelled, recalled HISTORY or denied renewal?

(If ‘‘Yes,’’ please state companies and provide full details.) Yes No 27. Have you in the last 10 years, been convicted of, or pled guilty or no contest to a felony, or are current felony charges pending? (If ‘‘Yes,’’ state offense and penalty, date of probation, duration of probation and end date in PERSONAL remarks section.) Yes No 28. Do you expect to travel outside of the U.S. or Canada, or change your country of residence in the next 2 years? (If ‘‘Yes,’’ complete Foreign Residence and Travel Questionnaire) Yes No 29. a. In the last 2 years have you ?own other than as a passenger? (if “Yes,” complete Aviation Questionnaire) Yes No b. In the next 2 years do you plan to ?y as other than a passenger? (If “Yes,” complete Aviation Questionnaire) Yes No c. In the last 2 years have you engaged in motor racing on land or water, underwater diving, skydiving, ballooning, hang gliding, parachuting or ?ying ultra-light aircraft?

(If “Yes,” complete Avocation Questionnaire) Yes No d. In the next 2 years do you plan to engage in motor racing on land or water, underwater diving, skydiving, ballooning, hang gliding, parachuting or ?ying ultra-light aircraft?

(If “Yes,” complete Avocation Questionnaire) Yes No 30. Are you a member of the armed forces, including the reserves? Yes No

(reserves includes active duty or full time training of 31 days or more per year)

(If ‘‘Yes,’’ you must also submit a completed and signed Life Insurance/Annuity Disclosure to Active Duty Members of the Armed Forces)

31. Have you ever received medical treatment or counseling for, or been advised by a physician to reduce or discontinue, the use of alcohol or prescribed or non-prescribed drugs? (If ‘‘Yes,’’ complete Substance Usage

Questionnaire) Yes No

USE Do not complete if Proposed Insured is age 0–17

32. Do you currently use or have you ever used tobacco or nicotine products? Yes No

If ‘‘Yes,’’ provide details in chart below.

Product Type(s) Amount and Frequency Indicate date last

Indicate amount and frequency of use used (mm/yyyy) Cigarettes # per Day Month Year Cigars Cigarillos # per Day Month Year ALCOHOL/DRUG/TOBACCO Pipe Chewing Tobacco Nicotine Patch or Gum Not Applicable Other (please specify)

Section to be completed only when submitting medical examinations of another insurance company If ‘‘Yes’’ to questions 34 or 35, complete a Medical Information Questionnaire

33. Name of Insurance Company Date of Exam (mm/dd/yyyy) MEDICAL CERTIFICATION 34. To the best of your knowledge and belief, have there been any changes to the statements in the examination? Yes No 35. Have you consulted a medical doctor or other practitioner since the examination indicated in question 33 above? Yes No

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Questions 36 and 37 a-c not required if completing Owner’s Questionnaire

“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.

36. Do you intend to ?nance any of the premium required to pay for this policy through a ?nancing or loan agreement? Yes No

(If ‘‘Yes,’’ submit a copy of the financing or loan agreement)

37. a. Indicate the source of funds used to purchase this insurance. Income Investments/Savings Loans Gifts/Inheritance

Settled Contracts (give details) Other (please specify) b. Have any of the Parties been offered or promised any incentive (?nancial or otherwise) as an inducement to FUNDS apply for or purchase the proposed policy, such as (but not limited to), zero cost or no cost life insurance or

OF cash payments? Yes No c. Has any compensation or other inducement (including cash, offers or discussions of free insurance, any FUNDS forgiveness or potential forgiveness of any debt, or other bene?ts) been discussed or offered directly or SOURCE OF indirectly to any of the following in connection with the application for the purchase of this policy: the Proposed Insured, the Owner or Bene?ciary, the Bene?ciary of any Trust owning the policy, and/or the owner of any legal entity owning the policy, or is there any expectation of receiving any such compensation or inducement? Yes No SOURCE If “Yes,” please state the compensation or inducement that will be received or could be received and by whom.

COMPLETE IF PROPOSED INSURED IS UNDER AGE 15 Medical Information Questionnaire is also required

38. a. Total amount of Insurance in force on the life of: Applicant $

Parent(s)/Legal Guardian if other than Applicant $ INSURANCE b. What is the relationship between the Applicant and the Proposed Insured if other than Parent/Legal Guardian? c. Any other children in the family insured for a lesser amount? Yes No If ‘‘Yes,’’ details JUVENILE d. Is Applicant different from the Owner? Yes No Applicant’s Name JUVENILE Applicant’s SSN Relationship to Proposed Insured

Applicant’s Address No. & Street Bldg./Apt./Suite City/Municipality State Zip Code

COMPLETE IF MONEY IS PAID WITH APPLICATION

Insurability Questions for Limited Temporary Insurance Agreement

39. Is any Proposed Insured less than 15 days or over 70 years of age? Yes No 40. 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 41. Within the past 10 years has any Proposed Insured been diagnosed with or treated for Acquired Immune De?ciency Syndrome (AIDS) by a member of the medical profession? Yes No 42. Within the past 12 months has any Proposed Insured: been admitted, or advised by a medical professional to be APPLICATION admitted, to a hospital or other licensed health care facility; had surgery performed or recommended; or been advised by a medical professional to have any diagnostic test (excluding AIDS-related test) that was not WITH completed? Yes No 43. Within the past 24 months has any Proposed Insured been declined for a life, health or Long-Term Care policy? Yes No PAID PAID COMPLETE ONLY IF ‘‘NO’’ TO ALL QUESTIONS IN 39-43 IN SECTION A OF THIS APPLICATION AND QUESTIONS 36 TO 40 IN THE SURVIVORSHIP PRODUCT QUESTIONNAIRE, IF APPLICABLE. IF ANY OF QUESTIONS 39-43 in SECTION A OF THIS

MONEY APPLICATION OR QUESTIONS 36-40 OF THE SURVIVORSHIP PRODUCT QUESTIONNAIRE, IF APPLICABLE, ARE ANSWERED ‘‘YES’’ or LEFT BLANK A PREMIUM MAY NOT BE PAID BEFORE THE POLICY IS DELIVERED AND NO TEMPORARY INSURANCE

WILL BE IN EFFECT.

44. Is money paid with this Application? Yes No If ‘‘Yes,’’ amount paid $

If ‘‘Yes,’’ and an amount paid is indicated above, complete and sign the Temporary Insurance Agreement.

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REMARKS – When providing details to questions, please reference question number. If additional space is needed, attach additional sheet(s) of paper with your name and signature.

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AXA Equitable Life Insurance Company MONY Life Insurance Company of America

(Referred to below as ‘‘the Company(ies)”)

SECTION D – AUTHORIZATION/AGREEMENT SIGNATURE

THIS DOCUMENT MUST BE COMPLETED, SIGNED AND SUBMITTED WITH ENTIRE APPLICATION

I (We) acknowledge that I (we) have reviewed the statement of the Underwriting Process of the Company(ies) (the ‘‘Statement’’) which describes from whom and why the Company(ies) obtains information about me (us), to whom such information may be reported and UNDERWRITING how I (we) may obtain a copy of it. The Statement contains the notice required by the Fair Credit Reporting Act.

OURPROCESS I (We) acknowledge that in the event the Company(ies) use lab results from another insurance company authorized by me (us) it does ACKNOWLEDGEMENT so with the belief that I (we) have satis?ed all consent and disclosure procedures for the other insurance company.

OF

TO

I (We) authorize any employer, business associate, government unit, ?nancial institution, consumer reporting agency, the Medical HEALTH Information Bureau, my (our) insurance agency and my (our) ?nancial professional to disclose to the Company(ies) and its authorized - representatives any information they may have about my (our) occupation, avocations, insurance activities, ?nances, driving record, NON character and general reputation. I (We) authorize the Company(ies) to obtain investigative consumer reports, as appropriate.

AUTHORIZATIONOBTAIN INFORMATION

OF I (We) understand that the information obtained will be used by the Company(ies) to determine my (our) eligibility for life insurance coverage and such other uses speci?ed in accordance with the Statement attached to this application. In addition, information may be PURPOSEAUTHORIZATIONS disclosed to the Medical Information Bureau (MIB).

I (We) understand that the Company(ies) may not issue coverage unless I (we) provide this authorization, and that, while I (we) may COVERAGECONDITIONS refuse to sign this authorization, my (our) refusal to do so could result in coverage not being issued.

I (We) understand that the Company(ies) may request additional authorizations in order to obtain the information the Company(ies) needs to complete its review of my (our) application and, if the policy is issued, in connection with any claim asserted under the policy, I (we) understand that I (we) am (are) not required to provide these authorizations but that, if I (we) choose not to provide them, this ADDITIONALAUTHORIZATIONS application and any claim made under the policy, if issued, may be rejected.

Unless otherwise revoked, I (we) agree that this authorization will expire on the earlier of: (a) the date that the Company(ies) declines my (our) application for coverage; and (b) if a policy is issued, (i) 24 months from the date of my (our) application, or (ii) the time limit, if any, permitted by applicable law in the state where the policy is delivered or issued for delivery. I (We) understand that I (we) may revoke my (our) authorizations at any time, except to the extent that the Company(ies) has (have) taken action in reliance on this DURATION authorization, and that this application and any claim made under the policy, if issued, may be rejected. My (Our) revocation must be submitted in writing to: Corporate Chief Underwriter, 1290 Avenue of the Americas, New York, New York 10104.

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SECTION D – AUTHORIZATION/AGREEMENT SIGNATURE

I (We) request and authorize my (our) Bank to charge monthly or quarterly my (our) checking account to pay premiums due under the IS policy(ies). It is understood that debits will be made automatically after the effective date determined by the Company checked on page 1 above section A of the Application and/or any other af?liated companies, and if charges are overlooked or inadvertently not made, the Company checked on page 1 above section A of the Application and/or any other af?liated companies may charge my (our) account at DRAFT a later date provided the policy(ies) is (are) active.

I (We) understand that the use of the Bank Draft Payment Plan does not change any policy provision.

BANK I (We) understand this authorization is to remain in full force and in effect, unless terminated. I (We) understand this Plan may be IF terminated by the depositor, the Owner or the Company checked on page 1 above section A of the Application and/or any other af?liated companies upon 30 days written notice to the other parties or if any charge due is not paid or is reversed by the Bank. I (We) ELECTED understand this Plan may be terminated upon closing of my account.

I (We) understand if this Plan is terminated, premiums for regular or scheduled premium policies will be payable directly to the Company checked on page 1 above Section A of the Application.

I (We) agree that this Plan may be terminated if any debit is not honored by the Bank or Depository for any reason. I (We) further AUTHORIZATION agree that if any such charge is dishonored, whether with or without cause and whether intentionally or inadvertently, the Company checked on page 1 above section A of the Application and/or any other af?liated companies shall be under no liability whatsoever, even if such dishonor results in the forfeiture of insurance.

Each signer of this Application agrees that:

1) Except when the required money is paid with this Application and as stated in the Temporary Insurance Agreement/Receipt, no insurance shall take effect on this Application: (a) until the date the policy and all amendments are delivered to the Owner(s) and all delivery requirements have been completed; (b) before any Register Date of the policy; and (c) unless the statements and answers in all parts of this Application and any applicable supplements continue to be true and complete to the best of my (our) knowledge and belief, without material change, as of the latest of the date: (i) the policy and all amendments are delivered to the Owner(s); (ii) all delivery requirements have been completed; and (iii) the full initial premium is paid while the person(s) proposed for insurance is (are) living.

2) If temporary insurance is to be provided, the full initial premium must accompany this Application; the Proposed Insured(s) and Owner(s) understand and agree to the terms of the Temporary Insurance Agreement/Receipt and have executed and the Owner(s) has received a copy of the Temporary Insurance Agreement/Receipt.

3) The Temporary Insurance Agreement/Receipt states the conditions that must be met before any insurance takes effect if the full initial premium is paid with this Application. Temporary insurance is not provided for a policy or bene?t applied for under the terms of a guaranteed insurability option or a conversion privilege.

4) No ?nancial professional or medical examiner has authority to modify this Application and/or its supplements or questionnaires, the AGREEMENT Temporary Insurance Agreement/Receipt (if applicable), or to waive any of our any of the Company’s rights or requirements.

5) We shall not be bound by any information unless it is stated in Application Part 1, Application Part 2 or any of its supplements or questionnaires.

6) I (We) acknowledge receipt of the Living Bene?ts Brochure (Accelerated Death Bene?t Rider Brochure), where applicable.

7) I (We) acknowledge that no representation is made that a particular rate or risk classi?cation is being offered based on the information provided in response to the policy Application questions.

8) If applicable, the Trustee(s) represent(s) that the Trust named as Owner is allowed to purchase life insurance and securities under the trust document. I (We) further represent that bene?cial interests in the Trust are at this time, and currently intend to be only for parties who are related closely by blood or law, and have a substantial interest in the Proposed Insured(s) engendered by love and affection, or those who have a lawful and substantial economic interest in the continued life of the Proposed Insured(s).

9) I (We) represent and certify to the Company checked on page 1 above section A of the Application and/or any other af?liated companies that none of the monies utilized to fund this policy derived directly or indirectly from illegal activities or sources and/or tax evasion.

Under the penalties of perjury, I (we) certify that (i) the number showing on this form is my (our) correct Taxpayer

Identi?cation Number (Social Security Number, Employer Identi?cation Number or other Taxpayer Identi?cation Number), and (ii) I (we) am (are) not subject to backup withholding because (A) I (we) am (are) exempt from backup withholding or (B) I (we) have not been noti?ed by the Internal Revenue Service (IRS) that I (we) am (are) subject to backup withholding as a result of a IDENTIFICATIONCERTIFICATION failure to report all interest or dividends or (C) the IRS has noti?ed me (us) that I (we) am (are) no longer subject to backup withholding and (iii) I (we) am (are) a U.S. person (including a U.S. resident alien). Certi?cation Instructions: You must cross out item (ii) above if you have been noti?ed by the Internal Revenue Service that you are currently subject to backup withholding because you have failed to report all interest or dividends on your tax return. The Internal Revenue Service does TAXPAYERNUMBER not require your consent to any provisions of this document other than the certi?cation required to avoid backup withholding.

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SECTION D – AUTHORIZATION/AGREEMENT SIGNATURE

FOR THE APPLICANT’S PROTECTION, THE LAWS OF CERTAIN STATES REQUIRE THIS NOTICE: ANY PERSON WHO KNOWINGLY FRAUD PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND STATE DISCLOSURES SUBJECT TO PENALTIES UNDER STATE LAW.

I (We) have a right to ask for and receive copies of this Authorization/Agreement Signature Form and all other authorizations signed by me (us). I (We) agree that reproduced copies will be as valid as the original.

CHECKING PLEASE INDICATE THE APPROPRIATE YOU HAVE REVIEWED BOX(ES) BELOW. THE APPLICATION FAILURE TO AND CHECK QUESTIONNAIRES THE APPROPRIATE AS THEY BOX(ES) HAVE WILL BEEN REQUIRE COMPLETED YOU TO BY SIGN AN APPLICATION AMENDMENT.

Section A - Proposed Insured Information

Section A.1 - Proposed Insured 2 Information (Complete for IUL Survivorship Products only)

Section B - Product Information (Must select at least 1 product) Section C - Additional Underwriting Requirements

Term Life Owner Questionnaire

Indexed Universal Life (IUL Protect) Foreign Residence and Travel Information Questionnaire Indexed Universal Life (BrightLife® Grow) Medical Information Questionnaire Variable Universal Life (LegacySM) Financial Information Questionnaire ACKNOWLEDGMENTS Variable Universal Life (OptimizerSM) Children’s Term Insurance Rider Questionnaire Survivorship Universal Life with Indexed Option (BrightLife® Substance Usage Questionnaire Protect Survivorship) Aviation Questionnaire Survivorship Indexed Universal Life (BrightLife® Grow Survivorship) Avocation Questionnaire Survivorship Variable Universal Life (SIL Legacy) Term Policy/Rider Conversion or Interest Sensitive Whole Life (ISWL) Purchase Option Questionnaire Corporate Owned IL (COIL) Long Term Care Services Rider Questionnaire (I have received the Outline of Coverage and, if required, the Personal Worksheet)

I (We), the undersigned agree that the statements and answers in all parts of the Application and any application questionnaires checked above are true and complete to the best of my (our) knowledge and belief. Further, I (we) understand that I am (we are) agreeing to all the terms and conditions of this application, including, but not limited to, the Authorization/Agreement Signature.

X X

Signature of Proposed Insured 1 Signature of Proposed Insured 2

SIGNATURES (Parent, Guardian, or Applicant if Proposed Insured is a Child, Issue Ages 0–14)

X Signature of Owner or Applicant if not Proposed Insured(s) Signed by Owner at City, State Dated on (mm/dd/yyyy)

(If corporation, print firm’s name, signature and title of authorized officer.) (If Trust, signature of trustee.)

Will any existing insurance be replaced, changed or affected (or has it been) assuming the insurance applied for will be issued? Yes No

If ‘‘Yes,’’ is the information provided in question 21 on Part 1 of the Application for Proposed Insured 1, and question 21 of the Survivorship Product Questionnaire for Proposed Insured 2, if applicable, complete and accurate? Yes No If ‘‘No,’’ provide details I certify that I have asked and recorded completely and accurately the answers to all questions on the fully completed Application Part 1, COMPLETE and know of nothing affecting the risk that has not been recorded herein.

I have witnessed the signature required on the fully completed Part 1.

TO

SECTION I have not witnessed the signature required on the fully completed Part 1. (Explain below.)

Certi?cation for VUL Policies Only, Signature required FOR ALL POLICIES:

THIS Based on the information furnished by the Proposed Insured(s) and Owner, if other than the Proposed Insured(s), in this and any other PROFESSIONAL part of the application(s), I certify that I have reasonable grounds for believing the purchase of the policy applied for is suitable for the Applicant or the Owner. I further certify the current prospectuses were delivered and that no written sales materials other than those furnished by the Company were used.

FINANCIAL X

Signature of Licensed Professional/Insurance Broker Dated on (mm/dd/yyyy) Print Licensed Financial Professional’s Name License Number

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