EQUITABLE ACCUMULATOR SELECT
[INSERT EQ LOGO] (IRA and NQ) COMBINATION VARIABLE
DEFERRED AND FIXED ANNUITY
Enrollment Form under Group Annuity Contract
No. AC7625, AC7627 and Application for Individual Contract
THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
- - -------------------------------------------------------------------------------
- - -----------
1. PROGRAM [ ] IRA [ ] Non-Qualified (NQ)
- - -----------
- - ---------
2. OWNER [ ] Individual [ ] Trustee (for an individual)
- - ---------
- - ----------------------------------------------- ------------------------------
Name (First, Middle, Last) Date of Birth (Month/Day/Year)
- - ----------------------------------------------- ------------------------------
Address (Street, City, State, Zip Code) Social Security No./TIN
[ ] Male [ ] Female
- - ------------------------ ------------------------
Home Phone Number Office Phone Number
- - ----------------------------------
3. ANNUITANT If other than Owner
- - ----------------------------------
- - ----------------------------------------------- ------------------------------
Name (First, Middle, Last) Date of Birth (Month/Day/Year)
- - ----------------------------------------------- ------------------------------
Address (Street, City, State, Zip Code) Social Security No./TIN
[ ] Male [ ] Female
- - ----------------------- ------------------------- ---------------------------
Home Phone Number Office Phone Number Relationship to Owner
- - ----------------------------------------------------------------------------
4. BENEFICIARY(IES) If more than one - indicate %. Total must equal 100%.
- - ----------------------------------------------------------------------------
- - --------------------------------------- ---------------------------- ------
Name (First, Middle, Last) Relationship to Annuitant %
- - --------------------------------------- ---------------------------- ------
Name (First, Middle, Last) Relationship to Annuitant %
- - --------------------------------------- ---------------------------- ------
Name (First, Middle, Last) Relationship to Annuitant %
- - --------------------------------------- ---------------------------- ------
Name (First, Middle, Last) Relationship to Annuitant %
[ ] If you are both the Owner and Annuitant you may designate your spouse as
the Successor Owner/Annuitant by checking the box and completing the following
information. Your spouse must also be named as the sole primary beneficiary.
[ ] Male [ ] Female
- - ---------------------------------- ------------------------------------------
Spouse's Social Security No. Spouse's Date of Birth (Month/Day/Year)
- - ----------------------------
5. ANNUITY COMMENCEMENT AGE
- - ----------------------------
SPECIFY AGE: (Annuitant age 90 if not indicated)
-----------------
- - ------------------------------------
6. INITIAL CONTRIBUTION INFORMATION
- - ------------------------------------
TOTAL INITIAL CONTRIBUTION: $
---------------
METHOD OF PAYMENT: [ ] By check payable to Equitable Life [ ] By wire
SOURCE OF FUNDS: [ ] Rollover from other IRA
[ ] Direct Rollover from qualified plan or TSA
[ ] Direct Transfer from other IRA
[ ] 1035 Exchange
- - -------------------------------------------------------------------------------
INCOME MANAGEMENT GROUP, P.O. BOX 1547, SECAUCUS, N.J. 07096-1547
(800) 338-3434
- - ---------------------------------------------------------------------------
7. baseBUILDER GUARANTEE ELECTION (Not applicable for New York residents)
- - ---------------------------------------------------------------------------
[ ] I choose to elect the baseBUILDER guarantee.
Select a death benefit option: [ ] 6% to Age 80 Roll Up OR
[ ] Annual Ratchet to Age 80
[ ] I choose to elect the Guaranteed Minimum Death Benefit Only.
Select a death benefit option: [ ] 6% to Age 80 Roll Up OR
[ ] Annual Ratchet to Age 80
- - -------------------------------------------------------------------------
8. WITHDRAWALS (Optional) Options A and C can be elected only under IRA
- - -------------------------------------------------------------------------
A. [ ] SUBSTANTIALLY EQUAL PAYMENT WITHDRAWALS. Available only under IRA
if you are below age 59 1/2.
Frequency: [ ] Monthly [ ] Quarterly [ ] Annually
Start Date: (Month, Day)
-------------------
Calculation Basis: [ ] Single Life [ ] Joint and 100% to Survivor
B. [ ] SYSTEMATIC WITHDRAWALS. Under IRA, available only if you are age
59 1/2 to 70 1/2.
Frequency: [ ] Monthly [ ] Quarterly [ ] Annually
Start Date: (Month, Day)
-------------------
Amount of Withdrawal: $ or %
---------- -----
C. [ ] MINIMUM DISTRIBUTION WITHDRAWALS. Available only if you have elected
Self-Directed Allocation under IRA and you are age 70 1/2 or older.
Minimum Distribution Withdrawals based on the period of:
[ ] Owner/Annuitant's life expectancy only
[ ] joint life expectancies of Owner/Annuitant and spouse
[ ] joint life expectancies of Owner/Annuitant and non-spouse
beneficiary
If joint life, indicate joint Annuitant's date of birth:
--------------
Do you want your life expectancy recalculated? [ ] yes [ ] no
If you elected joint life expectancies, do you want your life
expectancies recalculated? [ ] yes [ ] no
WITHHOLDING ELECTION INFORMATION (Please refer to enrollment form/application
instructions before completing)
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.
- - ---------------
9. SUITABILITY
- - ---------------
A. Did you receive the EQUITABLE ACCUMULATOR SELECT prospectus? [ ] Yes [ ] No
- - ------------------------ --------------------------------------------------
Date of Prospectus Date(s) of any Supplement(s) to Prospectus
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:
- - --------------- ---------------- ------------ ---------------------------
Year Issued Type of Plan Company Certificate/Contract Number
- - ------------------------
10. SPECIAL INSTRUCTIONS
- - ------------------------
- - -------------------------------------------------------------------------------
- - -------------------------------------------------------------------------------
- - -------------------------------------------------------------------------------
- - -------------------------------------------------------------------------------
Accumulator Select page 2
- - ---------------------------------------------------------
11. ALLOCATION AMONG INVESTMENT OPTIONS Choose A, B or C
- - ---------------------------------------------------------
(1) GUARANTEE PERIODS
- - -------------------------------------- February 15, 1998......... %
(A. [ ] SELF-DIRECTED ALLOCATION February 15, 1999......... %
Allocate initial contribution between February 15, 2000......... %
"(1) GUARANTEE PERIODS" and February 15, 2001......... %
"(2) INVESTMENT FUNDS." The February 15, 2002......... %
total of (1) and (2) must equal 100%. February 15, 2003......... %
- - -------------------------------------- February 15, 2004......... %
February 15, 2005......... %
February 15, 2006......... %
February 15, 2007......... %
SUBTOTAL ... % (1)
- - --------------------------------------
(B. [ ] PRINCIPAL ASSURANCE
Under Principal Assurance, an (2) INVESTMENT FUNDS
amount is allocated to a Guarantee
Period so that the maturity value EQ/Putnam Growth & Income Value..... %
will equal the initial contribution EQ/Putnam Investors Growth.......... %
in the year selected. EQ/Putnam International Equity...... %
MFS Research........................ %
SELECT MATURITY YEAR: MFS Emerging Growth Companies....... %
Alliance Money Market............... %
[ ] 2004 [ ] 2005 Alliance High Yield................. %
[ ] 2006 [ ] 2007 Alliance Common Stock............... %
Alliance Aggressive Stock........... %
Allocate the remaining amount of Alliance Small Cap Growth........... %
the initial contribution only to
"(2) INVESTMENT FUNDS." SUBTOTAL ... % (2)
The total must equal 100%. TOTAL ... 100%
- - --------------------------------------
- - --------------------------------------
(C. [ ] SPECIAL DOLLAR COST
AVERAGING
The initial contribution is allocated
to the Alliance Money Market Fund.
Thereafter, amounts are transferred
over a twelve month period from the
Alliance Money Market Fund to the
other Investment Funds based on
the percentages you indicate under
"(2) INVESTMENT FUNDS."
The total must equal 100%.
Do not indicate a percentage for the
Alliance Money Market Fund.
- - --------------------------------------
Accumulator Select page 3
- - -------------
12. 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
Annuity Account Value attributable to allocations to the Investment Funds and
variable annuity benefit payments, if a variable settlement option has been
elected, may increase or decrease and are not guaranteed as to dollar amount. I
understand that amounts allocated to the Guaranteed Period Account 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)
(NEW YORK AND OREGON RESIDENTS SIGN ABOVE, ALL OTHER RESIDENTS SIGN BELOW.)
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 REGISTERED
REPRESENTATIVE OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE
OR MISLEADING FACTS OR INFORMATION TO A CONTRACTOWNER 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.
New Jersey: ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM OR AN
ENROLLMENT FORM CONTAINING ANY FALSE, OR MISLEADING INFORMATION IS SUBJECT TO
CRIMINAL AND CIVIL PENALTIES.
Kentucky: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN ENROLLMENT FORM 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.
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)
..............................................................................
Do you have reason to believe that any existing life insurance or annuity has
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 on the life of the Annuitant?
[ ] Yes [ ] No
Florida License ID No(s).
---------------------------------------
- - -------------------------------------------------------------------------------
Registered Representative Signature Print Name & No. of Registered
Representative
- - -------------------------------------------------------------------------------
Registered Representative Broker-Dealer/Branch Client Account No.
Soc. Sec. No./TIN
Accumulator Select page 4