Equitable Financial Life Insurance Company

Equitable Financial Life Insurance Company of America

Mailing address: PO Box 1047, Charlotte, NC 28201-1047

Section C—Individually Owned Policy/Business Insurance Questionnaire

Forming a Part of the Application for Life Insurance

Proposed Insured Name Date of Birth (mm/dd/yyyy)

Business Information

1. Type: Partnership Limited Liability Corporation Other

2. Name of Business

3. Nature/Purpose of Business

4. Relationship to Proposed Insured

5. How many years has the business been in operation

6. Fair Market Value of Business $

7. Proposed Insured owns % of the business listed above.

a. Is there a Buy/Sell Agreement in place? Yes No    

b. Are all members of the business being similarly insured? Yes No

If “No,” please provide reason

If “Yes,” provide details of business coverage issued or applied for on other members.

Name and Title % of Business Owned Amount In Force or Applied For

8.Hasthebusinessfiledforbankruptcyand/orreorganizationinthepast5years? Yes No

If “Yes,” Chapter Date opened(mm/dd/yyyy) Date Closed(mm/dd/yyyy)

9. Business/corporation Finances (Complete chart below for the past 2 years)

Year Assets Liabilities Gross Sales NetProfit $ $ $ $ $ $ $ $

Business Insurance Purpose

10. Key Person Buy-Sell Deferred Comp Other

LoanIndemnification/AmountofLoan$

Duration

Interest charged on loan Collateral pledged to secure loan