Equitable Financial Life Insurance Company
Equitable Financial Life Insurance Company of America
Mailing address: PO Box 1047, Charlotte, NC 28201-1047
Section C—Foreign Residence and Travel Questionnaire
Proposed Insured Forming a Part of the Application for Life Insurance
If the Proposed Insured or Proposed Owner is a foreign national, please complete this form and submit a copy of a government issued photo ID evidencing Nationality or residence (e.g., Passport, Alien Registration, etc).
Proposed Insured Name: Date of Birth (mm/dd/yyyy) OR
2nd Proposed Insured Name: Date of Birth (mm/dd/yyyy)
1. Foreign National
Insured Name (first, Middle, Last) Date of Birth (mm/dd/yyyy)
a. Country of Citizenship Date of entry into the U.S. (mm/dd/yyyy)
b. Residents with legal permanent status (Resident) in the U.S. only please complete: Green Card/Visa Type Expiration Date (mm/dd/yyyy)
c. Residents residing in the U.S. temporarily (Non-Resident) with valid visa only please complete:    Visa # Visa Type Expiration Date (mm/dd/yyyy)    Passport # form I-94 Expiration/Departure Date (mm/dd/yyyy)
d. What is your country of permanent residence?
2. Foreign Travel/Residence
Provide details for every planned stay outside the U.S. or Canada in the next year (other than a two week or less vacation).
Country to be visited, Country of Departure Country Return Date Purpose of trip (e.g. City/Location Departure: Date: Returning to: (mm/dd/yyyy) Business, Vacation, (mm/dd/yyyy) Mission Work, other)
Please add any additional information regarding any planned travel/residency within the next 2 years that you believe was not adequately covered above.
Proposed Owner (if other than the Proposed Insured)
Proposed Owner Name: Date of Birth (mm/dd/yyyy) OR
Joint Owner Name: Date of Birth (mm/dd/yyyy)
3. Foreign National
a. Proposed Owner Name (first, Middle, Last)
b. Country of Citizenship Date of entry into the U.S. (mm/dd/yyyy)
c. Residents with legal permanent status (Resident) in the U.S. only please complete:    Green Card/Visa Type Expiration Date (mm/dd/yyyy)
d. Residents residing in the U.S. temporarily (Non-Resident) with valid visa only please complete:    Visa # Visa Type Expiration Date (mm/dd/yyyy)    Passport # form I-94 Expiration/Departure Date (mm/dd/yyyy)
e. What is your country of permanent residence?
Non-resident Proposed Owner
4. U.S. Bank Account Information
a. Provide the below information for all non-resident (foreign) Proposed Owners. (Individuals, businesses, corporations, trusts and partnerships that are foreign must have a U.S. bank account.) If the Owner is not a U.S.
Person (U.S. Citizen or U.S. Corporation, Partnership or Trust established or organized under the laws of a state of the United States), then he, she or it may have to provide additional documentation, including IRS form W-8 BEN.
U.S. Bank Name Account Number