EX-99.5C 11 e7754_ex99-5c.txt EQUI-VEST(R) Strategies 457(b) EDC Enrollment Form Mailing Instructions: Express Mail:(with money): [AXA LOGO] AXA EQUITABLE EQUI-VEST New Business ------------------------ JPMorganChase 4 Chase Metrotech Center EXPRESS MAIL: (without money): NY Remit One Image Lockbox EQUI-VEST New Business #13823 -7th Floor 1 MONY Plaza Brooklyn, NY 11245-0001 Syracuse, NY 13202 REGULAR MAIL: (with money): REGULAR MAIL: (without money): EQUI-VEST New Business EQUI-VEST New Business P.O. Box 13823, Newark, NJ 07188-0823 P.O. Box 4704, Syracuse, NY 13221-4704 -------------------------------------------------------------------------------- 1. Employer information ----------------------- -------------------------------------------------------------------------------- EMPLOYER NAME [ ] Existing Unit Number ------------------------------------------------------- [ ] New Unit (Must complete Unit Installation Form) -------------------------------------------------------------------------------- 2. PARTICIPANT INFORMATION (check appropriate boxes) --------------------------- [ ] Mr. [ ] Mrs. [ ] Miss [ ] Ms. [ ] Other ------------------------------ -------------------------------------------------------------------------------- First Name Middle Initial Last Name [ ] Male [ ] Female -------------------------------------------------------------------------------- Birth Date (M/D/Y) Age at Nearest Birthday --------------------------------------- [ ] Home [ ] Work Area Code Daytime Phone Number -------------------------------------------------------------------------------- Street Address - No. P.O. Box Permitted (if Non-U.S., Contact Branch) -------------------------------------------------------------------------------- City State Zip Code -------------------------------------- ------------------------------------ Social Security No. (Required) Retirement Age -------------------------------------------------------------------------------- Driver's License/Passport No. + -------------------------------------- ------------------------------------ State/Country Exp. Date + Required by the U.S. Patriot Act. -------------------------------------------------------------------------------- 3. BENEFICIARY(IES) INFORMATION -------------------------------- Include full name(s). Relationship(s) to Participant and the Social Security Number of EACH Beneficiary: Use #9 if you need more space. -------------------------------------------------------------------------------- Primary -------------------------------------------------------------------------------- Social Security Number -------------------------------------------------------------------------------- Relationship -------------------------------------------------------------------------------- Contingent (if any) -------------------------------------------------------------------------------- Social Security Number -------------------------------------------------------------------------------- Relationship -------------------------------------------------------------------------------- 4. OPTIONAL FEATURES --------------------- ENHANCED DEATH BENEFIT OPTION Would you like to elect the 3-year Enhanced Death Benefit? [ ] YES, I would like to elect the Ratcheted Death Benefit. [ ] NO, I would like to have only the sum of contributions (adjusted for loans and withdrawals) as the Minimum Death Benefit. ONCE THE RATCHETED DEATH BENEFIT IS ELECTED, IT CANNOT BE TERMINATED. A CHARGE OF .15% OF THE ACCOUNT VALUE WILL BE DEDUCTED ON EACH CERTIFICATE ANNIVERSARY -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- 5. SELECTION OF INVESTMENT OPTIONS AND ALLOCATION PERCENTAGES ------------------------------------------------------------- (Check either Box A or Box B but not both). IF THE EMPLOYER MAKES THIS SELECTION ON BEHALF OF THE PARTICIPANTS, THEN THE SELECTION HERE MUST BE THE SAME AS THE EMPLOYER'S. A. [ ] MAXIMUM TRANSFER FLEXIBILITY. By checking this box, you may invest only in those options listed below that have been shaded. Transfers out of the GIO will not be limited (see prospectus for details). B. [ ] MAXIMUM INVESTMENT OPTION CHOICE. By checking this box, you may invest in any of the options listed below (shaded and not shaded). Transfers out of the GIO will be limited (see Prospectus for details). CURRENT ALLOCATION: Select the allocation for the amounts that you may invest in these options in the future. You can change this allocation for future contributions at any time. The percentages entered below must be in whole numbers and total 100%. Guaranteed Interest Option _________% EQ/Equity 500 Index _________% EQ/Alliance Growth and Income _________% EQ/Alliance Common Stock _________% EQ/Alliance International _________% EQ/Alliance Small Cap Growth _________% EQ/Money Market _________% EQ/Alliance Intermediate Gov't. Securities _________% EQ/Alliance Quality Bond _________% EQ/JPMorgan Core Bond _________% AXA Premier High Yield _________% AXA Premier VIP Core Bond _________% AXA Conservative-Plus Allocation _________% AXA Conservative Allocation _________% EQ/Caywood-Scholl High Yield Bond _________% EQ/Evergreen International Bond _________% EQ/Long Term Bond _________% EQ/PIMCO Real Return _________% EQ/Short Duration Bond _________% EQ/Bernstein Diversified Value _________% EQ/JPMorgan Value Opportunities _________% EQ/MFS Emerging Growth Companies _________% EQ/Van Kampen Emerging Markets Equity _________% EQ/FI Mid Cap Value _________% EQ/Mercury Basic Value Equity _________% EQ/Alliance Large Cap Growth _________% EQ/Evergreen Omega _________% EQ/MFS Investors Trust _________% EQ/Capital Guardian Research _________% EQ/Capital Guardian U.S. Equity _________% EQ/Calvert Socially Responsible _________% EQ/Marsico Focus _________% EQ/Janus Large Cap Growth _________% EQ/FI Mid Cap _________% EQ/Capital Guardian International _________% EQ/Lazard Small Cap Value _________% EQ/Legg Mason Value Equity _________% EQ/Mercury International Value _________% EQ/Capital Guardian Growth _________% EQ/Small Company Index _________% AXA Aggressive Allocation _________% AXA Moderate-Plus Allocation _________% AXA Moderate Allocation _________% AXA Premier VIP Aggressive Equity _________% AXA Premier VIP Large Cap Growth _________% AXA Premier VIP Large Cap Core Equity _________% -------------------------------------------------------------------------------- Form #2004 EDC STRAT E6718 AXA Equitable Life Insuance Company Cat. No. 134592 (10/17/05) Page 1 of 3 -------------------------------------------------------------------------------- AXA Premier VIP Large Cap Value _________% AXA Premier VIP Mid Cap Growth _________% AXA Premier VIP Mid Cap Value _________% AXA Premier VIP International Equity _________% AXA Premier VIP Technology _________% AXA Premier VIP Health Care _________% EQ/TCW Equity _________% EQ/Boston Advisors Equity Income _________% EQ/Montag & Caldwell Growth _________% EQ/UBS Growth and Income _________% EQ/Bear Stearns Small Company Growth _________% EQ/GAMCO Small Company Value _________% EQ/GAMCO Mergers and Acquisitions _________% EQ/International Growth _________% EQ/Lord Abbett Growth and Income _________% EQ/Lord Abbett Large Cap Core _________% EQ/Lord Abbett Mid Cap Value _________% EQ/Van Kampen Comstock _________% EQ/Van Kampen Mid Cap Growth _________% EQ/Wells Fargo Montgomery Small Cap _________% TOTAL (MUST BE 100%) 100% -------------------------------------------------------------------------------- 6. CONTRIBUTION INFORMATION ---------------------------- Complete #6A only if a rollover or transfer check is provided when the Enrollment Form is signed. If payment will be forwarded at a later date, you must complete only #6B. A. Rollover/Transfer Amount provided with this Enrollment Form: (i) Total amount for investment options listed in #5. $ (Do not include amounts for the Fixed Maturity Options.) ----------- (ii) Total amount for Fixed Maturity Period(s) listed in #8. $ ----------- (iii) Employee Monthly Contribution $ ----------- (iv) Total amount remitted. $ ----------- B. Expected first-year contribution: Indicate the amount expected to be contributed in the first year of participation under this certificate. $ ----------- -------------------------------------------------------------------------------- 7. REMINDER / CONTRIBUTION STATEMENTS INFORMATION -------------------------- Plan Contribution Statement Frequency Note: You must check the same frequency as elected by your Institution. (i) [ ] Monthly [ ] Semi-Monthly [ ] Bi-Weekly You will be included on the Contribution Statement sent to your Institution. Each Contribution Statement will show the amount of the last contribution made. (ii) Initial Contribution Statement Reminder Amount $ ----------- -------------------------------------------------------------------------------- 8. FIXED MATURITY OPTIONS (FMOs) -------------------------------- FMOs ARE ONLY AVAILABLE IF THE RATE TO MATURITY IS MORE THAN 3%. For the amount shown in #6A(ii), please allocate by whole percentages to the following Fixed Maturity Period(s). FMOs are not available for ongoing contributions, only rollovers or direct transfers. (Do not select a Maturity Date that has already expired.) ----------- USE WHOLE PERCENTAGES ONLY ----------- PERCENTAGE OF AMOUNT MATURITY DATES SHOWN IN #5A (ii) [ ] June 15, 2006 % ---------- [ ] June 15, 2007 % ---------- [ ] June 15, 2008 % ---------- [ ] June 13, 2009 % ---------- [ ] June 15, 2010 % ---------- [ ] June 15, 2011 % ---------- [ ] June 15, 2012 % ---------- [ ] June 14, 2013 % ---------- [ ] June 13, 2014 % ---------- [ ] June 15, 2015 % ---------- TOTAL 100% -------------------------------------------------------------------------------- 9. SPECIAL INSTRUCTIONS ----------------------- (For P.O. Box Address, beneficiary, replacement or transfer information) -------------------------------------------------------------------------------- For Participants whose Mailing Address differs from their Primary Residential Address in #2. Participant's Mailing Address: -------------------------------------------------------------------------------- Mailing Address - P.O. Box Accepted -------------------------------------------------------------------------------- City State Zip Code -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- 10A. SUITABILITY ---------------- (All applicable questions must be answered.) 1. Did you receive the EQUI-VEST(R) Strategies prospectus and applicable supplement(s)? [ ] Yes [ ] No ------------------ ------------------------------------------ Date of prospectus Date(s) of any supplement(s) to prospectus CONSENT FOR DELIVERY OF INITIAL PROSPECTUS ON CD-ROM [ ] YES. By checking this box and signing the enrollment form below, I acknowledge that I received the initial prospectus on computer readable compact disk "CD," and that my computer has a CD drive and I am able to access the CD information. In order to retain the prospectus indefinitely, I understand that I must print or download it. I also understand that I may request a prospectus in paper format at any time by calling Customer Service at 1-877-222-2144, and that all subsequent prospectus updates and supplements will be provided to me in paper format, unless I enroll in AXA Equitable's Electronic Delivery Service. The Participant acknowledges that he or she is enrolling in EQUI-VEST for its features and benefits other than tax deferral, as the tax-deferral feature of such annuities does not provide additional benefits beyond those already provided by Section 457 of the Internal Revenue Code. Before enrolling, you should consider whether the certificate features and benefits beyond tax deferral meet your needs and goals. You may also want to consider the relative features, benefits and costs of these annuities with any other investment that is available in connection with your 457 plan. -------------------------------------------------------------------------------- Form #2004 EDC STRAT E6718 AXA Equitable Life Insurance Company Cat. No. 134592 (10/17/05) Page 2 of 3 -------------------------------------------------------------------------------- 10A. SUITABILITY (CONTINUED) ---------------------------- 2. (a) Do you have any other existing life insurance or annuities? [ ] Yes [ ] No (b) Will any existing life insurance or annuity be (or has it been) surrendered, withdrawn from, loaned against, changed or otherwise reduced in value, or replaced in connection with this transaction, assuming the certificate/contract applied for will be issued? [ ] Yes [ ] No If YES, complete the following: -------------------------------------- -------------------------------------- Year Issued Type of Plan -------------------------------------- -------------------------------------- Company Contract Number -------------------------------------------------------------------------------- Company Address (c) Are you applying for this certificate/contract in a state other than your state of residence? [ ] Yes [ ] No If YES, please provide reason: -------------------------------------------------------------------------------- 3. Participant Information -------------------------------------- -------------------------------------- Employer's Name Participant's Occupation -------------------------------------------------------------------------------- Employer's Street Address -------------------------------------- ----------- ------------------------- City State Zip Code -------------------------------------- -------------------------------------- Estimated Family Income Estimated Net Worth Investment Objective: [ ] Income [ ] Income & Growth [ ] Growth [ ] Aggressive Growth [ ] Safety of Principal Is Participant associated with or employed by a member of the NASD? [ ] Yes [ ] No If YES, affiliation: --------------------------------------------------------- Marital Status: Single [ ] Married [ ] Widowed [ ] Divorced [ ] Number of Dependents: -------------------- Federal Tax Bracket: % -------------------- Purpose of Investment: -------------------------------------------------------------------------------- INVESTMENT HORIZON: (Length of time certificate is expected to remain in force) [ ] (less than) 3 years [ ] 3-7 years [ ] (greater than) 7 years RISK TOLERANCE (Choose only one): The selected investment options should be consistent with the stated Investment Objective and Risk Tolerance. [ ] CONSERVATIVE: Prefer little risk and low volatility in return for accepting potentially lower returns. [ ] CONSERVATIVE/MODERATE: Willing to accept some risk and volatility in return for some growth potential. [ ] MODERATE: Willing to accept above-average amount of market risk and volatility or loss of principal to achieve potentially higher returns. [ ] MODERATE/AGGRESSIVE: Willing to accept above-average amount of market risk and volatility or loss of principal to achieve potentially greater returns. [ ] AGGRESSIVE: Willing to sustain substantial volatility or loss of principal and assume a high level of risk in pursuing potentially higher returns. -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- 4. Do you believe this purchase/transaction is in accordance with your investment objectives? [ ] Yes [ ] No Investment/Assets (Prior to this Investment) Cash (includes checking, savings, money market) $ ----------- Certificates of Deposit (CDs) $ ----------- Bonds $ ----------- Annuities $ ----------- Mutual Funds Income $ ----------- Growth $ ----------- Aggressive $ ----------- Other $ ----------- Total: $ ----------- Stocks $ ----------- Other $ ----------- GRAND TOTAL $ ----------- Comments: ----------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- 10B. OTHER REQUIRED INFORMATION ------------------------------- Is the Participant either: (A) A senior military, governmental, or political official in a non-U.S. country, or (B) Closely associated with or an immediate family member of such official? [ ] Yes [ ] No If yes, identify the name of the official, office held and country: -------------------------------------------------------------------------------- + Required by the U.S. Patriot Act. -------------------------------------------------------------------------------- 11. AGREEMENT ------------- All information and statements on this Enrollment Form are true and complete to the best of my knowledge and belief. I understand that no financial professional has the authority to make or modify any certificate on AXA Equitable's behalf, or to waive or alter any of AXA Equitable's rights and regulations. I UNDERSTAND THAT THE ANNUITY ACCOUNT VALUE ATTRIBUTABLE TO ALLOCATIONS TO THE VARIABLE INVESTMENT OPTIONS OF THE SEPARATE ACCOUNT OR VARIABLE ANNUITY BENEFIT PAYMENTS MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. For the Fixed Maturity Options, amounts transferred or payable under the certificate before the Maturity Date selected in item #8 are subject to market value adjustments. X -------------------------------------------------------------------------------- Proposed Participant's Signature -------------------------------- ----------------- ------------------------- Date City State -------------------------------------------------------------------------------- Form #2004 EDC STRAT E6718 AXA Equitable Life Insuance Company Cat. No. 134592 (10/17/05) Page 3 of 3 -------------------------------------------------------------------------------- ENROLLMENT FORM INSTRUCTIONS FOR REPRESENTATIVE Please read before completing Enrollment Form. A. GENERAL o No Enrollment Form will be processed without an EQUI-VEST Representative's Report o All checks must be made payable to AXA Equitable. o Print neatly or type (except where signatures are required). o Do not abbreviate o Any corrections must be initialed by Participant. o Unless otherwise indicated, complete all sections. -------------------------------------------------------------------------------- B. ITEM 1. EMPLOYER INFORMATION For new employer plans, an EDC 457 Group Annuity Contract Application must also be completed. 2. PARTICIPANT INFORMATION The individual on whose life annuity benefits are determined and upon whose death a death benefit is payable. Please note: Date of birth and social security number are mandatory. The maximum participant issue age is 75. The retirement age is the date on which the participant anticipates distributions will begin. The retirement age may not exceed the certificate maximum maturity age, which is age 85. 3. BENEFICIARY(IES) INFORMATION The individual who will receive the death benefit upon the death of the Participant. Your client must name a primary beneficiary(ies) and may also name a contingent beneficiary. 4. OPTIONAL FEATURES DEATH BENEFIT OPTION: This option resets the guaranteed death benefit every third contract anniversary date to the annuity account value, if greater than the previously established guaranteed death benefit (adjusted for loans, withdrawals and contributions). It has a 15 basis point charge that is deducted annually from the annuity account value. If this is not elected, the regular death benefit explained in the prospectus will apply. This feature is only available at certificate issue, and cannot be terminated once elected. 5. SELECTION OF INVESTMENT OPTIONS AND ALLOCATION PERCENTAGES Participants must select the allocation percentages that will be invested in these options. Your client can change this allocation for future contributions at any time. The percentages entered must be in whole numbers and total 100%. 6. CONTRIBUTION INFORMATION Part #6A is only completed when payment is made at the time the Enrollment Form is signed. If payment is to be made after the Enrollment Form is signed, the signed Enrollment Form must be submitted and payment must be forwarded promptly upon receipt. Part #6B must be completed in all cases. 7. REMINDER/CONTRIBUTION STATEMENTS INFORMATION Complete #7(i) and #7(ii) for all participants. 8. FIXED MATURITY OPTIONS FMOs are only available if the rate to maturity is more than 3%. Contributions to fixed maturity options (FMOs) are NOT available through salary reductions. Contributions to fixed maturity options are available through single sum contributions (rollover and transfers). 9. SPECIAL INSTRUCTIONS Use this section to enter the participant's mailing address if it differs from the primary residential address. Also, for any additional details regarding beneficiary, replacement, or transfer information. 10A. SUITABILITY Complete 1. to ensure that the participant has received the most current prospectus and supplement(s). Complete 2. in all cases. Complete 3. as required by the NASD. 10B. OTHER REQUIRED INFORMATION If the answer to any item in section 10B is "Yes," you must obtain a pre-approved exception, in writing, from AXA Equitable prior to submitting an enrollment for a certificate for this client. 11. AGREEMENT Participant must sign the Enrollment Form. REPRESENTATIVE REPORT If you are not able to see the driver's license or passport of the participant at the time the enrollment form is signed, you can arrange for the client to send you photocopies by mail. However, the enrollment form should not be submitted for processing until you have reviewed the copies and answered YES to this question on the Representative's Report. If you are uncertain how to proceed in a specific situation, contact your Branch Controls Manager. -------------------------------------------------------------------------------- Form #2004 EDC STRAT E6718 EQUI-VEST(R) Strategies EQUI-VEST(R) REPRESENTATIVE REPORT PLEASE PRINT IN BLACK INK. -------------------------------------------------------------------------------- A. [ ] I CERTIFY THAT A PROSPECTUS AND SUPPLEMENT(S) FOR THE CERTIFICATE HAVE BEEN GIVEN TO THE PROPOSED PARTICIPANT AND THAT NO WRITTEN SALES MATERIALS OTHER THAN THOSE APPROVED BY AXA EQUITABLE HAVE BEEN USED. (THE REPRESENTATIVE WHO SECURES THIS ENROLLMENT FORM MUST SIGN IN THE SPACE PROVIDED BELOW.) B. [ ] DO YOU HAVE REASON TO BELIEVE THAT ANY LIFE INSURANCE OR ANNUITY HAS BEEN OR WILL BE SURRENDERED, WITHDRAWN FROM, LOANED AGAINST, CHANGED OR OTHERWISE REDUCED IN VALUE, OR REPLACED IN CONNECTION WITH THIS TRANSACTION, ASSUMING THE CERTIFICATE APPLIED FOR WILL BE ISSUED ON THE LIFE OF THE PARTICIPANT? [ ] YES [ ] NO (IF YES, ATTACH A COPY OF OLD/NEW APPROPRIATENESS FORM.) C. [ ] DID YOU VIEW THE DRIVER'S LICENSE OR PASSPORT OF THE PARTICIPANT? DID YOU DETERMINE THE CUSTOMER'S SOURCE OF FUNDS? [ ] YES (IF YOU ARE UNABLE TO ANSWER YES TO BOTH THESE QUESTIONS, CONTACT YOUR BRANCH MANAGER.) -------------------------------------------------------------------------------- NAME AND SIGNATURE OF THE FINANCIAL REPRESENTATIVE WHO ANSWERED THE ABOVE QUESTIONS AND VERIFIED THE ABOVE DOCUMENTS. -------------------------------------------------------------------------------- PRINT NAME SIGNATURE DATE -------------------------------------------------------------------------------- EQUI-VEST ISSUES MUST ADEQUATELY REFLECT THE COMMISSION INTEREST OF ALL REPRESENTATIVES ON PREVIOUS CONTRACTS.
------------------------------------------------------------------------------------------------------------ PRINT LAST DISTRICT REPRESENTATIVE REPRESENTATIVE(S) NAME(S) NAME REPRESENTATIVE REPRESENTATIVE AGENCY MANAGER INSURANCE (SERVICE REPRESENTATIVE FIRST) INITIAL NUMBER % CODE CODE LICENSE #* ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------
* WHERE REQUIRED BY STATE REGULATIONS -------------------------------------------------------------------------------- FOR EQUI-VEST PROCESSING OFFICE USE REPRESENTATIVE(S) SHOWN ABOVE IS (ARE) EQUITY QUALIFIED AND LICENSED IN THE STATE IN WHICH THE REQUEST IS SIGNED. ENROLLMENT FORM NO. EAO REC'D -------------------------- --------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- PROCESSING: -------------------- ---------------- ------------------ ---------------- CERTIFICATE NUMBER BATCH NUMBER INQUIRY NUMBER PROCESSOR -------------------------------------------------------------------------------- Form #2004 EDC STRAT E6718 EQUI-VEST(R) Strategies