See All of This Company's Exhibits
EX-99.4RR
9
e6719_ex99-4rr.txt
EQUI-VEST STRATEGIES 457(B) EDC ENROLLMENT FORM
[Logo of AXA EQUITABLE]
EQUI-VEST(R) Strategies
457(b) EDC Enrollment Form
MAILING INSTRUCTIONS:
EXPRESS MAIL: EQUI-VEST New Business
c/o Bank One, N.A.
300 Harmon Meadow Boulevard, 3rd Floor
Attn: Box 13823, Secaucus, NJ 07094
REGULAR MAIL: EQUI-VEST New Business
P.O. Box 13823, Newark, NJ 07188-0823
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1. Employer information
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EMPLOYER NAME
[ ] Existing Unit Number
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[ ] New Unit (Must complete Unit Installation Form)
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2. Participant information (check appropriate boxes)
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[ ] Mr. [ ] Mrs. [ ] Miss [ ] Ms. [ ] Other
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First Name Middle Initial Last Name
[ ] Male [ ] Female
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Birth Date (M/D/Y) Age at Nearest Birthday
[ ] Home [ ] Work
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Area Code Daytime Phone Number
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Street Address - No P.O. Box Permitted (If Non-U.S., Contact Branch)
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City State Zip Code
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Social Security No. (Required) Retirement Age
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Driver's License/Passport No.+
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State/Country Exp. Date
+ Required by the U.S. Patriot Act.
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3. Beneficiary(ies) information
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Include full name(s). Relationship(s) to Participant and the Social Security
Number of EACH Beneficiary. Use #9 if you need more space.
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Primary
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Social Security Number
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Relationship
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Contingent (if any)
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Social Security Number
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Relationship
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4. Optional features
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ENHANCED DEATH BENEFIT OPTION
Would you like to elect the 3-year Enhanced Death Benefit?
[ ] YES, I would like to elect the Ratcheted Death Benefit.
[ ] NO, I would like to have only the sum of contributions (adjusted for loans
and withdrawals) as the Minimum Death Benefit.
ONCE THE RATCHETED DEATH BENEFIT IS ELECTED, IT CANNOT BE TERMINATED. A CHARGE
OF .15% OF THE ACCOUNT VALUE WILL BE DEDUCTED ON EACH CERTIFICATE ANNIVERSARY.
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5. Selection of investment options
and allocation percentage
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(Check either Box A or Box B but not both). IF THE EMPLOYER MAKES THIS SELECTION
ON BEHALF OF THE PARTICIPANTS, THEN THE SELECTION HERE MUST BE THE SAME AS THE
EMPLOYER'S.
A.[ ] MAXIMUM TRANSFER FLEXIBILITY. By checking this box, you may invest only in
those options listed below that have been shaded. Transfers out of the GIO
will not be limited (see prospectus for details).
B.[ ] MAXIMUM INVESTMENT OPTION CHOICE. By checking this box, you may invest in
any of the options listed below (shaded and not shaded). Transfers out of
the GIO will be limited (see Prospectus for details).
CURRENT ALLOCATION: Select the allocation for the amounts that you may
invest in these options in the future. You can change this allocation for
future contributions at any time. The percentages entered below must be in
whole numbers and total 100%.
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Guaranteed Interest Option _____%
EQ/Equity 500 Index _____%
EQ/Alliance Growth & Income _____%
EQ/Alliance Common Stock _____%
EQ/Alliance International _____%
EQ/Alliance Small Cap Growth _____%
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EQ/Money Market _____%
EQ/Alliance Intermediate Gov't. Securities _____%
EQ/Alliance Quality Bond _____%
EQ/ J.P. Morgan Core Bond _____%
AXA Premier High Yield _____%
AXA Premier VIP Core Bond _____%
AXA Conservative-Plus Allocation _____%
AXA Conservative Allocation _____%
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EQ/Bernstein Diversified Value _____%
EQ/JP Morgan Value Opportunities _____%
EQ/MFS Emerging Growth Companies _____%
EQ/Emerging Markets Equity _____%
EQ/FI Small/Mid Cap Value _____%
EQ/Mercury Basic Value Equity _____%
EQ/Alliance Premier Growth _____%
EQ/Evergreen Omega _____%
EQ/MFS Investors Trust _____%
EQ/Capital Guardian Research _____%
EQ/Capital Guardian U.S. Equity _____%
EQ/Calvert Socially Responsible _____%
EQ/Marsico Focus _____%
EQ/Janus Large Cap Growth _____%
EQ/FI Mid Cap _____%
EQ/Capital Guardian International _____%
EQ/Lazard Small Cap Value _____%
EQ/Mercury International Value _____%
EQ/Capital Guardian Growth _____%
EQ/Small Company Index _____%
AXA Aggressive Allocation _____%
AXA Moderate-Plus Allocation _____%
AXA Moderate Allocation _____%
AXA Premier VIP Aggressive Equity _____%
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Form #2004 EDC STRAT E6718 AXA Equitable Life Insurance Company
Cat. No. 134592 (12/04) Page 1 of 3
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AXA Premier VIP Large Cap Growth _____%
AXA Premier VIP Large Cap Core Equity _____%
AXA Premier VIP Large Cap Value _____%
AXA Premier VIP Small/Mid Cap Growth _____%
AXA Premier VIP Small/Mid Cap Value _____%
AXA Premier VIP International Equity _____%
AXA Premier VIP Technology _____%
AXA Premier VIP Health Care _____%
EQ/Enterprise Equity _____%
EQ/Enterprise Equity Income _____%
EQ/Enterprise Growth _____%
EQ/Enterprise Growth and Income _____%
EQ/Enterprise Small Company Growth _____%
EQ/Enterprise Small Company Value _____%
100%
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TOTAL (MUST BE 100%)
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6. Contribution information
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Complete #6A only if a rollover or transfer check is provided when the
Enrollment Form is signed. If payment will be forwarded at a later date, you
must complete only #6B.
A. Rollover/Transfer Amount provided with this Enrollment Form:
(i) Total amount for investment options listed in #5. $
(Do not include amounts for the Fixed Maturity Options.) ------------
(ii) Total amount for Fixed Maturity Period(s) listed in #8. $
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(iii)Employee Monthly Contribution $
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(iv) Total amount remitted. $
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B. Expected first-year contribution: Indicate the amount expected to be
contributed in the first year of participation under this certificate.
$
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7. Reminder/Contribution
statements information
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Plan Contribution Statement Frequency
Note: You must check the same frequency as elected by your Institution.
(i) [ ] Monthly [ ] Semi-Monthly [ ] Bi-Weekly
You will be included on the Contribution Statement sent to your
Institution. Each Contribution Statement will show the amount of the last
contribution made.
(ii) Initial Contribution Statement Reminder Amount $
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8. Fixed maturity options (FMOs)
--------------------------------
FMOS ARE ONLY AVAILABLE IF THE RATE TO MATURITY IS MORE THAN 3%.
For the amount shown in #6A(ii), please allocate by whole percentages to the
following Fixed Maturity Period(s). FMOs are not available for ongoing
contributions, only rollovers or direct transfers. (Do not select a Maturity
Date that has already expired.)
PERCENTAGE OF AMOUNT
MATURITY DATES SHOWN IN #5A (ii)
[ ] June 15, 2005 __________%
[ ] June 15, 2006 __________%
----------- [ ] June 15, 2007 __________%
USE WHOLE [ ] June 15, 2008 __________%
PERCENTAGES [ ] June 13, 2009 __________%
ONLY [ ] June 15, 2010 __________%
----------- [ ] June 15, 2011 __________%
[ ] June 15, 2012 __________%
[ ] June 14, 2013 __________%
[ ] June 13, 2014 __________%
TOTAL 100%
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9. Special instructions
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(For P.O. Box Address, beneficiary, replacement or transfer information)
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For Participants whose Mailing Address differs from their Primary Residential
Address in #2.
Participant's Mailing Address:
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Mailing Address - P.O. Box Accepted
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City State Zip Code
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10A. Suitability
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(All applicable questions must be answered.)
1. Did you receive the EQUI-VEST(R) Strategies
prospectus and applicable supplement(s)? [ ] Yes [ ] No
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Date of prospectus Date(s) of any supplement(s) to prospectus
CONSENT FOR DELIVERY OF INITIAL PROSPECTUS ON CD-ROM
[ ] YES. By checking this box and signing the enrollment form below, I
acknowledge that I received the initial prospectus on computer readable
compact disk "CD," and that my computer has a CD drive and I am able to
access the CD information. In order to retain the prospectus indefinitely, I
understand that I must print or download it. I also understand that I may
request a prospectus in paper format at any time by calling Customer Service
at 1-877-222-2144, and that all subsequent prospectus updates and supplements
will be provided to me in paper format, unless I enroll in AXA Equitable's
Electronic Delivery Service.
The Participant acknowledges that he or she is enrolling in EQUI-VEST for its
features and benefits other than tax deferral, as the tax-deferral feature of
such annuities does not provide additional benefits beyond those already
provided by Section 457 of the Internal Revenue Code. Before enrolling, you
should consider whether the certificate features and benefits beyond tax
deferral meet your needs and goals. You may also want to consider the
relative features, benefits and costs of these annuities with any other
investment that is available in connection with your 457 plan.
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Form #2004 EDC STRAT E6718 AXA Equitable Life Insurance Company
Cat. No. 134592 (12/04) Page 2 of 3
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10A. Suitability (continued)
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2. (a) Do you have any other existing life insurance or annuities?
[ ] Yes [ ] No
(b) 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:
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Year Issued Type of Plan
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Company Contract Number
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Company Address
(c) 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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3. Participant Information
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Employer's Name Participant's Occupation
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Employer's Street Address
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City State Zip Code
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Estimated Family Income Estimated Net Worth
Investment Objective:
[ ] Income [ ] Income & Growth [ ] Growth [ ] Aggressive Growth
[ ] Safety of Principal
Is Participant associated with or employed by a member of the NASD?
[ ] Yes [ ] No
If YES, affiliation:
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Marital Status: Single [ ] Married [ ] Widowed [ ] Divorced [ ]
Number of Dependents:
-----------
Federal Tax Bracket: %
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Purpose of Investment:
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INVESTMENT HORIZON:
(Length of time certificate is expected to remain in force)
[ ] (less than) 3 years [ ] 3-7 years [ ] (greater than) 7 years
Investment Objective:
[ ] Income [ ] Income & Growth [ ] Aggressive Growth [ ] Safety of Principal
RISK TOLERANCE (Choose only one):
The selected investment options should be consistent with the stated
Investment Objective and Risk Tolerance.
[ ] CONSERVATIVE: Prefer little risk and low volatility in return for
accepting potentially lower returns.
[ ] CONSERVATIVE/MODERATE: Willing to accept some risk and volatility in
return for some growth potential.
[ ] MODERATE: Willing to accept above-average amount of market risk and
volatility or loss of principal to achieve potentially higher returns.
[ ] MODERATE/AGGRESSIVE: Willing to accept above-average amount of market
risk and volatility or loss of principal to achieve potentially greater
returns.
[ ] AGGRESSIVE: Willing to sustain substantial volatility or loss of
principal and assume a high level of risk in pursuing potentially higher
returns.
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4. Do you believe this purchase/transaction is in accordance with your
investment objectives? [ ] Yes [ ] No
Investment/Assets (Prior to this Investment)
Cash (includes checking, savings, money market) $____________
Certificates of Deposit (CDs) $____________
Bonds $____________
Annuities $____________
Mutual Funds
Income $____________
Growth $____________
Aggressive $____________
Other $____________
Total: $____________
Stocks $____________
Other $____________
GRAND TOTAL $____________
Comments:
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10B. Other required information
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Is the Participant either: (A) A senior military, governmental, or political
official in a non-U.S. country, or (B) Closely associated with or an immediate
family member of such official? [ ] Yes [ ] No
If yes, identify the name of the official, office held and country:
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+ Required by the U.S. Patriot Act.
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11. Agreement
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All information and statements on this Enrollment Form are true and complete to
the best of my knowledge and belief. I understand that no financial professional
has the authority to make or modify any certificate on AXA Equitable's behalf,
or to waive or alter any of AXA Equitable's rights and regulations. I UNDERSTAND
THAT THE ANNUITY ACCOUNT VALUE ATTRIBUTABLE TO ALLOCATIONS TO THE VARIABLE
INVESTMENT OPTIONS OF THE SEPARATE ACCOUNT OR VARIABLE ANNUITY BENEFIT PAYMENTS
MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. For the
Fixed Maturity Options, amounts transferred or payable under the certificate
before the Maturity Date selected in item #8 are subject to market value
adjustments.
X
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PROPOSED PARTICIPANT'S SIGNATURE
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DATE CITY STATE
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Form #2004 EDC STRAT E6718 AXA Equitable Life Insurance Company
Cat. No. 134592 (12/04) Page 3 of 3
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ENROLLMENT FORM INSTRUCTIONS FOR REPRESENTATIVE
PLEASE READ BEFORE COMPLETING ENROLLMENT FORM.
A. GENERAL
o No Enrollment Form will be processed without an EQUI-VEST Representative's
Report
o All checks must be made payable to AXA Equitable.
o Print neatly or type (except where signatures are required).
o Do not abbreviate
o Any corrections must be initialed by Participant.
o Unless otherwise indicated, complete all sections.
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B. ITEM
1. EMPLOYER INFORMATION
For new employer plans, an EDC 457 Group Annuity Contract Application
must also be completed.
2. PARTICIPANT INFORMATION
The individual on whose life annuity benefits are determined and upon
whose death a death benefit is payable. Please note: Date of birth and
social security number are mandatory. The maximum participant issue age
is 75. The retirement age is the date on which the participant
anticipates distributions will begin. The retirement age may not exceed
the certificate maximum maturity age, which is age 85.
3. BENEFICIARY(IES) INFORMATION
The individual who will receive the death benefit upon the death of the
Participant. Your client must name a primary beneficiary(ies) and may
also name a contingent beneficiary.
4. OPTIONAL FEATURES
DEATH BENEFIT OPTION: This option resets the guaranteed death benefit
every third contract anniversary date to the annuity account value, if
greater than the previously established guaranteed death benefit
(adjusted for loans, withdrawals and contributions). It has a 15 basis
point charge that is deducted annually from the annuity account value.
If this is not elected, the regular death benefit explained in the
prospectus will apply. This feature is only available at certificate
issue, and cannot be terminated once elected.
5. SELECTION OF INVESTMENT OPTIONS AND ALLOCATION PERCENTAGES
Participants must select the allocation percentages that will be
invested in these options. Your client can change this allocation for
future contributions at any time. The percentages entered must be in
whole numbers and total 100%.
6. CONTRIBUTION INFORMATION
Part #6A is ONLY completed when payment is made at the time the
Enrollment Form is signed. If payment is to be made after the
Enrollment Form is signed, the signed Enrollment Form must be submitted
and payment must be forwarded promptly upon receipt. Part #6B must be
completed in all cases.
7. REMINDER/CONTRIBUTION STATEMENTS INFORMATION
Complete #7(i) and #7(ii) for all participants.
8. FIXED MATURITY OPTIONS
FMOs are only available if the rate to maturity is more than 3%.
Contributions to fixed maturity options (FMOs) are NOT available
through salary reductions. Contributions to fixed maturity options are
available through single sum contributions (rollover and transfers).
9. SPECIAL INSTRUCTIONS
Use this section to enter the participant's mailing address if it
differs from the primary residential address. Also, for any additional
details regarding beneficiary, replacement, or transfer information.
10A. SUITABILITY
Complete 1. to ensure that the participant has received the most
current prospectus and supplement(s).
Complete 2. in all cases.
Complete 3. as required by the NASD.
10B. OTHER REQUIRED INFORMATION
If the answer to any item in section 10B is "YES," you must obtain a
pre-approved exception, in writing, from AXA Equitable prior to
submitting an enrollment for a certificate for this client.
11. AGREEMENT
Participant must sign the Enrollment Form.
REPRESENTATIVE REPORT
If you are not able to see the driver's license or passport of the
participant at the time the enrollment form is signed, you can arrange
for the client to send you photocopies by mail. However, the enrollment
form should not be submitted for processing until you have reviewed the
copies and answered YES to this question on the Representative's Report.
If you are uncertain how to proceed in a specific situation, contact
your Branch Controls Manager.
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Form #2004 EDC STRAT E6718 EQUI-VEST(R) Strategies
EQUI-VEST(R) REPRESENTATIVE REPORT
PLEASE PRINT IN BLACK INK.
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A.[ ] I CERTIFY THAT A PROSPECTUS AND SUPPLEMENT(S) FOR THE CERTIFICATE HAVE
BEEN GIVEN TO THE PROPOSED PARTICIPANT AND THAT NO WRITTEN SALES
MATERIALS OTHER THAN THOSE APPROVED BY AXA EQUITABLE HAVE BEEN USED.
(THE REPRESENTATIVE WHO SECURES THIS ENROLLMENT FORM MUST SIGN IN THE
SPACE PROVIDED BELOW.)
B.[ ] DO YOU HAVE REASON TO BELIEVE THAT ANY 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 APPLIED FOR WILL BE ISSUED ON THE
LIFE OF THE PARTICIPANT?
[ ] YES [ ] NO (IF YES, ATTACH A COPY OF OLD/NEW APPROPRIATENESS FORM.)
C.[ ] DID YOU VIEW THE DRIVER'S LICENSE OR PASSPORT OF THE PARTICIPANT? DID
YOU DETERMINE THE CUSTOMER'S SOURCE OF FUNDS?
[ ] YES (IF YOU ARE UNABLE TO ANSWER YES TO BOTH THESE QUESTIONS,
CONTACT YOUR BRANCH MANAGER.)
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NAME AND SIGNATURE OF THE FINANCIAL REPRESENTATIVE WHO ANSWERED THE
ABOVE QUESTIONS AND VERIFIED THE ABOVE DOCUMENTS.
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PRINT NAME SIGNATURE DATE
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EQUI-VEST ISSUES MUST ADEQUATELY REFLECT THE COMMISSION INTEREST OF ALL
REPRESENTATIVES ON PREVIOUS CONTRACTS.
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PRINT LAST DISTRICT REPRESENTATIVE
REPRESENTATIVE(S) NAME(S) NAME REPRESENTATIVE REPRESENTATIVE AGENCY MANAGER INSURANCE
(SERVICE REPRESENTATIVE FIRST) INITIAL NUMBER % CODE CODE LICENSE #*
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* WHERE REQUIRED BY STATE REGULATIONS
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FOR EQUI-VEST PROCESSING OFFICE USE
REPRESENTATIVE(S) SHOWN ABOVE IS (ARE) EQUITY QUALIFIED AND LICENSED IN THE
STATE IN WHICH THE REQUEST IS SIGNED.
ENROLLMENT FORM NO. EAO REC'D
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PROCESSING:
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CERTIFICATE NUMBER BATCH NUMBER INQUIRY NUMBER PROCESSOR
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Form #2004 EDC STRAT E6718 EQUI-VEST(R) Strategies