Regular Equitable Mail: For Assistance, please call 888-517-9900
Equitable Financial Life Insurance Company (EFLIC), PO Retirement Box 1424 Service Solutions www.equitable.com
domiciled in New York Charlotte, NC 28201-1424
Equitable Financial Life Insurance Company of America (EFLOA),Express Equitable Mail:
domiciled in Arizona Retirement Service Solutions
Issuing Company: The issuing Company unless the for primary the contract will Agent be Equitable is an Equitable Financial Life 8501 IBM Dr Insurance Advisors Financial Company of Professional America, whose selling Ste 150-IR business address is in the state of New York, in Charlotte, NC 28262 which case the issuing Company will be Equitable Financial Life Insurance Company.
STRUCTURED CAPITAL STRATEGIES PLUS®
Application for an Individual Variable and Index Linked Deferred Annuity
1. Contract Series and Type R A. Contract Series
E All share Classes may not be available at all Broker Dealers
Q Series B Series Select Series ADV (Advisory) U $25,000 Minimum Contribution $25,000 Minimum Contribution $25,000 Minimum Contribution I Withdrawal Charges No Withdrawal Charges No Withdrawal Charges R 6 year: 7%,7%,6%,5%,4%,3%
E
D B. Choose a Contract Type.
Non-Qualified (NQ)    Inherited IRA Beneficiary Continuation Option (BCO) Traditional Individual Retirement Account (IRA) (Direct Transfer of Decedent IRA) Roth IRA    Inherited Roth IRA BCO (Direct Transfer of Decedent Roth IRA) SEP IRA    Inherited NQ (1035 Exchange of Decedent NQ) Qualified Plan Defined Contribution (QPDC)    Non-Spousal Beneficiary of Qualified Plan (QP) (Direct Rollover to Qualified Plan Defined Benefit (QPDB)     an Inherited IRA BCO)    Non IRA -BCO) Spousal Beneficiary of QP (Direct Rollover to an Inherited Roth
2. Total Initial Contribution(s) R
Initial Contribution $ (Minimum: $25,000) Estimated Value Required In Case of Transfer
E
Q Specify Method(s) of Payment:
U Check or Wire (make check payable to: Equitable) Rollover (IRA, Roth IRA or SEP IRA)
I 1035 Exchange (NQ, Inherited NQ) Employer Contribution to SEP IRA (Employee contributions not permitted) R CD or Mutual Funds Proceeds (NQ) Direct Rollover (Non-Spousal Beneficiary QP to Inherited IRA BCO) E Direct Transfer (IRA, Roth IRA or SEP IRA) Direct Rollover (Non-Spousal Beneficiary QP to Inherited Roth IRA BCO)
D
(Equitable’s Financial Professional/Client assistance in collecting will request funds is funds not required.) (IRA or Roth IRA)
3. Account Registration (Must be a legal resident of U.S. or U.S. territories) R (Check one)
E Individual Uniform Gift to Minors Act / Uniform Transfer to Minors Act (Child’s SSN )
Q The Owner types below require additional form(s). See the New Business Form Booklet for more information.
U
I Trust Qualified Plan Trust (QPDC/QPDB) Other Non-Natural Owner Custodian (IRA/ROTH) R Beneficiary of the Deceased IRA or NQ Owner Non-Spousal Beneficiary of Deceased QP Participant
E
A. Owner D
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone # Owner Name (First) (Middle Initial) (Last) Employer Name (for SEP IRA contracts only)
Owner Taxpayer Identification Number (Check one)
Social Security Number (SSN) Employer Identification Number (EIN) Individual Taxpayer Identification Number (ITIN)
Home Offices: EFLIC 1345 Avenue of the Americas, New York, NY 10105
EFLOA 3030 North Third Street, Suite 790 Phoenix, AZ 85012 Cat. No. 900239 ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS® Page 1 of 9

3. Account Registration (cont’d) R
E A. Owner (cont’d)
Q
U U.S. Primary Resident Address only – No P.O. Box City State Zip Code
I
R If your Mailing Address is different from the Primary Residential Address above, please provide your Mailing Address E in Section 12.
D
Email Address
B. PATRIOT Act Information Owner must complete this section. If the Owner is not an individual, the Annuitant R must complete this section.
E
Q U.S. Citizen Yes No
U If no, check either: U.S. Visa (Complete below) or Permanent Resident (Green Card) (Copy of document required)
I R
E Identification/Passport# Exp. Date U.S. Visa Type (if applicable)
D
C. Joint Owner (Must be a legal resident of U.S. or U.S. territories) NQ Only
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Name
(First) (Middle Initial) (Last)
Relationship to Owner (Check one) Spouse Other
Taxpayer Identification Number (Check one) SSN ITIN
U.S. Primary Resident Address only – No P.O. Box City State Zip Code Email Address Joint Owner Form of Identification (Check one)  Valid Driver’s License Passport State Issued ID
Identification Number     Exp. Date (MM/DD/YYYY)
D. Annuitant (Required if other than Owner.) Annuitant must complete the PATRIOT Act Information in section 3B if the Owner is NOT an individual.
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Name
(First) (Middle Initial) (Last)
Taxpayer Identification Number (Check one) SSN ITIN
U.S. Primary Residential Address only – No P.O. Box City State Zip Code Contract Maturity Date: The Contract Maturity Date may not be later than the Contract Date Anniversary on or following the Annuitant’s 98th birthday. You may commence annuity payments earlier by submitting a written request to our Processing Office in accordance with the Contract.
E. Joint Annuitant Only complete this section if this is a NQ 1035 Exchange of a contract with existing Joint Annuitants who are spouses.
Male Female Date of Birth (MM/DD/YYYY) Daytime Phone #
Name (First) (Middle Initial) (Last) Taxpayer Identification Number (Check one) SSN ITIN
U.S. Primary Residential Address only – No P.O. Box City State Zip Code
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS®  Page 2 of 9

4. Beneficiary(ies) (Please use Special Instructions Section for Additional Beneficiaries.)
R Enter the beneficiaries full name below. Unless otherwise indicated, proceeds will be divided equally.
E A. Primary
Q 1. %
U 1
I Primary Beneficiary Name Relationship to Owner
R SSN EIN ITIN
E Date of Birth (MM/DD/YYYY)
D
Address Phone #
2. %
Primary Beneficiary Name Relationship to Owner1 SSN EIN ITIN Date of Birth (MM/DD/YYYY)
Address Phone #
B. Contingent
1. %
Contingent Beneficiary Name Relationship to Owner1 SSN EIN ITIN Date of Birth (MM/DD/YYYY)
2. Address % Phone #
Contingent Beneficiary Name Relationship to Owner1 SSN EIN ITIN Date of Birth (MM/DD/YYYY)
1 Address Phone #
Enter the relationship to the Annuitant when the Owner is not an Individual.
5. Optional Guaranteed Minimum Death Benefit (GMDB) Election
This optional rider is purchased for an additional charge. You should read the prospectus and any applicable supplements, as well as the disclosure on page 7 of this application for more complete information including restrictions, charges and other information that applies to this feature before making a selection.
• The Return of Premium (ROP) GMDB Rider is declined unless you check the box below.
Yes, I wish to elect the ROP GMDB (Owner/Joint Owners issue ages 0-75 only. Not available for non-spousal Joint Owners and a Non-Natural Owner with Joint Annuitants.)
6. Segment Performance Cap Rate Hold
This option may only be elected at the time of application. You should read the prospectus, disclosure below and on page 6 and applicable supplements for more complete information including the limitations, restrictions and other information that apply to this option before making an election.
Yes, I wish to elect the Segment Performance Cap Rate Hold and invest in segments based on the rates as of the
Application Received Date*. The rates will be applied to all segments starting on or before the Rate Hold Expiration Date, which is OR the segment start date on or immediately following 30 days after the Application Received Date.
R No, I do not wish to elect the Segment Performance Cap Rate Hold and I understand that I will be invested in segments
E based on current rates as of the segment start date.
Q • I understand that the secured Performance Cap Rate that will be applied to any amount that is invested in a Segment on U or before the Rate Hold Expiration Date may be lower than the Performance Cap Rate otherwise in effect on any Segment Start Date during that period, and therefore electing the Segment Performance Cap Rate Hold does not guarantee me a I higher Performance Cap Rate than the Performance Cap Rate that would have otherwise been applied to my investment in a R Segment had I not elected the Segment Performance Cap Rate Hold.
E • The Segment Performance Cap Rate Hold does not begin until the Application Received Date, and therefore it is possible D that Cap the Rate secured in effect Segment on the date Performance that I sign Cap this Rate application. applicable to investment in a Segment may be lower than the Performance • Any investment in a Segment that I make after the Rate Hold Expiration Date will not receive the secured Segment Performance Cap Rate. If my application is incomplete when submitted, it may take additional time for my application to be finalized and for certain investment to a Segment to be received by Equitable; in such situations I understand that the Rate Hold Expiration Date is not extended and therefore it may be more likely that those investments in a Segment do not receive the Segment Performance Cap Rate Hold.
• Dollar Cap Averaging in Section 7 is not available if the Segment Performance Cap Rate Hold is elected.
*_Your_Application_Received_Date_is_either_the_date_your_application_is_received_in_our_processing_office_for_a_paper_application,_ or the date your application is submitted for an electronic application.
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS® Page 3 of 9

7. Dollar Cap Averaging (DCA) Optional (Not available if “Yes” elected for Segment Performance Cap Rate Hold in Section 6)
Check box for one time period. 3 months (maximum 28 Segment Types) 6 months (maximum 14 Segment Types)
By checking one of the two boxes above, I acknowledge that:
• 100% of the initial contribution will be allocated to DCA.
• The the same initial as DCA the transfer contract will date, occur then on the the initial Segment transfer Start will Date occur following on the the contract contract date. date, unless the Segment Start Date is • subsequent The initial DCA DCA transfer transfer will will be occur the Segment on the SSD Start on Date or immediately (SSD) on or following immediately the monthiversary following establishing of the initial the DCA DCA program. transfer. Each
• You must complete Section 8A below. Section 8B is not available if DCA is elected.
• The DCA account invests in the EQ/Money Market fund.
• The funds will be systematically transferred monthly from the DCA account into Segment Type Holding Accounts and will be transferred to the Segment(s) on the Segment Start Date if all the Segment Participation Requirements are met.
• The DCA total program, maximum you can number choose of Segments up to a maximum that you of can 28 invest Segment in at Types, any time or ifis you 84. choose This means the 6 that month if you DCA choose program, the 3 you month can choose up to a maximum of 14 Segment Types.
R 8. Investment Selection
E • You must allocate your initial contribution to the Structured Investment Option in Section 8A and/or the Variable Q Investment Option in Section 8B.
U
I • All future contributions will be allocated according to the percentages below unless indicated otherwise.
R • If you elected DCA in Section 7, your initial contribution will be allocated 100% to the DCA EQ/Money Market and the DCA
E transfers will be allocated according to your allocation instructions provided below. The initial DCA transfer will occur on the D Segment Start Date following the contract date, unless the Segment Start Date is the same as the contract date, then the initial transfer will occur on the contract date.
8A. Structured Investment Option: Segment Selection (Please use whole percentages)
If Holding you elect Account any of until the your Segment Segment(s) Types listed becomes below, available once amounts on the Segment are received, Start they Date. will At be that first time, placed your in funds a Segment will be allocated Type per your selection(s) below provided that all Segment Participation Requirements specified in the Contract are met.
1 Year Segment Options
Standard Segments Dual Direction Segments
Segment duration Segment Buffer Segment duration Segment Buffer 1-Year -10% -15% -20% -40% 1-Year -10% -15%
S&P 500 % % % % S&P 500 % % Russell 2000® % % % % Russell 2000® % % MSCI EAFE % % % % MSCI EAFE % % NASDAQ 100 % % % % NASDAQ 100 % % MSCI Emerging Markets % % — —EURO STOXX 50® % % — —
Step Up Segments Dual Step Up Segments
Segment duration Segment Buffer Segment duration Segment Buffer 1-Year -10% -15% 1-Year -10% -15%
S&P 500 % % S&P 500 % % Russell 2000® % % Russell 2000® % % MSCI EAFE % % MSCI EAFE % % NASDAQ 100 % % NASDAQ 100 % %
Enhanced Upside Segments Loss Limiter Segments
125% Enhancement 90% Segment Investment Protection Segment duration Segment Buffer Segment duration Segment Buffer 1-Year -10% 1-Year -10%
S&P 500 % S&P 500 %
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS®  Page 4 of 9

8. Investment Selection (cont’d)
8A. Structured Investment Option: Segment Selection (cont’d) (Please use whole percentages)
6 Year Segment Options
Standard Segments Dual Direction Segments
Segment duration Segment Buffer Segment duration Segment Buffer 6-Year -10% -15% -20% -40% 6-Year -10% -15% -20%
S&P 500 % % % % S&P 500 % % % Russell 2000® % % % % Russell 2000® % % % MSCI EAFE % % % % MSCI EAFE % % % NASDAQ 100 % % % % NASDAQ 100 % % %
Step Up Segments Annual Lock Segments
Segment duration Segment Buffer Segment duration Segment Buffer 6-Year -10% 6-Year -10%
S&P 500 % S&P 500 % Russell 2000® % MSCI EAFE % NASDAQ 100 %
Enhanced Upside Segments Enhanced Upside Segments
110% Enhancement 125% Enhancement
Segment duration Segment Buffer Segment duration Segment Buffer 6-Year -10% -15% 6-Year -10% -15%
S&P 500 % % S&P 500 % %
Loss Limiter Segments
95% Segment Investment Protection Segment duration Segment Buffer 6-Year -10%
S&P 500 %
8B. Variable Investment Option (Please use whole percentages)
EQ/Money Market %
8C. Contribution Allocation Total
Structured Investment Option Total % + Variable Investment Option Total % = 100%
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS® Page 5 of 9

9. Broker Transfer Authority Disclosure
Professionals Yes. I/we hereby assigned grant to authority my contract to each in the of future), my Financial to act Professional(s) as my agent and assigned provide to investment my contract option (including transfer any instructions Financial in writing, by telephone or electronically, to Equitable. By granting such authority, I direct Equitable to act on such instructions. Isuch understand instructions, and acknowledge and (ii) will have that no Equitable liability for (i) may any claim, rely in loss, good liability, faith on or the expense stated identity that may of arise the person(s) in connection providing with such as instructions. Equitable’s I further Processing understand Office receives and acknowledge from me written that Equitable notification will continue that broker to transfer act upon authority this authorization has been until terminated. such time I transfer understand instructions that upon on receipt my behalf. of such I further notification, understand Equitable and acknowledge will terminate that the Equitable Financial Professional’s(s’) may (i) change or ability terminate to provide 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.
10. Current Insurance BOTH questions in the Owner Response and the Financial Professional Response columns must be completed and match for the contract to be issued.
R E
Financial Professional Q Replacement Questions Owner Response Response U
I 1. Does the Owner have any other existing life insurance policy or Yes No Yes No R annuity contract(s)?
E (If yes, submit a Requirements Questionnaire (which is Equitable’s D state replacement form), if required, even if you answer no for question 2)
2. Will any existing life insurance policy or annuity contract(s)be (or Yes No Yes No 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 on the life of the Owner?
(If yes, complete the following below and submit a Requirements Questionnaire, (which is Equitable’s state replacement form), if required.)
Please list the contract(s) below that will be used to fund this new Equitable contract
COMPANY TYPE OF PLAN YEAR ISSUED CONTRACT NO.
COMPANY TYPE OF PLAN YEAR ISSUED CONTRACT NO.
COMPANY TYPE OF PLAN YEAR ISSUED CONTRACT NO.
11. Fraud Warning offense Any person and who subject knowingly to penalties presents under a false state statement law. in an application for insurance may be guilty of a criminal 12. Special Instructions Attach a separate sheet if additional space is needed. For Owners whose Mailing Address differs from their Primary Residential Address in Section 3, please complete the following:
Mailing Address — P.O. Box accepted City State Zip Code
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS® Page 6 of 9

13. Signature and Acknowledgements GENERAL DISCLOSURE. BY SIGNING BELOW, I / WE UNDERSTAND AND ACKNOWLEDGE THAT: R
E • Annuity Account Value(s) attributable to allocations to the investment options, and any variable annuity benefit
Q payments I may elect, may increase or decrease and are not guaranteed as to dollar amount.
U
I • Amounts I allocate to any of the Segment Types will first be allocated to the applicable Segment Type Holding Account, R with the exception of (i) maturing Segments for which the allocation instructions on file are to allocate directly to another E Segment; or (ii) amounts that I allocate to a Segment Type on a Segment Start Date (and which are received or held by D Equitable on the Segment Start Date), which will be allocated directly to the selected Segment.
• Each Segment in the Structured Investment Option provides a rate of return tied to the performance of a specified index. The Segments are not index funds and do not invest in underlying mutual funds that hold investments tracked by a specified index.
• The Annual Lock Performance Cap Rate does not change during the duration of the Annual Lock Segment. The Annual Lock Segment performance may be different than that of the other segments of similar duration or that track similar indices.
• The Step Up, Dual Direction, Dual Step Up, Enhanced Upside, and Loss Limiter Segments will generally have lower Performance Cap Rates than Standard Segments with the same Index, Segment Duration and Segment Buffer. • The Segment Rate of Return for Segments using one Segment Option may differ from Segments using different Segment Options even though the Segments have similar durations and/or track similar indices. In addition, because of the way the Segment Rate of Return is calculated for Step Up, Dual Step Up, and Dual Direction Segments, I understand that in certain circumstances a very small difference in the Index Performance Rate can result in a much larger difference in the Segment Rate of Return for those Segments.
• For Enhanced Upside Segments, the Segment Rate of Return—inclusive of any application of the Enhanced Upside Rate—is always subject to, and thus limited by, the Performance Cap Rate. This means that even if the Index Performance Rate multiplied by the Enhanced Upside Rate is greater than the Performance Cap Rate, the Segment Rate of Return will equal the Performance Cap Rate.
• The prospectus and applicable supplements contain more complete information including the limitations, restrictions and conditions that apply to the Contract.
• In the case of IRAs and Qualified Plans, by signing this application I acknowledge that I am buying the Contract for its features and benefits other than tax deferral. IRAs and Qualified Plans derive tax deferral from the Internal Revenue Code and therefore the tax deferral feature of the Contract does not provide additional benefits.
• Under penalty of perjury, I certify that all the Taxpayer Identification Numbers in Sections 3 and 4 are correct.
• All information and statements furnished in this application are true and complete to the best of my knowledge and belief.
• 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 Equitable, or to waive or alter any of Equitable’s rights and regulations. Equitable must agree to any change made to the Contract, or to the age at issue, in writing signed by an officer of the company.
• Structured Capital Strategies PLUS® is not sponsored, endorsed, or promoted by Morgan Stanley Capital International (MSCI), and MSCI bears no liability with respect to such product or any index on which such product is based. The prospectus contains a more detailed description of the limited relationship that MSCI has with Equitable and any related products.
• The S&P 500® Price Return Index is a product of S&P Dow Jones Indices LLC (“SPDJI”), and has been licensed for use by Equitable. The Structured Capital Strategies PLUS® contract is not sponsored, endorsed, sold or promoted by SPDJI, Dow Jones, S&P or any of their respective affiliates (collectively, “S&P Dow Jones Indices”). S&P Dow Jones Indices makes no representation or warranty, express or implied, to the owners of the Structured Capital Strategies PLUS® contract.
• For Series ADV, the Contract is available through registered investment advisors who charge an advisory fee for management and advice.
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS®  Page 7 of 9

13. Signature and Acknowledgements (cont’d)
R
E OPTIONAL BENEFIT DISCLOSURE. I/WE UNDERSTAND AND ACKNOWLEDGE THAT:
Q • There is an additional charge if the ROP GMDB is elected. U • The ROP GMDB cannot be terminated once it is elected.
I • The ROP GMDB does not provide an Annuity Account Value or Cash Value and cannot be withdrawn.
R • If I/We elect the ROP GMDB, the maximum age I/We may make contributions to the Contract will be through age 75 (or E first Contract Date Anniversary if later) of the older of the original Owner or Annuitant.
D • Withdrawals under the Contract may reduce my ROP GMDB.
• because The ROP withdrawals GMDB may that be of are limited made use from if required this Contract minimum to meet distributions the required apply, amount now or may in significantly the future, to reduce my Contract the benefit.
• Owners For jointly are owned married Contracts, at issuance the of ROP the GMDB contract is payable and continue upon to the be death married of the upon surviving the death Joint of Owner the first provided Joint Owner. the Joint • of If the the Joint designation Owners of divorce, the single Equitable Owner must of the be contract notified before using we a form will acceptable remove the to joint us measuring of the change life. in The marital notice status must and be GMDB signed by to be both payable Joint Owners upon the and death must of be the received single Owner. by Equitable I/We understand while both that Joint if Owners Equitable are is alive not notified in order using for the a form ROP acceptable ROP GMDB, to will us be before payable the death and the of fees either for former the ROP spouse GMDB and will signed not be by returned. both Joint Owners, then the Cash Value, not the • understand If I/We change that the if the Owner new of Owner the Contract, dies before the the original original Owner Owner, will remain the Cash as Value the measuring under the life Contract for the is ROP payable. GMDB. The I/We ROP
GMDB is not payable if the original Owner is still alive at the time of the new Owner’s death.
Prospectus Information: I acknowledge that I have received the most current prospectus and supplements, for Structured Capital Strategies PLUS®. After reviewing my financial information and goals with my Financial Professional, I believe that this Contract will meet my financial goals.
By signing the application below, I acknowledge that I received the initial prospectus, I understand that all subsequent prospectus updates and supplements will be provided to me in paper format, unless I enroll in
Equitable’s Electronic Delivery Service. By signing this application, I acknowledge and agree to the elections I have made and understand the terms and conditions set forth in this application.
Contract State:
We will issue and deliver a contract to you based on the state of primary residence. If you sign the application in a state other than the primary residence state: I acknowledge that either:
I have a second residence where the application was signed (the state of sale); or
I work or maintain a business in the state where the application was signed (the state of sale).
R X
E Owner’s Signature City, State Date (MM/DD/YYYY)
Q U I X
R Joint Owner’s Signature City, State Date (MM/DD/YYYY)
E D
X
Annuitant’s Signature (if other than Owner) City, State Date (MM/DD/YYYY)
X
Joint Annuitant’s Signature (if other than Owner) City, State Date (MM/DD/YYYY)
ICC25 App SCSPL21 X04677_Compact Structured Capital Strategies PLUS®  Page 8 of 9

14. Financial Professional Information
R A. Did you (i) verify the identity by reviewing the driver’s license/passport of the Owner, or in the case E of an entity Owner, obtain documentary evidence of entity’s existence (e.g. articles of incorporation, Q trust agreement, etc.), and (ii) inquire about the source of the customer’s assets and income? Yes No U B. Is the Proposed Owner/Annuitant currently an Active Duty* Member of the Armed Forces? Yes No
I
R MEMBERS (If Yes, you must OF THE also ARMED submit FORCES) a completed . and signed LIFE INSURANCE/ANNUITY DISCLOSURE TO ACTIVE DUTY
E
D component *Active Duty (National means full-time Guard and duty Reserve) in active while military serving service under of the published United States orders and for active includes duty members or full-time of the training. reserve It does not calls include or orders members specifying of the periods reserve of component less than 31 who calendar are performing days. active duty or active duty for training under military C. information NORTH CAROLINA provided ONLY: by the I certify Proposed that Owner. I have truly and accurately recorded on the application the Yes No D. Please check this box in if you state are of an  Equitable Advisors Financial Professional and the primary selling Agent’s business address is the New In all York, other in cases, which the case issuing the issuing company company will be for Equitable the contract Financial will be Life Equitable Insurance
Company Financial of Life America. Insurance Company.
The applicant understands that he/she is applying for an indexed-based annuity, and that while the values of the policy may be affected by an external index, the policy does not directly participate in any stock or equity investments.
R X
E Primary Financial Professional Signature
Q Please provide at least one of the following numbers in full:
Equitable Advisors ONLY
U
I
R Social Security    Central Registration Depository National Producer Number Agent Code
E
D %
Print Name Phone Number
Email Address Client (BIN) Client linking Number Agent Location
X
Financial Professional Signature
Please provide at least one of the following numbers in full: Equitable Advisors ONLY
Social Security    Central Registration Depository National Producer Number Agent Code
% 
Print Name Phone Number
Financial Professional Use Only. Contact your home office for program information. Once selected, program cannot be changed.
Contract Series B:
Option I  Option II  Option III Contract Series Select: Option I
Please be sure that the commission option elected is approved by your Broker Dealer.
Cat. No. 900239 ICC25 App SCSPL21 Structured Capital Strategies PLUS®
X04677_Compact Page 9 of 9