[GRAPHIC: Equitable Logo]
FOR CONTRIBUTIONS:
EXPRESS MAIL: Equitable Accumulator Advisor
c/o Bank One, N.A.
300 Harmon Meadow Boulevard, 3rd Floor
Attn: Box 13014, Secaucus, NJ 07094
REGULAR MAIL: Equitable Accumulator Advisor
P.O. Box 13014, Newark, NJ 07188-0014
FOR ASSISTANCE CALL 800-789-7771
EQUITABLE
ACCUMULATOR ADVISOR(SM)
combination variable and fixed deferred annuity
Enrollment Form under Group Annuity Contract No. AC6725 (Non-Qualified),
No. AC6727 (Qualified) and Application for Individual Contract
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1. type of contract
--------------------
|_| Non-Qualified (NQ)
|_| Rollover IRA (traditional)
|_| Roth Conversion IRA
|_| ERISA Tax-Sheltered Annuity (Rollover TSA)
|_| Non-ERISA Tax-Sheltered Annuity (Rollover TSA)
|_| Qualified Plan-Defined Contributions (DC)
|_| Qualified Plan-Defined Benefit (DB)
All of the above are subject to state availability.
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---------
2. owner
---------
|_| Individual
|_| Trustee (for an Individual)
|_| UGMA/UTMA*
|_| Custodian (IRA)
|_| Qualified Plan Trustee-DC
|_| Qualified Plan Trustee-DB
|_| Male |_| Female
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Address (Street)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City State ZIP Code
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Home Phone Office Phone
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Social Security No./TIN Date of Birth (M/D/Y)
*As a Custodian under the ________(state) Uniform Gifts to Minors Act (UGMA) or
Uniform Transfer to Minors Act (UTMA).
See instructions for additional information.
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--------------
3. joint owner
--------------
OPTIONAL. (NQ certificates/contracts only)
|_| Male |_| Female
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Address (Street)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City State ZIP Code
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Home Phone Office Phone
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Social Security No. Date of Birth (M/D/Y)
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-------------------
4. successor owner
-------------------
OPTIONAL. (NQ certificates/contracts only) Available only if owner and
annuitant are different persons.
|_| Male |_| Female
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Date of Birth (M/D/Y)
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5. annuitant
-------------
If other than owner
|_| Male |_| Female
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Address (Street)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City State ZIP Code
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Social Security No. Date of Birth (M/D/Y)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relationship to Owner
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--------------------
6. beneficiary(ies)
--------------------
If more than one -- indicate %. Total must equal 100%. If additional space is
needed, please use Section 15.
PRIMARY
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relationship to Annuitant %
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relationship to Annuitant %
CONTINGENT
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relationship to Annuitant %
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name (First, Middle, Last)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Relationship to Annuitant %
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Accum App 01 E2816 The Equitable Life Assurance Society of the United States
0300727
<PAGE>
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------------------------
7. initial contribution
------------------------
Specify Amount $__________________
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---------------------
8. method of payment
---------------------
NON-QUALIFIED:
|_| Check payable to Equitable Life
|_| Wire
|_| 1035 Exchange
QUALIFIED PLAN:
|_| Check payable to Equitable Life
|_| Wire
ROLLOVER IRA:
|_| Rollover from traditional IRA
|_| Direct rollover from qualified plan or TSA
|_| Direct transfer from other traditional IRA
ROTH CONVERSION IRA:
|_| Conversion rollover from traditional IRA
|_| Direct transfer from other Roth IRA
|_| Rollover from Roth IRA
ROLLOVER TSA:
|_| Direct 90-24 transfer from another carrier
|_| Rollover by check
|_| Direct rollover from another carrier
See instructions for additional information.
--------------------------------------------------------------------------------
-----------------------
9. principal assurance
-----------------------
A. Under Principal Assurance (with a minimum initial contribution of $5,000),
an amount is allocated to a fixed maturity option so that its maturity value
will equal your initial contribution in the year you select below.
|_| 2007 |_| 2008 |_| 2009 |_| 2010
B. The remaining amount of your initial contribution will be allocated to the
variable investment options as you indicate in Section 10 (complete variable
investment options section only). The total must equal 100%.
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-------------------------------------
10. allocation to investment options
-------------------------------------
1) FIXED MATURITY OPTIONS (Each fixed maturity option matures on February 15th
of the maturity year.)
(106) 2001 ______________% (111) 2006 _____________________%
(107) 2002 ______________% (112) 2007 _____________________%
(108) 2003 ______________% (113) 2008 _____________________%
(109) 2004 ______________% (114) 2009 _____________________%
(110) 2005 ______________% (115) 2010 _____________________%
SUBTOTAL (1) _____________________%
2) VARIABLE INVESTMENT OPTIONS
(833) EQ/Aggressive Stock ____________________%
(831) Alliance Common Stock ____________________%
(828) Alliance Conservative Investors ____________________%
(832) Alliance Global ____________________%
(830) Alliance Growth and Income ____________________%
(829) Alliance Growth Investors ____________________%
(837) Alliance High Yield ____________________%
(835) Alliance Intermediate Government Securities ____________________%
(836) Alliance International ____________________%
(834) Alliance Money Market ____________________%
(855) EQ/Alliance Premier Growth ____________________%
(838) Alliance Small Cap Growth ____________________%
(858) EQ/Alliance Technology ____________________%
(859) EQ/AXP New Dimensions ____________________%
(860) EQ/AXP Strategy Aggressive ____________________%
(856) Capital Guardian Research ____________________%
(857) Capital Guardian U.S. Equity ____________________%
(839) EQ Equity 500 Index ____________________%
(852) EQ/Evergreen ____________________%
(853) EQ/Evergreen Foundation ____________________%
(861) FI Mid Cap ____________________%
(851) FI Small/Mid Cap Value ____________________%
(862) EQ/Janus Large Cap Growth ____________________%
(841) EQ Small Company Index ____________________%
(840) EQ International Equity Index ____________________%
(846) Mercury Basic Value Equity ____________________%
(847) Mercury World Strategy ____________________%
(845) MFS Emerging Growth Companies ____________________%
(854) MFS Growth with Income ____________________%
(844) MFS Research ____________________%
(848) Morgan Stanley Emerging Markets Equity ____________________%
(843) EQ/Putnam Balanced ____________________%
(842) EQ/Putnam Growth and Income Value ____________________%
(849) T. Rowe Price Equity Income ____________________%
(850) T. Rowe Price International Stock ____________________%
SUBTOTAL (2) ____________________%
SUBTOTAL OF (1) + SUBTOTAL OF (2) MUST EQUAL 100%
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----------------
11. rebalancing
----------------
OPTIONAL. This option may not be elected if you have elected dollar cost
averaging.
Your account value in the variable investment options will be re-adjusted
quarterly, semi-annually or annually on a contract year basis according to the
percentages indicated in Section 10 of this enrollment form/application.
Rebalancing will be on the same day of the month as the contract date.
SELECT REBALANCING FREQUENCY: (Choose one)
|_| Quarterly |_| Semi-Annually |_| Annually
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Accum App 01
<PAGE>
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--------------------------
12. systematic withdrawals
---------------------------
OPTIONAL. For IRA certificates/contracts, available only if you are age 59 1/2
to 70 1/2. Other withdrawal options are available for IRA certificates/
contracts.
FREQUENCY: |_| Monthly |_| Quarterly |_| Annually
START DATE: ______________________(Month, Day)
AMOUNT OF WITHDRAWAL: $______________ or _____________% (minimum $250)
WITHHOLDING ELECTION INFORMATION (Please read application instructions)
|_| A. I do not want to have Federal income tax withheld.
(U.S. residence address and Social Security No./TIN required)
|_| B. I want to have Federal income tax withheld from each payment.
--------------------------------------------------------------------------------
--------------------------
13. dollar cost averaging
--------------------------
OPTIONAL. You must have a minimum account value of $5,000 in the Alliance
Money Market option.
A. TRANSFER AMOUNT (minimum of $250) $_____________ or ____________%
|_| Monthly |_| Quarterly |_| Annually
B. VARIABLE INVESTMENT OPTIONS
___________________________________________ $_____________ or _____________%
___________________________________________ $_____________ or _____________%
___________________________________________ $_____________ or _____________%
___________________________________________ $_____________ or _____________%
___________________________________________ $_____________ or _____________%
Total must equal transfer amount in A. above or 100%. If additional space is
needed, please use Section 15.
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---------------------------------
14. automatic investment program
---------------------------------
OPTIONAL. (NQ certificates/contracts only) Attach a VOID check (not a deposit
slip) and complete the following information. See instructions for additional
information.
A. Amount to be allocated to the investment options (as indicated in section 10)
$______________________
B. Day of the month:______________________(no later than the 28th)
C. The amount indicated above will be deducted from the following
bank/financial institution account (check one)
|_| Bank Checking |_| Bank Money Market |_| Credit Union Checking
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Account Name Account Number
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Name of Bank/Financial Institution
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
Bank/Financial Institution Address (Street)
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
City State ZIP Code
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-----------------------
15 special instructions
-----------------------
Attach a separate sheet if additional space is needed.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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----------------
16. suitability
----------------
A. Did you receive the Equitable Accumulator Advisor prospectus? |_| Yes |_| No
In the case of IRAs that provide tax deferral under the Internal Revenue Code,
by signing this enrollment form/application you acknowledge that you are buying
the certificate/contract for its features and benefits other than tax deferral,
as the tax deferral feature of the certificate/contract does not provide
additional benefits.
Date of prospectus_____________________________________________________________
Date of any supplements to prospectus__________________________________________
B. Do you believe the certificate/contract is in accordance with your investment
objectives? |_| Yes |_| No
C. 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 Certificate/Contract Number
D. Are you applying for this certificate/contract in a state other than your
state of residence? |_| Yes |_| No
If Yes, please provide reason:_________________________________________________
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Accum App 01
<PAGE>
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-------------
17. agreement
-------------
All information and statements furnished in this enrollment form/application are
true and complete to the best of my knowledge and belief. I understand and
acknowledge that no registered representative has the authority to make or
modify any certificate/contract on behalf of Equitable Life, or to waive or
alter any of Equitable Life's rights and regulations. I understand that the
account value attributable to allocations to the variable investment options and
variable annuity benefit payments, if a variable settlement option has been
elected, may increase or decrease and is not guaranteed as to dollar amount. I
understand that amounts allocated to the fixed maturity options may increase or
decrease in accordance with a market value adjustment until the expiration date.
Equitable Life may accept amendments to this enrollment form/application
provided by me or under my authority. I understand that any change in benefits
applied for or age at issue must be agreed to in writing on an amendment.
X
_______________________________________________________________________________
Proposed Annuitant's Signature Date Signed at: City, State
X
_______________________________________________________________________________
Proposed Owner's Signature Date Signed at: City, State
(if other than annuitant)
X
_______________________________________________________________________________
Proposed Joint Owner's Signature Date Signed at: City, State
(if other than annuitant)
(VIRGINIA RESIDENTS READ AND SIGN ABOVE; ALL OTHER RESIDENTS READ ABOVE
AND BELOW AND SIGN BELOW.)
ARKANSAS/KENTUCKY/NEW MEXICO: Any person who knowingly and with intent to
defraud any insurance company or other person files an enrollment form/
application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts
or information to a contract owner or claimant for the purpose of defrauding or
attempting to defraud the contract owner or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.
FLORIDA: Any person who knowingly and with intent to injure, defraud or deceive
an insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony of the third degree.
Equitable Life is a subsidiary of AXA Financial, Inc. AXA is the majority
shareholder of AXA Financial, Inc. Neither AXA Financial, Inc. or AXA has any
responsibility for the insurance obligations of Equitable Life.
DISTRICT OF COLUMBIA/LOUISIANA/MAINE: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or a denial
of insurance benefits.
NEW JERSEY: Any person who knowingly files a statement of claim containing any
false or misleading information is subject to criminal and civil penalties.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating
a fraud against an insurer, submits an enrollment form/application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any
insurance company files an enrollment form/application or statement of claim
containing any materially false, misleading or incomplete information is guilty
of a crime which may be punishable under state or Federal law.
X
_______________________________________________________________________________
Proposed Annuitant's Signature Date Signed at: City, State
X
_______________________________________________________________________________
Proposed Owner's Signature Date Signed at: City, State
(if other than annuitant)
X
_______________________________________________________________________________
Proposed Joint Owner's Signature Date Signed at: City, State
(if other than annuitant)
--------------------------------------------------------------------------------
Do you have a 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 certificate/contract applied for will be issued on the life of the
annuitant? |_| Yes |_| No
_______________________________________________________________________________
Registered Representative Print Name & No. of Rep Phone No.
Signature Registered Representative
_______________________________________________________________________________
Agency Location Client Account No. Registered Rep Email Address
Soc. Sec. No./TIN
Florida License ID#_______________
--------------------------------------------------------------------------------
Accum App 01
