AXA Equitable Life Insurance Company TERM POLICY/RIDER CONVERSION

MONY Life Insurance Company of America OR PURCHASE OPTION

1290 Avenue of the Americas, New York, NY 10104 APPLICATION

‘‘AXA Equitable’’ is the brand name of AXA Equitable Financial Services, LLC and its family of companies, including the AXA Equitable Life Insurance Company and MONY Life Insurance Company of America.

Not for use if conversion involves an increase in face amount, change in rating or addition of new riders.

Original Policy Number(s)

New Plan Type New Face Amount Complete and attach Section B-Product Information for New Plan

Is (are) the original policy(ies) attached? Yes No If ‘‘No,’’ is (are) the original policy(ies) lost? Yes No Full Conversion (Entire amount of Term policy being converted) Partial Term Conversion (If allowed, balance of term coverage remaining after conversion to be continued with premium payment corresponding to remaining coverage only if the term coverage remaining meets minimum requirements.) Partial Term Conversion (Term coverage remaining after conversion to be discontinued) Term Rider Conversion Term Dividend Conversion Option to Purchase Additional Insurance (Purchase Option) Check appropriate box and/or provide information as requested REQUEST i. Scheduled Purchase Option Advanced Privilege/Option B or C (at time other than the scheduled Option date) ii. Option date used (mm/dd/yyyy)

CONVERSION/PURCHASE Complete only if the Advanced Privilege/Option B or C box is checked.

OF OPTION iii. Event

Marriage Date (mm/dd/yyyy) Name of Spouse TYPE Birth or ?nalized legal adoption of child

Name of child Born Date of ?nalized adoption

(mm/dd/yyyy) (mm/dd/yyyy) If there are unearned premium(s) on the Term contract, would you like the unearned premium(s): Applied to the new contract Or Refunded to the Owner(s) of the Term contract?

1. Name First Middle Last

2. Sex Male Female 3. Date of birth (mm/dd/yyyy)

4. SSN 5. Are you currently disabled? Yes No INSURED 6. Primary residential address Bldg/Apt/Suite

City/Municipality County/Parish* State Zip

* County/Parish required in AL, FL, GA, KY, LA and SC

7. If no contingent beneficiary is selected, the contingent beneficiary will be: (1) the Insured’s surviving children, if any, in equal shares; or (2) if the Insured has no surviving children, the contingent beneficiary will be the Insured’s estate.

Total percentage must equal 100% for each category of bene?ciary. If percentage shares are left blank, the shares will be deemed equal. If beneficiary is a Trust (other than Owner), include full name and date of Trust.

INFORMATION Full Name Relationship to Insured Type Bene?ciary Percentage (%)

Primary Contingent Primary Contingent

BENEFICIARY Primary Contingent

8a. Is the Insured the Owner? Yes No (If ‘‘No,’’ complete questions 8b and 9)

8b. Owner Name Date of Birth SS# (mm/dd/yyyy) OWNER 9. Address:

INFORMATION No. & Street City State Zip Code 10. Email address of owner as stated in 8a or 8b

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11. Including any policies and riders with the Company checked on page 1, its af?liates and any other life insurance company: a. Do you have any life insurance/annuities currently in force, including any policy that has been sold, settled or assigned to or with a settlement or viatical company or any other person or entity? Yes No b. Will the coverage applied for replace, change, or affect any existing policy(ies) or contracts? Yes No

Complete as appropriate if either question 11a or b is ‘‘Yes’’ (Use remarks section if additional space is needed)

P-Personal To Be INSURANCE G-Group Replaced

Total Amount Year Policy/ B-Business Changed or 1035 OTHER Name of Company (Face Plus Riders) Issued Contract # A-Annuity Affected Exchange

P B

G A Yes No Yes No P B

G A Yes No Yes No

12. 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

MILITARY SERVICE Forces)

If additional space is needed, attach additional sheet(s) of paper with your name and signature.

REMARKS

The Owner(s) agree(s) that:

(1) For Term Policy or Term Rider conversion, this Application and any new policy is contingent on the cancellation of coverage for the same amount under the term policy or term rider.

(2) No insurance will be in effect under this request, or under any new policy issued by the Company checked on page 1, unless or until the policy has been delivered and accepted and the ?rst full modal premium for the issued policy has been paid.

(3) The respective period for incontestability or suicide exclusion will be the same as the remaining period on the term life insurance policy or the policy from which the term rider is to be converted, if any.

(4) No ?nancial professional has authority to modify this Agreement and/or waive any of our rights and/or requirements. The Company checked on page 1 shall not be bound by any information unless it is stated in this Application.

(5) I (We) acknowledge receipt of the Living Bene?ts Brochure (Accelerated Death Bene?t Rider Brochure), where applicable.

(6) If applicable, I (we) as the trustee(s) represent(s) that the Trust named as Owner is allowed to purchase life insurance and securities under the Trust document. I (We) further represent that beneficial interests in the Trust are only for parties who are related closely by AGREEMENT/ACKNOWLEDGEMENT blood or law, and who have a substantial interest in the Insured engendered by love and affection, or those who have a lawful and substantial economic interest in the continued life of the Insured.

(7) I (We) represent and certify to the Company checked on page 1 that none of the monies utilized to fund this policy derived directly or indirectly from illegal activities or sources and/or tax evasion.

I (We) request and authorize the Company checked on page 1 to charge my (our) checking account to pay premiums due under the policy(ies). It is understood that debits will be made automatically after the effective date determined by the Company checked on page BANK 1 and if charges are overlooked or inadvertently not made, the Company checked on page 1 may charge my (our) account at a later date for these missed charges provided the policy(ies) is active. I (We) understand that the use of the Bank Draft Payment Plan does

IF not change any policy provision. I (We) understand this authorization is to remain in full force and in effect, unless terminated. I (We) ELECTED understand this Plan may be terminated by the depositor, the Owner or the Company checked on page 1 upon 30 days written notice to IS the other parties or if any charge due is not paid or is reversed by the Bank. I (We) understand this Plan may be terminated upon closing of my (our) bank account. I (We) understand if this Plan is terminated, premiums for regular or scheduled premium policies will DRAFT be payable directly to the Company checked on page 1. I (We) agree that this Plan may be terminated if any debit is not honored by AUTHORIZATION my (our) Bank or Depository for any reason. I (We) further agree that if any such charge is dishonored, whether with or without cause and whether intentionally or inadvertently, that the Company checked on page 1 shall be under no liability whatsoever, even if such dishonor results in the forfeiture of insurance.

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

Identi?cation Number (Social Security Number, Employer Identi?cation Number or other Taxpayer Identi?cation 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 that I (we) am (are) no longer subject to backup IDENTIFICATION CERTIFICATION withholding and (iii) I (we) am (are) a U.S. person (including a U.S. resident alien).

Certi?cation Instructions: You must cross out item (ii) above if you have been noti?ed 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.

TAXPAYER NUMBER The Internal Revenue Service does not require your consent to any provisions of this document other than the certi?cation required to avoid backup withholding.

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN FRAUD INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING AN INTENTIONALLY FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.

STATE DISCLOSURES

PLEASE INDICATE YOU HAVE REVIEWED THE 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 A.1-Proposed Insured 2 Information (Complete for IUL Survivorship Products only) Section B-Product Information (must select at least 1 product)

Indexed Universal Life (IUL Protect) Variable Universal Life (LegacySM)

Indexed Universal Life (BrightLife® Grow) Survivorship Universal Life with Indexed Option (BrightLife® Protect Survivorship) ACKNOWLEDGMENTS Variable Universal Life (OptimizerSM) Survivorship Indexed Universal Life (BrightLife® Grow Survivorship) Interest Sensitive Whole Life (ISWL) Survivorship Variable Universal Life (SIL Legacy)

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.

SIGNATURES Signature of Owner(s) Signed by Owner(s) in City, State Dated on (mm/dd/yyyy) (If corporation, print firm’s name, signature and title of authorized officer.) (If Trust, signature of trustee.)

I certify that I have asked and recorded completely and accurately the answers to all questions on this fully completed Application.

TO

For VUL Policies Only:

SECTION Based on the information furnished by the Owner 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 PROFESSIONALTHIS delivered and that no written sales materials other than those furnished by the Company checked on page 1 were used.

COMPLETE Signature of Licensed Financial Professional/Insurance Broker Dated on (mm/dd/yyyy) FINANCIAL Print Licensed Financial Professional’s Name/Insurance Broker Name

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FINANCIAL PROFESSIONAL/BROKER CERTIFICATION

Brokerage Name/Agency Code

13. Did you: a. Verify the identity of the Owner by reviewing the driver’s license/passport or other Government issued ID? Yes No b. Inquire about the source of the Owner’s assets and income? Yes No c. Is the policy/contract for the bene?t of a Politically Exposed Person (PEP)*? Yes No If Yes, de?ne PEP position and Country: * A Politically Exposed Person (PEP) is de?ned as: 1. A current or former senior foreign (non-U.S.) political ?gure; 2. His/her immediate family members (e.g., parents, spouse, sibling, children, in-laws); 3. Close associates - People who are widely and publicly known to maintain a close relationship with the PEP, including people who are in a position to conduct substantial PROFESSIONAL ?nancial transactions on behalf of the PEP; 4. Any corporation, business or other entity that has been formed by, or for the bene?t of, the PEP. d. Select Commission Schedule (Applies only to VUL OptimizerSM policies without the Cash Value Plus Rider.) INFORMATION Semi-Heaped or Heaped

Financial Professional(s) Name(s) Financial Professional % Contact by Annualize

Number Phone E-mail Fax Commission INSURED/FINANCIAL Contact or E-mail Address Retail Only

Do not prepay (4) Prepay (5) Do not prepay (4) Prepay (5)

THESE QUESTIONS MUST BE COMPLETED BY AXA ADVISORS FINANCIAL PROFESSIONALS FOR VARIABLE AND INDEXED PRODUCTS ONLY. QUESTION 14 p. MUST BE COMPLETED BY ALL DISTRIBUTION CHANNELS.

14. These questions MUST BE COMPLETED with respect to the OWNER 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: Safety of Principal Income Income & Growth Growth Aggressive Growth (for this purchase only) e. Risk Tolerance: Conservative Conservative-Plus Moderate Moderate-Plus Aggressive (for this purchase only) f. Marital Status: Single Married Widowed Divorced Separated Domestic Partner g. # of Dependents: h. Federal Tax Bracket: % INFORMATION i. Currently employed? Yes No Retired j. Occupation k. Liquid Net Worth $ Est. Monthly Expenses $ Est. Net Monthly Income $ l. Estimated Gross Annual Household Income $ SUITABILITY m. Investments/Assets (prior to this investment): CDs $ OWNER Stocks $ Mutual Funds Bonds $ Income $ Annuities $ Growth $ Retirement Accounts $ Aggressive $ Investment Real Estate (Net Equity) $ Other Funds $

Other (excluding primary residence) $ n. Total Investments/Assets $ Investment Experience Chart

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

Total Investments/ CDs Assets (above) and Cash $ Stocks Bonds o. Investment Experience (in years)—Complete chart at right Annuities Mutual Funds

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p. Source of Funds for this purchase: (Check box and circle sub-item(s)). If more than one box is checked, provide % breakdown. (Must add up to 100%) Cash: Death Claim, Gift, Inheritance, Checking, Savings, Money Market, Payroll Deduction, CDs: % Borrowing: Mortgage (including Reverse Mortgage), Personal Loan, Credit: % NQ Annuity or Life Insurance: (Replacement, Surrender/Exchange, Policy Loan, Dividend, Withdrawal): % Quali?ed Annuity: (Replacement, Surrender/Exchange, Policy Loan, Dividend, Withdrawal): %

401K, Pension Plans, Other Group Retirement Plans: %

NQ: Brokerage, Investment Advisory Assets, Mutual Fund Shares, UIT Shares, Stocks or Bonds: % Quali?ed: Brokerage, ERISA Plan, Investment Advisory Assets, Mutual Funds Shares, UIT Shares, Stocks or Bonds: %

Employer Contribution: %

Other: Sale of Car, Home, Business, or Other Asset (specify: ),

Legal Settlement, Lottery/Gaming Proceeds, Other: : % INFORMATION 15. 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 SUITABILITY Green Card/Visa Type Expiration Date (mm/dd/yyyy) c. Residents residing in the U.S. temporarily (Non-Resident) with valid Visa only OWNER Visa # Visa Type Expiration Date (mm/dd/yyyy) Form I-94 Expiration Date (mm/dd/yyyy) Passport # Complete Question 16 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).

16. U.S. bank name Account #

Purpose of Insurance

17. Complete For Personal Insurance

Income Replacement Mortgage/Debt Repayment Estate Planning Charitable/Giving Other

18. Type of Business: Sole Proprietorship Partnership Corporation Limited Liability Corporation Trust Estate

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

I, the agent, have con?rmed the account holder name provided is the actual account holder of the bank information provided.

Signature of Licensed Financial Professional/Insurance Broker Date (mm/dd/yyyy) CERTIFICATION/ AGREEMENT Print Licensed Financial Professional/Insurance Broker’s Name License Number

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