AXA Equitable Life Insurance Company MONY Life Insurance Company of America

SECTION C – CHILDREN’S TERM INSURANCE RIDER QUESTIONNAIRE FORMING PART OF THE APPLICATION FOR LIFE INSURANCE

Name of Proposed Insured Date of Birth (mm/dd/yyyy) Policy # (If known)

Amount $

NAME OF CHILDREN TO BE INSURED

1. List all children proposed for insurance

Only the natural children, legally adopted children, or stepchildren of the person listed in question 1 of section A of the Application

who have not reached their 18th birthday are eligible for coverage.

Name and Gender of Child

Date of Birth

(mm/dd/yyyy) Height/Weight

Relationship to

Proposed Insured

Name, Address and Phone No. of

Primary Care Physician

First:

Middle:

Last:

Gender: _ Male _ Female

First:

Middle:

Last:

Gender: _ Male _ Female

First:

Middle:

Last:

Gender: _ Male _ Female

First:

Middle:

Last:

Gender: _ Male _ Female

MEDICAL HISTORY

List details of all ‘‘Yes’’ answers to Questions 2, 3 and 4 in chart on page 2

2. Has any child proposed for insurance ever had a driver’s license suspended or revoked or, within the last 5 years,

been convicted of, or cited for any moving violations for driving under the influence of alcohol or drugs? _ Yes _ No

3. Has any child proposed for insurance:

a. Ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical

profession for asthma, diabetes, cancer or tumor, or any disorder of the heart or blood vessels, including heart

murmur? _ Yes _ No

b. In the last 5 years, consulted a physician, or been examined or treated at a hospital or other medical facility?

(Include medical checkups in the last 2 years. Do not include colds or minor injuries.) _ Yes _ No

c. In the last 10 years:

i. Used, except as legally prescribed by a physician, marijuana, opiates, cocaine, crack, heroin, morphine,

methadone, ecstasy, barbituates, sedatives, benzodiazepines, tranquilizers, amphetamines, methamphetamines,

illegal stimulants, hallucinogens, LSD or PCP? _ Yes _ No

(If ‘‘Yes,’’ complete Substance Usage Questionnaire)

ii. Received counseling or treatment regarding the use of alcohol or drugs including attendance at meetings

or membership in any self-help group or program such as Alcoholics Anonymous or Narcotics Anonymous? _ Yes _ No

(If ‘‘Yes,’’ complete Substance Usage Questionnaire)

d. In the last 10 years, been diagnosed with, or treated for, Acquired Immune Deficiency Syndrome (AIDS)

by a member of the medical profession? _ Yes _ No

4. Is any child proposed for insurance receiving special training because of physical or mental disability, or unable

to participate actively at work, or in school, or to perform normal activities? _ Yes _ No

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DETAILS

5. List details of all ‘‘Yes’’ answers to Questions 2, 3 and 4. (Use remarks section if additional room is needed)

Name of Child

Date of Diagnosis

(mm/dd/yyyy)

Duration of Illness

Diagnosis/Treatment/Medication/

Restrictions in Activity

Name, Address and Phone

Number of Health Professional

or facility consulted or seen

(Include City & State)

COVERAGE AND PREMIUM

CHARGE NOTICE

The Owner of this Rider is the Owner of the life insurance policy unless otherwise specified in the Remarks section of the Application.

I (We) understand that the coverage provided under the Children’s Term Insurance Rider terminates for each eligible child the earliest of:

the termination of the policy; when he/she reaches age 25; and the day before the policy anniversary nearest the Proposed Insured’s

65th birthday. This coverage applies to all children I (we) currently have, and may have (or adopt) in the future. Because AXA Equitable

(or the Insurance Company checked on page 1 above section A of the application) does not have any means of knowing how many

children I (we) may have (or adopt) in the future, I (we) understand that AXA Equitable (or the Insurance Company checked on page 1

above section A of the Application and/or any other affiliated companies will continue to charge for this rider until the policy anniversary

nearest the Proposed Insured’s 65th birthday. I (We) also understand that if I (we) have no children under age 25 and want to terminate

this rider, I (we) must notify AXA Equitable (or the Insurance Company checked on page 1 above section A of the Application) and/or

any other affiliated companies in writing.

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