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 for the contract will be Equitable 8501 IBM Dr Financial Life Insurance Company of America, unless the primary selling Agent Ste 150-IR is an Equitable Advisors Financial Professional whose business address is in the Charlotte, NC
28262 state of New York, in which case the issuing Company will be Equitable Financial Life Insurance Company. STRUCTURED CAPITAL STRATEGIES PREMIER 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 U $25,000 Minimum Contribution $25,000 Minimum Contribution I Withdrawal Charges No Withdrawal Charges R 6 year: 8%,8%,7%,6%,5%,4% 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) IRA Non-Spousal BCO)
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 Plan Trust Qualified Trust (QPDC/QPDB) Other Non-Natural Owner Custodian (IRA/ROTH) I 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. 900310 ICC25 App SCSPR
X04794_Compact Structured Capital Strategies Premier Page 1 of 10
3. Account Registration (cont’d) R A. Owner (cont’d) E Q U Email Address I am interested in receiving all documents I
electronically from Equitable via e-delivery. R E D U.S. Primary Resident Address only – No P.O. Box City State Zip Code If your Mailing Address is different from the Primary Residential Address above, please provide your Mailing Address in
Section 12. B. PATRIOT Act Information Owner must complete this section. If the Owner is not an individual, the Annuitant R must complete this section. E Yes No U.S. Citizen Q U If no, check either: U.S. Visa (Complete below) or Permanent Resident
(Green Card) (Copy of document required) I R Identification/Passport# Exp. Date U.S. Visa Type (if applicable) E 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 Email Address U.S. Primary Resident Address only – No P.O. Box City State Zip Code 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 Relationship to Annuitant (Check one) Spouse Other 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 Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact Page 2 of 10
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 U I 1. % R Primary Beneficiary Name Relationship to Owner1 E D SSN EIN ITIN Date of Birth (MM/DD/YYYY) 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) Address Phone # 2. % Contingent Beneficiary Name Relationship to Owner1 SSN EIN
ITIN Date of Birth (MM/DD/YYYY) Address Phone # 1Enter the relationship to the Annuitant when the Owner is not an Individual. 5. Optional Guaranteed Minimum Death Benefit (GMDB) If you are age 75 or younger, your contract will be issued with a
Return of Premium GMDB Rider (ROP GMDB) at no additional cost unless you select one of the optional GMDBs below. If you are issue age 76 or older, your Contract will be issued with the Annuity Account Value Death Benefit. The optional Highest
Anniversary Value (HAV) GMDB and Greater of Roll-Up or HAV (Greater of) GMDB Riders can be purchased for an additional charge and may only be chosen at the time of application. You should read the prospectus and applicable supplements for more
complete information including the limitations, restrictions, charges and other information that apply before making a selection. Once elected, the HAV GMDB and Greater of GMDB Riders cannot be voluntarily terminated from the contract. Yes, I wish
to elect the HAV GMDB (Owner/Joint Owners issue ages 0-75 only. Not available for non-spousal Joint Owners or a Non-Natural Owner with non-spousal Joint Annuitants). OR Yes, I wish to elect the Greater of GMDB Rider (Owner/Joint Owners issue ages
0-75 only. Not available for non-spousal Joint Owners or a Non-Natural Owner with non-spousal JointAnnuitants). Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact Page 3 of 10
6. Rate Hold This Rate Hold provides you the option to invest in Segments based on the Segment Performance Cap Rate, Participation Rate
and Step Rate for Dual Step Tier Segments (collectively “Rate(s)”) 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 the Segment Start Date on or
immediately following 30 days after the Application Received Date. This option may only be elected at the time of application. You should read the prospectus, disclosure below 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 Rate Hold and invest in Segments based on the Application Received Date, as described in this section. R OR E Q No, I do
not wish to elect the Rate Hold and I understand that I will be invested in Segments based on current Rates as of U the Segment Start Date. I R I understand that the secured Rate(s) that will be applied to any amount that is invested in a Segment on
or before the Rate E Hold Expiration Date may be lower than the Rate(s) otherwise in effect on any Segment Start Date during that period, and D therefore electing the Rate Hold does not guarantee me higher Rate(s) than the Rate(s) that would have
otherwise been applied to my investment in a Segment had I not elected the Rate Hold. The Rate Hold does not begin until the Application Received Date, and therefore it is possible that the secured Rate(s) applicable to investment in a Segment may
be lower than the Rate(s) in effect on the date that I sign this application. Any investment in a Segment that I make after the Rate Hold Expiration Date will not receive the secured Rate(s). 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 Rate Hold. Dollar Cap Averaging in Section 7 is not available if the 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. 7. Dollar Cap Averaging (DCA) Optional Special DCA Program, which has an enhanced crediting rate, is only available for Series B. The General DCA Program
is only available for Series Select. (Not available if “Yes” is elected for Rate Hold in Section 6) Check box for one time period. 3 months (maximum 41 Segment Types) 6 months (maximum 23 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 Segment initial 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 Segment Start Date Start on Date or immediately on or immediately following following establishing the
monthiversary the DCA program. of the Each initial DCA transfer. You must complete Section 8 below. 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 is 167. total This maximum means that number if you of choose Segments the 3 that month you DCA can invest program, in, and/or you can provide choose
segment up to a allocation maximum instructions of 41 Segment for, at Types, any time or if you choose the 6 month DCA program, you can choose up to a maximum of 23 Segment Types. Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact
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8. Investment Selection R You must allocate your initial contribution to the Structured Investment Option in Section 8A and/or the
Guaranteed E Interest Option in Section 8B. Q U All future contributions will be allocated according to the percentages below unless indicated otherwise. I If you elected DCA in Section 7, your initial contribution will be allocated 100% to the DCA
and the DCA transfers will be R allocated according to your allocation instructions provided below. The initial DCA transfer will occur on the Segment Start E Date following the Contract Date, unless the Segment Start Date is the same as the
Contract Date, then the initial transfer D will occur on the Contract Date. 8A. Structured Investment Option: Segment Selection (Please use whole percentages) Holding If you elect Account any of until the your Segment Segment(s) Types listed becomes
below, available once amounts on the Segment are received, Start Date. they will At that be 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% -20% S&P 500 % % % % S&P 500 % % % Russell
2000® % % % % Russell 2000® % % % MSCI EAFE % % % % MSCI EAFE % % % NASDAQ 100 % % % % NASDAQ 100 % % % Step Up Segments Dual Step Up Segments Segment duration Segment Buffer Segment duration Segment Buffer 1-Year -10% -15% -20% -40% 1-Year
-10% -15% -20% -40% S&P 500 % % % % S&P 500 % % % % Russell 2000® % % % % Russell 2000® % % % % MSCI EAFE % % % % MSCI EAFE % % % % NASDAQ 100 % % % % NASDAQ 100 % % % % Enhanced Upside Dual Step Tier Segments
125% Segments Segment duration Segment Buffer Segment duration Segment Buffer 1-Year -10% 1-Year
-10% S&P 500 % S&P 500 % Russell 2000® % MSCI EAFE % NASDAQ 100 % Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact Page 5 of 10
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% -40% S&P 500 % % % % S&P 500 % % % % Russell 2000® % % % %
Russell 2000® % % % % MSCI EAFE % % % % MSCI EAFE % % % % NASDAQ 100 % % % % NASDAQ 100 % % % % Step Up Segments Dual Step Up Segments Segment duration Segment Buffer Segment duration Segment Buffer 6-Year -10% -20% -40% 6-Year -10% -20% -40%
S&P 500 % % % S&P 500 % % % Russell 2000® % % % MSCI EAFE % % % NASDAQ 100 % % % Best Entry Segments Dual Step Tier Segment Segment duration Segment Buffer Segment duration Segment Buffer 6-Year -10% 6-Year -10% -20% S&P 500 %
S&P 500 % % Russell 2000® % % MSCI EAFE % % NASDAQ 100 % % 8B. Guaranteed Interest Option Guaranteed Interest Option % 8C. Contribution Allocation Total Structured Investment Option Total % + Guaranteed Interest Option Total % = 100% 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. such I 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 other or electronic electronic or
overnight transfer services mail transfer because procedures of disruptive at any transfer time without activity prior . notice, and (ii) restrict fax, internet, telephone and Structured Capital Strategies Premier ICC25 App SCSPR X04794_ Compact
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10. Current Insurance BOTH questions in the Owner Response and the Financial Professional Response R columns must be completed and match
for the contract to be issued. E Financial Professional Q Replacement Questions Owner Response U Response I 1. Does the Owner have any other existing life insurance policy or Yes No Yes No R annuity contract(s)? E (If yes, a Requirements
Questionnaire (which is Equitable’s state D replacement form) is 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 Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact Page 7 of 10
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 Structured Investment Option, I may elect, may Q increase or decrease and are not guaranteed as to dollar amount. U I Amounts I allocate to any of the Segment Types may 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. The Each Segments Segment are in the not Structured index funds Investment and do not Option invest provides in
underlying a rate mutual of return funds tied that to the hold performance investments of tracked a specified index. by a specified index. The Performance Step Up, Cap Dual Rates Direction, than Dual Standard Step Segments Tier, Dual Step with the
Up, same and Enhanced Index, Segment Upside Duration Segments and will Segment generally Buffer. have lower Options The Segment even though Rate of the Return Segments for Segments have similar using durations one Segment and/or Option track may
similar differ indices. from Segments In addition, using because different of the Segment way the that Segment in certain Rate circumstances of Return is calculated a very small for Step difference Up, Dual in the Step Index Up, Performance Dual
Direction, Rate and can Dual result Step in Tier a much Segments, larger I difference understand in the Segment Rate of Return for those Segments. Rate For Enhanced - is always Upside subject Segments, to, and thus the limited Segment by, Rate the
Performance of Return - inclusive Cap Rate. of This any application means that of even the if Participation the Index Performance Rate the Performance multiplied by Cap the Rate. Participation The Participation Rate is greater Rate than for this the
Segment Performance Option Cap is generally Rate, the higher Segment compared Rate of to Return other will Segment equal Options offered with the same Index, Segment Duration and Segment Buffer. understand For Best Entry that Segments, in certain
circumstances, a reset of the Best there Entry may Value not be is a always reset to dependent a lower value on negative as of the Index first four performance. monthiversary I of my Segment. conditions The prospectus that apply and applicable to
the Contract. supplements contain more complete information including the limitations, restrictions and features In the case and of benefits IRAs and other Qualified than tax Plans, deferral. by signing IRAs and this Qualified application Plans I
acknowledge derive tax deferral that I am from buying the Internal the Contract Revenue for its 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. of No Equitable’s Financial Professional rights and regulations. has the authority Equitable to make must or agree modify to any any change Contract made on behalf to the of Contract, Equitable, or or to the to
waive age at or issue, alter any in writing signed by an officer of the company. (MSCI), Structured and Capital MSCI Strategies bears no liability Premier with is not respect sponsored, to such endorsed, product or or any promoted index on by which
Morgan such Stanley product Capital is based. International The prospectus products. contains a more detailed description of the limited relationship that MSCI has with Equitable and any related 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 Jones, Equitable. S&P The or any Structured of their Capital respective Strategies affiliates Premier (collectively, contract “S&P is not Dow
sponsored, Jones Indices”) endorsed, . S&P sold Dow or promoted Jones Indices by SPDJI, makes Dow no representation or warranty, express or implied, to the owners of the Structured Capital Strategies Premier contract. Structured Capital
Strategies Premier ICC25 App SCSPR X04794_Compact Page 8 of 10
13. Signature and Acknowledgements (cont’d) R E For purposes of this section, the references to Owner and Joint Owner below
include Annuitant and Joint Annuitant, Q respectively, in the case of non-natural owners. U I OPTIONAL BENEFIT DISCLOSURE. I/WE UNDERSTAND AND ACKNOWLEDGE THAT: R There is an additional charge if the HAV GMDB or Greater of GMDB Rider is elected. E
The HAV GMDB or Greater of GMDB cannot be voluntarily terminated once it is elected. D The HAV GMDB or Greater of GMDB Rider does not provide an Annuity Account Value or Cash Value and cannot be withdrawn. Withdrawals under the Contract will reduce
my ROP GMDB or HAV GMDB or Greater of GMDB. or The in ROP the future, GMDB to or my HAV Contract GMDB because or Greater withdrawals of GMDB that may are be made of limited from use this if Contract required to minimum meet the distributions
required amount apply, may now significantly reduce the benefit. the For death jointly of owned the first contracts Owner. with The the death ROP benefit GMDB is or only HAV payable GMDB upon or Greater the death of GMDB, of the surviving the death
Joint benefit Owner. is not payable after as For described non-spousal in Section joint owners 72(s) with of the the Internal ROP GMDB, Revenue because Code after the entire the owner’s interest death in the the annuity surviving contract
owner’s must beneficiaries be distributed may not receive the benefit of the ROP GMDB. 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 of Owner. the change The notice in marital must status be signed and HAV by both GMDB Joint or Owners Greater and of GMDB must be to received be payable by Equitable upon the death while both of the Joint single Owners Owner. are
I/We alive understand in order for that the if ROP Equitable GMDB is not or Cash notified Value, using not a form the ROP acceptable GMDB to or us HAV before GMDB the or death Greater of either of GMDB, former will spouse be payable and signed and
the by fees both for Joint the Owners, HAV GMDB then or the Greater of GMDB will not be returned. divorce If I/We remove cases mentioned an Owner above. of the Contract, the ROP GMDB or HAV GMDB or Greater of GMDB is terminated, except in 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. I have reviewed my financial information and goals with my Financial Professional. 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). X Owner’s Signature City, State Date (MM/DD/YYYY) X R Joint Owner’s Signature City, State Date (MM/DD/YYYY) E Q U X I R
Annuitant’s Signature (if other than Owner) City, State Date (MM/DD/YYYY) E D X Joint Annuitant’s Signature (if other than Owner) City, State Date (MM/DD/YYYY) Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact Page 9
of 10
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 (If MEMBERS Yes, you must OF THE also ARMED submit a FORCES) 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 includes active duty members or full-time of the training. reserve It does calls not include
or orders members specifying of the periods reserve of less component than 31 who calendar are performing days. active duty or active duty for training under military C. NORTH information CAROLINA provided ONLY: by the I Proposed certify that Owner.
I have truly and accurately recorded on the application the Yes No D. Please check this is box if you are an Equitable Advisors Financial Professional and the primary selling Agent’s business address is in the state of New York, in which case
the issuing company for the contract will be Equitable Financial Company of Life America. Insurance Company. In all other cases, the issuing company will be Equitable Financial Life Insurance The applicant understands that he/she is applying for an
index-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. 900310 Structured Capital Strategies Premier ICC25 App SCSPR X04794_Compact Page 10 of 10