Select the appropriate box

?Proposed Insured part of group with Multiple Proposed Insureds – Employer Owned

(If this box is checked, complete Section I only. Each Proposed Insured must complete the Consent to Insurance Application Supplement.)

?Proposed Insured—Employee owner or Single insured- Employee Owned/Individual, Trust Owned/Other Single Owner Arrangement

(If this box is checked, complete Sections I and II, date and sign the application as well.)

PRODUCT

INFORMATION

1.Product Name             

Complete and attach Section B-Product Information Questionnaire for Plan.

Complete Owner Questionnaire if Owner is a Trust.

SECTION I Complete Owner Information

COMPLETE FOR ALL OWNER TYPES

If Trust is Owner, complete Section 1 and questions 2-11 (Trust Section) of Owner Questionnaire

2. Owner’s name             

3. Relationship to Proposed Insured             

4. ?SSN ?EIN ?ITIN             

5. Address             

City            State             Zip Code            

If P.O. Box, put residential address in Remarks Section

6. Person(s) authorized to act on behalf of Owner.

Name             Title            Phone #             

Email address            

Name             Title            Phone #             

Email address            

7. If Third Party Administrator (TPA) is authorized person, include Name and Contact Information.

Name            Phone Number            

Address:             

Email address            

OWNER OTHER INSURANCE

Complete question 8 if replacing policies of Owner.

8. Including any policies and riders with the Company checked above its affiliates and any other life insurance company will the

coverage applied for replace, change, or affect any existing policy(ies) or contract(s)? ?Yes ?No

If “Yes,” please complete chart.

Name of Company

Total Amount

(Face Plus

Riders)

Year

Issued

Policy/

Contract #

P-Personal

G-Group

B-Business

A-Annuity

1035

Exchange

? P ? B

? G ? A ?Yes ? No

? P ? B

? G ? A ?Yes ? No

ICC12-AXA-GI (2/15)

1290 Avenue of the Americas, New York, NY 10104

(Select One)

? AXA Equitable Life Insurance Company

? MONY Life Insurance Company of

America

Guaranteed Issue

Application for individual

Life Insurance

1

BENEFICARY

9. Is the beneficiary the same as the Owner? ?Yes ?No

10. If “No,” complete as appropriate.

Full Name            Relationship to Insured            %

Full Name            Relationship to Insured            %

Full Name            Relationship to Insured            %

SOURCE OF

FUNDS

11. Employer assets/funds (including policies on List/Salary Allotment billing where premiums are to be paid by employer)

? Company Assets ? Other (please specify)             

COMPLETE FOR INDIVIDUAL OWNER

Complete questions 12 to 17 only if Individual owners.

12. Is the Proposed Insured the Owner? ?Yes ?No If “No,” relationship to Proposed Insured             

13. Do you have a driver’s license? ?Yes ?No If “Yes,” provide license #, state and expiration date

Number            State             Expiration Date             (mm/dd/yyyy)

If “No” to driver’s license, do you have a government issued ID? ?Yes ?No

If “Yes,” to government issued ID, type of ID             Government ID #            

14. Date of birth            (mm/dd/yyyy)

15. 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)

16. Are you a U.S. citizen? ? Yes ? No (If ‘‘No,’’ please complete ‘‘a’’ and ‘‘b’’ or ‘‘c,’’ where applicable)

a. Country of Citizenship             Date of Entry into the U.S.             (mm/dd/yyyy)

b. Residents with legal permanent status (Resident) in U.S. only

Green Card/Visa Type             Expiration Date             (mm/dd/yyyy)

c. Residents residing in the U.S. temporarily (Non-Resident) with valid Visa only

Visa #            Visa Type            Expiration Date            (mm/dd/yyyy)

Form I-94 Expiration Date            (mm/dd/yyyy) Passport #             

Complete Question 17 for all non-resident (foreign) Owners. 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. Any foreign Owner (Individual, Trust, Corporation, Partnership, Other Entity) must have a US

bank account).

17. U.S. bank name             Account #            

ICC12-AXA-GI

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SECTION II Proposed Insured to Complete

PROPOSED INSURED

Face Amount            

18. Name First             Middle             Last             

19. Date of birth            (mm/dd/yyyy)

20. SSN            

21. Sex ? Male ? Female

22. Job Title            

23. Work site address             

City            State             Zip Code            

Complete only if Proposed Insured and Owner are different.

24. Do you have a driver’s license? ?Yes ?No If “Yes,” provide license #, state and expiration date

Number            State             Expiration Date             (mm/dd/yyyy)

25. Are you a member of the armed forces, including the reserves? ?Yes ?No

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

26. Are you a U.S. citizen? ? Yes ? No (If ‘‘No,’’ please complete ‘‘a’’ and ‘‘b’’ or ‘‘c,’’ where applicable)

a. Country of Citizenship             Date of Entry into the U.S.             (mm/dd/yyyy)

b. Residents with legal permanent status (Resident) in U.S. only

Green Card/Visa Type             Expiration Date             (mm/dd/yyyy)

c. Residents residing in the U.S. temporarily (Non-Resident) with valid Visa only

Visa #            Visa Type            Expiration Date            (mm/dd/yyyy)

Form I-94 Expiration Date            (mm/dd/yyyy) Passport #             

UNDERWRITING

QUESTIONS

27. During the previous three (3) months have you, the Proposed Insured, engaged in active full-time employment (at least 30 hours per

week in a normal capacity and, in particular, not been hospitalized or absent from work due to illness or accident for more than five (5)

consecutive working days)? ?Yes ?No

(If “No,” give details below.)

28. Are you, the Proposed Insured, actively at work on the date this application form was signed? ?Yes ?No

TOBACCO USE

29. 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 amount and frequency of use

Indicate date last

used (mm/yyyy)

?Cigarettes #            ?Pk(s) ?Single per

?Day ?Month ? Year

?Cigars ?Cigarillos #            ?Pk(s) ?Single per

?Day ?Month ? Year

?Pipe ?Chewing Tobacco ?Nicotine Patch or Gum

?Other (please specify)             

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.

ICC12-AXA-GI 3

AGREEMENT

AGREEMENT. Each signer of this application agrees that:

(1). The statements and answers in all parts of this application are true and complete to the best of my (our) knowledge and belief. AXA

Equitable/MLOA may rely on them in acting on this application.

(2). No insurance shall take effect on this application: (a) until a policy is delivered and the full initial premium for it is paid, or an approved

payment authorization is signed, while the person(s) proposed for insurance is (are) living; (b) before any Register Date specified in this

application; and (c) unless to the best of my (our) knowledge and belief the statements and answers in all parts of this application continue to

be true and complete, without material change, as of the time such premium is paid or an approved payment authorization is signed.

(3). No financial professional has authority to modify this Agreement, nor to waive any of the Company checked on page 1 rights or

requirements. The Company checked on page 1 shall not be bound by any information unless it is stated in this Application.

TAXPAYER

IDENTIFICATION NUMBER

CERTIFICATION

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

Number (Social Security Number, Employer Identification Number or other Taxpayer Identification 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 notified

by the Internal Revenue Service (IRS) that I (we) am (are) subject to backup withholding as a result of a failure to report all interest

or dividends or (C) the IRS has notified 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). Certification Instructions: You must cross out item (ii) above if you have been

notified 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 not require your consent to any provisions of this

document other than the certification required to avoid backup withholding.

STATE FRAUD

DISCLOSURES

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER,

SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING AN INTENTIONALLY FALSE OR DECEPTIVE STATEMENT MAY BE

GUILTY OF INSURANCE FRAUD.

ACKNOWLEDGMENTS

PLEASE INDICATE YOU HAVE REVIEWED THE APPLICATION AND QUESTIONNAIRES AS THEY HAVE BEEN COMPLETED BY

CHECKING THE APPROPRIATE BOX(ES) BELOW. FAILURE TO CHECK THE APPROPRIATE BOX(ES) WILL REQUIRE YOU TO

SIGN AN APPLICATION AMENDMENT.

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

?Term Life ?Owner Questionnaire (if Trust Owned)

?Universal Life (Athena UL)

?Universal Life with Indexed Option(s) (BrightLife Protect)

?Indexed Universal Life (BrightLife Grow)

?Variable Universal Life (IL Optimizer II)

?Variable Universal Life (IL Legacy III)

?Interest Sensitive Whole Life (ISWL)

?Employer Sponsored Life Insurance (ESLI)

?Corporate Owned Incentive Life (COIL)

SIGNATURES

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 Acknowledgment and Authorization.

X Signature of Proposed Insured            

X            

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

If trust is Owner, trustee must sign on behalf of the trust. If corporation is Owner, an authorized officer of corporation must sign.

If Corporation: Name of Firm (print)             

Name of authorized officer who signed application (print):             

FINANCIAL PROFESSIONAL TO

COMPLETE THIS SECTION

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 8 on Section 1 of the Application. ?Yes ?No

If ‘‘No,’’ provide details            

Certification for VUL Policies Only, signature required FOR ALL POLICIES

Based on the information furnished by the Proposed Insured(s) and Owner, if other than the Proposed Insured(s), in this and any other 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.

X Signature of Licensed Financial Professional/Insurance Broker             

Dated on (mm/dd/yyyy)

Print Licensed Financial Professional’s Name            License Number            

ICC12-AXA-GI

4

FINANCIAL PROFESSIONAL/BROKER CERTIFICATION

SIONAL/AGENT/BROKER CERTIFICATION

INSURED/FINANCIAL

PROFESSIONAL INFORMATION

Brokerage Name/Agency Code             

Financial

Professional(s)

Name(s)

Financial

Professional

Number %

Contact by:

?Phone ?E-mail ?Fax

Contact or E-mail Address

OWNER SUITABLITY INFORMATION

THESE QUESTIONS MUST BE COMPLETED BY AXA ADVISORS FINANCIAL PROFESSIONAL FOR VARIABLE AND INDEXED PRODUCTS ONLY. DO

NOT COMPLETE FOR OTHER PRODUCT TYPES.

BUSINESS INSURANCE

(1) Is the owner a member or an affiliate of a member of FINRA? ? Yes ? No

(2) Persons authorized to transact business on behalf of Owner:

Name:             Title:            

Name:             Title:            

(3) Total Assets (as of last fiscal quarter): $            

If the answer to Question 3 above is less than $50 million, please answer (a) and (b) below.

(a) Net Income (last fiscal quarter): ? less than $500,000 ?$501,000?2 million ? $2 million?5 million

? $5 million?10 million ?$10 million +

(b) Net Worth (last fiscal quarter): ?less than 0 ? $0?500,000 ?$501,000?2 million

? $2 million?5 million ? $5 million?10 million ?10 million +

(4) Purpose ? Key Person ? Buy-Out Funding ? Deferred Comp. ? Salary Continuation ? Executive Bonus

?Overhead Expense ?Qualified Retirement Plan ?Investment/Savings ? 401(k) Plan ? 125 Cafeteria Plan ? (Other)

(5) Type of Business ?Manufacturing ? Wholesale ?Transportation ? Agriculture ? Construction ? Service

? Professional Service ? Mining ?Retail ? Financial, Real Estate ?Insurance ? (Other)

(6) No. of Employees ? 10?24 ? 25?49 ? 50?99 ? 100?499 ? 500+

INDIVIDUAL OWNERS

1. a. Is the Owner affiliated with or employed by a member of FINRA? ?Yes ?No

b. Has a Financial Plan been prepared by AXA Advisors, LLC for the client in the last 12 months? ?Yes ? No

Plan # or Planning Tool Name:            

c. Investment Time Horizon : ?< 5 years ?5?9 years ?10?14 years ?15?19 years ?20+ years

d. Investment Objective (for this purchase only): ?Safety of Principal ? Income ?Income & Growth ?Growth ?Aggressive Growth

e. Risk Tolerance (for this purchase only): ?Conservative ?Conservative-Plus ?Moderate ?Moderate-Plus ?Aggressive

f. Marital Status: ?Single ?Married ?Widowed ? Divorced ? Separated ?Domestic Partner

g. # of Dependents:            h. Federal Tax Bracket:             % i. Currently employed? ?Yes ?No ?Retired

j. Liquid Net Worth $            k. Estimated Gross Annual Household Income $            

l. Total Net Worth $            

m. Investments/Assets (prior to this investment):

?CDs $             ?Mutual Funds $            

?Stocks $             ?Income $            

?Bonds $             ?Growth $            

?Annuities $             ?Aggressive $            

?Retirement Accounts $             ?Other Funds $            

?Real Estate (Mortgage/Equity) $            

?Other (excluding primary residence $             

n. Total Investments/Assets $             o. Investment Experience (in years)

Cash (Checking, Savings, MMA) $             None < 1 1?4 5+

Total Investments/ CDs ? ? ? ?

Assets (above) and Cash $             Stocks ? ? ? ?

Bonds ? ? ? ?

Annuities ? ? ? ?

Mutual Funds ? ? ? ?

ICC12-AXA-GI-FPCert

1

OWNER

IDENTIFICATION

Did you :

(i) verify the identity of the Policyowner by reviewing certified articles of incorporation, a business license, a partnership

agreement or a trust instrument? ?Yes ?No

(ii) inquire about the source of the customer’s assets and income? ?Yes ?No

If “No”, sales associate must contact Branch Controls Person

CERTIFICATION/

AGREEMENT

I certify that I have truly and accurately recorded all information supplied by Owner(s) onto this Application.

Signature of Licensed Financial Professional/Insurance Broker            Date            (mm/dd/yyyy)

Print Licensed Financial Professional/Insurance Broker’s Name            

License Number            

ICC12-AXA-GI-FPCert

2