INVESTMENT EDGE & INVESTMENT EDGE SELECT

Transcription

1 INVESTMENT EDGE & INVESTMENT EDGE SELECT Application for an Individual Annuity 1. Contract Series and Type Please make checks payable to: AA Equitable First-Class Mail: AA Equitable Retirement Service Solutions P.O. Box 1577 Secaucus, NJ CONTRACT SPECIFICS A. Choose a Contract Series: Series availability varies and is subject to state approval. Investment Edge Investment Edge Select B. Choose a Contract Type. Non-Qualified Traditional IRA Roth IRA Qualified Plan Defined Contribution (DC) Qualified Plan Defined Benefit (DB) Express Mail: AA Equitable Retirement Service Solutions 500 Plaza Drive, 6th Floor Secaucus, NJ For Assistance, please call AA Advisors, LLC Inherited IRA BCO (Direct Transfer of Decedent IRA) Inherited Roth IRA BCO (Direct Transfer of Decedent Roth IRA) Non-Spousal Beneficiary QP Direct Rollover to an Inherited IRA BCO Non-Spousal Beneficiary QP Direct Rollover to an Inherited Roth IRA BCO C. Total Initial Contribution(s): $ Please review your prospectus to determine the minimum contribution requirements. Specify Method(s) of Payment: Check or Wire 1035 Exchange (from Single Owner Contract, NQ only) 1035 Exchange (from Joint Owner Contract, NQ only) CD or Mutual Fund Proceeds (NQ only) Direct Transfer (IRA or Roth) Rollover from eligible retirement plan (IRA or Roth) IRA Regular Contribution for the year 20 (IRA or Roth) Direct Rollover (Non-Spousal Beneficiary QP to Inherited IRA only) Direct Rollover (Non-Spousal Beneficiary QP to an Inherited Roth IRA) 2. Account Registration (Please print) A. Owner (Must be legal resident of US.) Individual Trust Qualified Plan Trust (DC/DB) UGMA/UTMA (State Child s SSN ) Other Non-Natural Owner Beneficiary of Deceased IRA Owner Non-Spousal Beneficiary of Deceased QP Participant Male Female (mm/dd/yyyy) Daytime Phone # Name (First) (Middle Initial) (Last) Taxpayer Identification Number (Please check one.) U.S.A. Primary Residential Address only No P.O. Box Permitted City State ZIP Code If your Mailing Address is different from the Primary Residential Address above, please provide your Mailing Address in Section 11. Address Annuity Commencement Date: The Annuity Commencement Date will be the Contract Date Anniversary following the Annuitant s 95th Birthday. You may commence payments earlier by submitting a written request to our Processing Office in accordance with the Contract. AA Equitable Life Insurance Company Home Office: 1290 Avenue of the Americas, New York, NY _National Cat. No All Series ICC13 App 01 IE AA Advisors, LLC Page 1 of 9

2 Patriot Act Information 1 1. Are you a US Citizen? (If Yes proceed to question 3.) Yes No 2. If you are not a US citizen do you hold a valid US visa, which under the US Patriot Act permits you to purchase this annuity? (Please attach proper documentation.) Yes No US Visa Category (The following categories are NOT permitted: B, C, D, F, J, M, Q, TWOV.) 3. Your Occupation 4. Your Employer Owner Form of Identification (Please check one.) Valid Driver s License Passport State Issued ID Identification Number Exp. Date (mm/dd/yyyy) 1 The annuitant must complete this section if the owner is not an individual. B. Joint Owner (Must be legal resident of US.) The individual designated below is the Joint Owner. Male Female (mm/dd/yyyy) Daytime Phone # Name (First) (Middle Initial) (Last) Taxpayer Identification Number (Please check one.) SSN ITIN U.S.A. Primary Residential Address only No P.O. Box Permitted City State ZIP Code Address Joint Owner Form of Identification (Please check one.) Valid Driver s License Passport State Issued ID Identification Number Exp. Date (mm/dd/yyyy) C. Annuitant (If other than Owner.) 1 Male Female (mm/dd/yyyy) Daytime Phone # Name (First) (Middle Initial) (Last) Taxpayer Identification Number (Please check one.) SSN ITIN U.S.A. Primary Residential Address only No P.O. Box Permitted City State ZIP Code 1 Annuitant must complete the Patriot Act Information section if the owner is NOT an individual. D. Joint Annuitant For NQ 1035 Exchange Contracts that are Joint Annuitants who are spouses. Male Female (mm/dd/yyyy) Daytime Phone # Name (First) (Middle Initial) (Last) Taxpayer Identification Number (Please check one.) SSN ITIN U.S.A. Primary Residential Address only No P.O. Box Permitted City State ZIP Code ICC13 App 01 IE Page 2 of 9

3 3. Beneficiary(ies) (Please use Special Instructions for Additional Beneficiaries.) Please enter the beneficiaries full name below. Unless otherwise indicated, proceeds will be divided equally. A. Primary 1. Primary Beneficiary Name 2. Primary Beneficiary Name 3. Primary Beneficiary Name B. Contingent 1. Contingent Beneficiary Name 2. Contingent Beneficiary Name 3. Contingent Beneficiary Name 1 Please enter the relationship to the annuitant when the Owner is not an Individual. 4. General Dollar Cost Averaging (DCA) By completing this section you are allocating 100 of your initial contribution(s) to the DCA EQ/Money Market. Please select the DCA destination funds in Section 5. Your future contributions will be allocated according to the instructions provided in Section 5, unless otherwise instructed by you. Check box for one time period. 3 months 6 months 12 months 5. Investment Selection You must allocate your initial contribution among the Packaged Portfolios/Alternative Options and the Investment Options below using the Contribution Allocation column. All future contributions will be allocated according to the percentages below unless otherwise instructed by you. If you elected General Dollar Cost Averaging in Section 4, your initial contribution will be allocated 100 to the DCA EQ/Money Market and the DCA transfers will be allocated according to the allocation instructions provided below. ICC13 App 01 IE Page 3 of 9

4 5. Investment Selection (Continued) Packaged Portfolios and Alternative Options Percentages must be whole numbers and must total 100. Contribution Allocation (Required) Charter Asset Allocation Portfolios Diversified Portfolios Charter SM Fixed Income Charter SM Conservative Charter SM Moderate Charter SM Moderate Growth Charter SM Growth Charter SM Aggressive Growth Charter SM Equity International Portfolios Charter SM International Conservative Charter SM International Moderate Charter SM International Growth Income and Rising Rate/Inflation Portfolios Charter SM Income Strategies Charter SM Interest Rate Strategies Charter SM Real Assets Alternative Portfolios Charter SM Alternative 100 Conservative Plus Charter SM Alternative 100 Moderate Charter SM Alternative 100 Growth Contribution Allocation (Required) Asset Allocation Risk Based Portfolios AA Moderate Allocation AA Moderate-Plus Allocation AA Aggressive Allocation Manager Select Portfolios 7Twelve TM Balanced Portfolio Asset Allocation Fund SM BlackRock Global Allocation V.I. Fund EQ/AllianceBernstein Dynamic Wealth Strategies First Trust/Dow Jones Dividend & Income Allocation Portfolio Franklin Income Securities Fund Franklin Templeton VIP Founding Funds Allocation Fund Invesco V.I. Balanced-Risk Allocation Fund Ivy Funds VIP Asset Strategy Janus Aspen Balanced Portfolio PIMCO VIT Global Multi-Asset Portfolio SEI VP Conservative Strategy Fund SEI VP Moderate Strategy Fund SEI VP Balanced Strategy Fund SEI VP Market Growth Strategy Fund SEI VP Market Plus Strategy Fund All Asset Alternative Portfolios All Asset Aggressive - Alt 25 All Asset Aggressive - Alt 50 All Asset Aggressive - Alt 75 Specialty Alternatives/Specialty AA SmartBeta TM Equity EQ/Convertible Securities EQ/GAMCO Mergers and Acquisitions EQ/Low Volatility Global ETF Guggenheim VT Global Managed Futures Strategy Fund Janus Aspen INTECH U.S. Low Volatility Portfolio Putnam VT Absolute Return 500 Fund Commodities EQ/Energy ETF EQ/Natural Resources PLUS Ivy Funds VIP Energy PIMCO VIT CommodityRealReturn Strategy Portfolio Van Eck VIP Global Hard Assets Fund REITs EQ/Real Estate PLUS Invesco V.I. Global Real Estate Fund Sector Invesco V.I. Global Health Care Fund Ivy Funds VIP Science and Technology MFS Utilities Series Multimanager Technology T. Rowe Price Health Sciences Portfolio-II ICC13 App 01 IE Page 4 of 9

5 5. Investment Selection (Continued) Investment Options Contribution Allocation (Required) Large Cap Value Stocks EQ/BlackRock Basic Value Equity EQ/Boston Advisors Equity Income EQ/Large Cap Value Index MFS Value Series Mutual Shares Securities Fund T. Rowe Price Equity-Income Portfolio-II Large Cap Blend Stocks Growth-Income Fund SM EQ/Common Stock Index EQ/Equity 500 Index Fidelity VIP Contrafund Portfolio Franklin Rising Dividends Securities Fund MFS Investors Trust Series Large Cap Growth Stocks EQ/Calvert Socially Responsible EQ/Large Cap Growth Index EQ/Montag & Caldwell Growth EQ/T. Rowe Price Growth Stock JPMorgan Insurance Trust Intrepid Growth Portfolio MFS Research Series Mid Cap Stocks Mid Cap Value Stocks American Century VP Mid Cap Value Fund Mid Cap Blend Stocks EQ/Mid Cap Index Mid Cap Growth Stocks EQ/Morgan Stanley Mid Cap Growth Federated Kaufmann Fund II Fidelity VIP Mid Cap Portfolio JPMorgan Insurance Trust Mid Cap Growth Portfolio Small Cap Stocks Small Cap Value Stocks EQ/GAMCO Small Company Value Multimanager Small Cap Value Small Cap Blend Stocks EQ/Small Company Index Invesco V.I. Small Cap Equity Fund Small Cap Growth Stocks EQ/AllianceBernstein Small Cap Growth Ivy Funds VIP Micro Cap Growth Multimanager Small Cap Growth Contribution Allocation (Required) International Stocks International Stocks International Growth and Income Fund SM EQ/International Equity Index EQ/MFS International Growth Invesco V.I. International Growth Fund JPMorgan Insurance Trust International Equity Portfolio MFS International Value Portfolio Emerging Market Stocks New World Fund Delaware VIP Emerging Markets Series EQ/Emerging Markets Equity PLUS Lazard Retirement Emerging Markets Equity Portfolio Global Stocks Global Growth Fund SM Global Small Capitalization Fund SM BlackRock Global Opportunities V.l. Fund EQ/Oppenheimer Global EQ/Templeton Global Equity Bonds Core Bonds Delaware VIP Diversified Income Series Eaton Vance VT Floating-Rate Income Fund EQ/Core Bond Index EQ/Intermediate Government Bond Fidelity VIP Strategic Income Portfolio Janus Aspen Flexible Bond Portfolio Lord Abbett Series Fund Bond Debenture Portfolio PIMCO VIT Total Return Portfolio Short Term Bonds Delaware VIP Limited-Term Diversified Income Series EQ/AllianceBernstein Short Duration Government Bond EQ/PIMCO Ultra Short Bond Inflation Linked (TIPS) American Century VP Inflation Protection Fund EQ/PIMCO Global Real Return High Yield Bonds EQ/High Yield Bond Federated High Income Bond Fund II Invesco V.I. High Yield Fund International Bonds PIMCO VIT Emerging Markets Bond Portfolio PIMCO VIT Global Bond Portfolio (Unhedged) Templeton Global Bond Securities Fund Van Eck VIP Unconstrained Emerging Markets Bond Fund Cash/Cash Equivalents EQ/Money Market ICC13 App 01 IE Page 5 of 9

6 6. Rebalancing Your account value will be automatically reallocated to the Allocation selections in Section 5. Please select a frequency. Quarterly Semi-Annually Annually 7. Broker Transfer Authority Disclosure Yes. I have given authority to my Financial Professional to act as my agent and provide to AA Equitable Investment Option transfer instructions by telephone or electronically, and I hereby authorize AA Equitable to act on such instructions. I understand and acknowledge that AA Equitable (i) may rely in good faith on the stated identity of the person placing such instructions, and (ii) will have no liability for any claim, loss, liability, or expense that may arise in connection with such instructions. AA Equitable will continue to act upon this authorization until such time as we receive written notification in our processing office that broker transfer authority has been terminated. Upon receipt of such notification, AA Equitable will terminate the Financial Professionals ability to provide transfer instructions on your behalf. AA Equitable may (i) change or terminate telephone or electronic or overnight mail transfer procedures at any time without prior notice, and (ii) restrict fax, internet, telephone and other electronic transfer services because of disruptive transfer activity. 8. Current Insurance 1. Do you have any other existing life insurance or annuities? Yes No 2. 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 Contract applied for will be issued? Yes No If Yes to question number 2, complete the following: Company Type of Plan Year Issued Contract Number Company Type of Plan Year Issued Contract Number Company Type of Plan Year Issued Contract Number 9. Contract State The Contract State is your state of primary residence (Owner s primary residential address from Section 2) unless you sign the application in a different state. If you are signing this application in a state other than your state of primary residence, check one box below: I have a second residence where the application was signed (the state of sale) or I work or conduct business in the state where the application was signed (the state of sale). If none of the above apply the application must be signed in your state of Primary Residence, unless we approve another state. 10. Fraud Warnings Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. ICC13 App 01 IE Page 6 of 9

7 11. Special Instructions Attach a separate sheet if additional space is needed. For Owners whose Mailing Address differs from their Primary Residential Address in Section 2, please complete the following: Mailing Address P.O. Box accepted City State Zip Code 12. Electronic Delivery If you are enrolled to receive electronic delivery of ALL DOCUMENTS by your second contract date anniversary and maintain that enrollment going forward, the Annual Administrative Charge of $50 will be waived. I consent to receive electronically all documents including Annuity Statements, Confirmation Notices, Prospectuses, Privacy Policy and other related communications. 1 My address is: 1 Custodially owned contracts: please provide the annuitant s address. Other non-natural owners (such as trusts): please provide the address of the authorized signatory. This consent will continue unless and until revoked and will cover delivery to you in the form of an or by notice to you of a document s availability on AA Equitable s website. Please logon to axa-equitable.com to update your address, revoke your consent to electronic delivery or request paper copies. Certain types of correspondence may continue to be delivered by the United States Postal Service for compliance reasons. Registration at axa-equitable.com is required for electronic delivery of Contract related correspondence. Upon issuance of your contract you will receive an providing a temporary password and instructions to register for online access at axa-equitable.com. Through this online account you can view, download or save statements and other documents to your home computer. If the provided is not a valid address, you will receive paper versions of your statements and other contract related documents. The computer hardware and software requirements that are necessary to receive, process and retain electronic communications that are subject to this consent are as follows: To view and download material electronically, you must have a computer with internet access, an active account and Adobe Acrobat Reader. If you don t already have Adobe Acrobat Reader, you can download it free from There is no charge for the electronic delivery of electronic communications, although you may incur costs of internet access and of such computer and related hardware and software as may be necessary for you to receive, process and retain electronic communication from AA Equitable. Please make certain that you have given AA Equitable a current address. Also, let AA Equitable know if that address changes. We will notify you of a document s availability through . You may request paper copies, whether or not you consent or revoke your consent for electronic delivery, at any time. Even if you have given us consent, we are not required to make electronic delivery and we have the right to deliver any communications in paper form. ICC13 App 01 IE Page 7 of 9

8 13. Signature and Acknowledgements GENERAL DISCLOSURE. I/WE UNDERSTAND AND ACKNOWLEDGE THAT: ACCOUNT VALUE(S) ATTRIBUTABLE TO ALLOCATIONS TO THE VARIABLE INVESTMENT OPTIONS, AND ANY VARIABLE ANNUITY BENEFIT PAYMENTS I MAY ELECT, MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. In the case of IRAs and Qualified Plans that provide tax deferral under the Internal Revenue Code, by signing this application I acknowledge that I am buying the Contract for its features and benefits other than tax deferral, as the tax deferral feature of the Contract does not provide additional benefits. Under penalty of perjury, I certify that the Taxpayer Identification Number in Section 2 is correct. All information and statements furnished in this application are true and complete to the best of my knowledge and belief. AA Equitable may accept amendments to this application provided by me or under my authority. No Financial Professional has the authority to make or modify any Contract on behalf of AA Equitable, or to waive or alter any of AA Equitable s rights and regulations. AA Equitable must agree to any change made to the Contract and benefits applied for, or to the age at issue, in writing. Charges under the Contract generally apply for the duration of the Contract. Fees, Charges and Investment Options vary by Series. Consent for Delivery of Initial Prospectus on CD-ROM: Yes. By checking this box and signing the application below, I acknowledge that I received the initial prospectus on computer readable compact disk CD, and I am able to access the CD information. In order to retain the prospectus indefinitely, I understand that I must print it. I also understand that I may request a prospectus in paper format at any time by calling Customer Service at , and that all subsequent prospectus updates and supplements will be provided to me in paper format, unless I enroll in AA Equitable s Electronic Delivery Service. When you sign this application, you are agreeing to the elections that you have made in this application and acknowledge that you understand the terms and conditions set forth in this application. Proposed Owner s Signature Signed at: City, State Date Proposed Annuitant s Signature (if other than Owner) Signed at: City, State Date Proposed Joint Owner s Signature (if other than Annuitant) Signed at: City, State Date Proposed Joint Annuitant s Signature (if other than Owner) Signed at: City, State Date ICC13 App 01 IE Page 8 of 9

9 14. Financial Professional Section 1. Does the Proposed Owner have any existing life insurance or annuity contracts? 1... Yes No 2. Do you have reason to believe that any existing 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 Contract applied for will be issued on the life of the Annuitant(s)/Owner(s)? 1... Yes No 3. Did you verify the identity by reviewing the driver s license/passport of each Owner/Annuitant, inquire about the source of the customer s assets and income, and confirm that the Proposed Insured and Owner is not (nor family member of or associates with) a foreign military, government or political official? Yes No 4. Is the Proposed Insured currently an Active Duty* Member of the Armed Forces?... Yes No (If Yes, you must also submit a complete and signed LIFE INSURANCE/ANNUITY DISCLOSURE TO ACTIVE DUTY MEMBERS OF THE ARMED FORCES.) 1 Please confirm that your response to this question is consistent with the response provided in section 8, Current Insurance. * Active Duty means full-time in the active military service of the United States and includes members of the reserve component (National Guard and Reserve) while serving under published orders for active duty or full-time training. The term does not include members of the reserve component who are performing active duty or active duty for training under military calls or orders specifying periods of less than 31 calendar days. Primary Registered Representative Signature Social Security Number Rep. Code Print Name ( ) - Phone Number Client Account Number Address Broker Dealer Location Secondary Financial Professional Signature Social Security Number Agent Code Print Name ( ) - Phone Number Tertiary Financial Professional Signature Social Security Number Agent Code Print Name ( ) - Phone Number Financial Professional Use Only. Contact your home office for program information. Option I Option II 2 Option III 2 (Once selected, program cannot be changed. Certain commission options may not be available through all selling Broker Dealers. Please check with your Broker Dealer for availability.) 2 Applicable to Investment Edge only. Cat No ICC13 App 01 IE Page 9 of 9