THE EQUITABLE LIFE ASSURANCE SOCIETY OF THE UNITED STATES
Application and Agreement for Establishment of Plan
Participation in the Momentum Plus Program
Group Annuity Contract
Employer:
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Employer Address:
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Employer Plan:
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I. Plan/Trust Type: The Employer will participate in Equitable's Momentum Plus
Program through (Check one):
A. [] Adoption of the Members Retirement Plan and Trust by the
Employer.
B. [] Adoption of the Pooled Trust for Members Retirement Plans by the
Employer and Participating Trust. The name of the Participating
Trust is:
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II. Investment Options: The following Divisions, as described in the Momentum
Plus Program Prospectus and Group Annuity Contract, are hereby elected as
investment options to be available under the Contract for the Employer Plan
(check all applicable boxes):
A. [] Guaranteed Interest Divisions - (This may be elected for any
Employer Plan but must be checked if no Type B Investment
Divisions are elected below.)
Type A Investment Divisions -
B. [] The Stock Division
C. [] The Balanced Division
D. [] The Aggressive Stock Division
E. [] The Global Division
F. [] The Growth Investors Division
Type B Investment Divisions - (The Money Market Division must be checked if
any Type B Investment Divisions are elected.)
G. [] The Conservative Investors Division
H. [] The High Yield Division
I. [] The Intermediate Government Securities Division
PF10,715 Page 1
J. [] The Money Market Division
K. [] The Short-Term World Income Division
No investment option under the Contract will be available with respect to
the Employer Plan unless checked above or later added by a change in your
election. Any such change must be made in keeping with Equitable's rules
and on Equitables form received in its Processing Office.
III. Application and Agreement: By signature of duly authorized person(s), the
Employer, and, if applicable the Trustee(s) of the Participating Trust,
hereby:
A. Acknowledges having received and read the Prospectus and Group Annuity
Contract for Equitable's Momentum Plus Program, as well as the ERISA
Information Statement;
B. Acknowledges understanding of the fees, charges, and funding
arrangements under the Momentum Plus Program;
C. Applies for participation in the Momentum Plus Program Group Annuity
Contract as funding vehicle for the Employer Plan;
D. Agrees to be bound by the terms and conditions of the Group Annuity
Contract; and
E. Acknowledges understanding that no Agent of Equitable has authority to
make or modify any contract or agreement on Equitable's behalf, or to
waive or alter any of Equitable's rights or requirements.
This Application and Agreement will become effective only upon acceptance,
by signature below, of a duly authorized signatory on Equitable's behalf.
FOR EMPLOYER:
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Print Name of Employer City State
or Officer
By
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Signature & Title of Employer or Officer Date
PF10,715 Page 2
FOR TRUSTEE(S):
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Print Name of Trustee City State
or Officer
By
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Signature of Trustee Date
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Print Name of Trustee City State
By
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Signature of Trustee Date
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Print Name of Trustee City State
By
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Signature of Trustee Date
ACCEPTED FOR EQUITABLE:
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By
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Print Name of Authorized Signatory Signature of Authorized
Signatory
EFFECTIVE DATE: CLIENT NO.
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A copy of the Application/Agreement should be retained in Applicant's files and
the original should be given to the Agent for forwarding to the Equitable
Processing Office along with the other installation materials. These documents
will be signed by Equitable and returned to the Applicant after being
underwritten. Initial contributions will be accepted by Equitable only after
installation documents have been approved by the Equitable Processing Office.
PF10,715 Page 3
