The Equitable Life Assurance Society of the United States
APPLICATION
(Consisting of Parts A and B)
PART A -- Application and Agreement for Participation in Contract
Employer:
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Employer Address:
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Participant:
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Participant Address:
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Beneficiary:
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relationship
Contingent Beneficiary:
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relationship
Contract: Group Annuity Contract No. [0000]
I. Plan/Trust Type: The Plan will participate in the Contract through
The Pooled Trust for the Members Retirement Plans of The Equitable
Life Assurance Society of the United States.
II. Contract Terms: Part B of this Application identifies certain
terms which relate to the Plan's participation in the Contract.
III. Application and Agreement: By signature below of the Participant,
the Participant hereby:
A. acknowledges having received and read the Contract, as well
as the ERISA Information Statement;
B. acknowledges and understands the fees, charges, and funding
arrangements under the Contract;
C. applies for participation in the Contract as a funding
vehicle for the Plan;
D. agrees to be bound by the terms and conditions of the
Contract and amendments and modifications made thereto
pursuant to Sections 10.01 and 10.02 of the Contract;
E. acknowledges and understands 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;
F. authorizes Chase Manhattan Bank, N.A., to act as trustee for
participation in The Pooled Trust for Members Retirement
Plans of The Equitable Life Assurance Society of the United
States; and
G. understands that Chase Retirement Bank, N.A., shall be the
Contract Holder of the Contract issued pursuant to this
Application.
PF 10,798A-MP-OH Page 1 of [55]
PART B -- Contract Terms
I. Investment Options (Contract Part II)
Investment Options: The following Investment Options are
available under the Contract:
Guaranteed Interest Account
Type A Investment Options:
The Common Stock Fund EQ/▇▇▇▇▇▇ Growth &Income Value
The Balanced Fund EQ/▇▇▇▇▇▇ Balanced
The Aggressive Stock Fund MFS Research
The Global Fund MFS Emerging Growth Companies
The Growth Investors Fund ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Emerging Markets Equity
The Growth and Income Fund Warburg Pincus Small Company Value
The Equity Index Fund ▇▇▇▇▇▇▇ ▇▇▇▇▇ World Strategy
The International Fund ▇▇▇▇▇▇▇ ▇▇▇▇▇ Basic Value Equity
The Small Cap Growth Fund
▇. ▇▇▇▇ Price International Stock
▇. ▇▇▇▇ Price Equity Income
Type B Investment Options:
The Conservative Investors Fund
The High Yield Fund
The Intermediate Government Securities Fund
The Money Market Fund
The Quality Bond Fund
Type A and B Investment Options are Investment Funds of Equitable
Separate Account A.
You must use the TOPS system to allocate your current and future
allocations among the Investment Options. Allocations will also
apply to Employer contributions. Allocation percentages must be in
whole numbers and this sum must equal 100. If we receive your
initial contribution before we receive your allocation
instructions or if your allocations do not add up to 100%, we will
allocate all or a portion of your initial contribution to the
Money Market Fund.
II. Guaranteed Interest Rate(s) (Contract Section 2.01)
The initial Guaranteed Interest Rate(s) is [4%] which applies from
the Contract Date through [December 31, 1999], and thereafter the
Guaranteed Interest Rate will never be less than 3%.
III. Minimum Contributions (Contract Section 3.01)
[Not Applicable]
IV. Transfer Rules (Contract Section 4.02)
The percentage of the amount in the Guaranteed Interest Account
which may be transferred, as described in Section 4.02 of the
Contract is [25%.]
PF 10,798A-MP-OH Page 2 of [55]
V. Termination of Coverage Under Contract (Contract Section 5.03)
The terms of Section 5.03 apply.
VI. Loan Charges (Section 9.05)
Set-up Charge: [$25]
Loan Recordkeeping Charge: [$6 deducted each calendar quarter]
VII. Withdrawal Charges (Contract Section 9.01)
A withdrawal or a termination payment made under Part V of the Contract
is subject to a Withdrawal Charge.
[The Withdrawal Charge is equal to 6% of the amount withdrawn during
the first 5 Contract Years or, if less, 8.5% of the Contributions made
by or on behalf of the Participant. If a portion of the Annuity Account
Value is forfeited pursuant to the Plan terms, the Charge will not be
assessed against unvested amounts.]
The Withdrawal Charge will be waived as described in item XI below.
[The years during which the Plan participated under the Prior Contract
will be included as Contract Years for purposes of determining the
Withdrawal Charge.]
VIII. Administrative Charges (Contract Section 9.02)
As of the last Business Day of each calendar quarter, Equitable will
withdraw an Administrative Charge from the Annuity Account Value. Such
charge is equal to [$7.50 each calendar quarter or if less, 0.50% of
the Annuity Account Value, plus any outstanding loan balance].
[However, no Charge will apply if the Annuity Account Value is more
than $25,000.]
IX. Daily Separate Account Charge (Contract Section 9.04)
Assets of the Investment Funds will be subject to a daily asset charge.
Such charge will be applied after any deduction to provide for taxes
and will be at a rate not to exceed a guaranteed annual rate of
[2.00%.]
For the first two Contract Years, and each Year thereafter until
Equitable notifies the Participant otherwise, the Charge will equal the
annual rate of [1.35%].
X. Basic Plan Recordkeeping and Service Charge (Contract Section
9.06)
Not Applicable
XI. Waiver of Withdrawal Charge and Market Value Adjustment (Contract
Sections 9.01 and 9.08)
[Notwithstanding anything in this Application and the Contract to the
contrary, no Withdrawal Charge or Market Value Adjustment will be
applied in connection with the following:
PF 10,798A-MP-OH Page 3 of [55]
(a) Amounts paid in annual installments pursuant to Section 5.03;
(b) Amounts withdrawn or applied with respect to a Participant for
purposes of a "Benefit Distribution" (the definition contained in
Section 5.03 applies for this purpose as well) or for purposes of
compliance with any qualified domestic relations order as defined in
Section 414(p) of the Code;
(c) Withdrawals of Contributions which are "excess contributions" as
such term is defined in Section 401(k)(8)(b) of the Code, including the
income thereon, and less any loss allocable thereto, provided the
withdrawal is made no later than the end of the plan year following the
plan year in which such excess contributions were made;
(d) Withdrawals of Contributions which are "excess aggregate
contributions" as such term is defined in Section 401(m)(6)(B) of the
Code, including the income thereon, and less any loss allocable
thereto, provided the withdrawal is made no later than the end of the
plan year following the plan year in which such excess aggregate
contributions were made;
(e) Withdrawals of amounts which are "excess deferrals" as such term is
defined in Section 402(g)(2) of the Code including the income thereon
and less any loss allocable thereto provided the withdrawal is made no
later than April 15 following the calendar year in which such excess
deferrals were made;
(f) Refunds of Contributions which are remitted by the Employer on
behalf of the Participant due to mistake of fact made in good faith,
provided such Contributions, less any loss allocable thereto are
refunded to the Employer (or Plan trustee(s)) on behalf of the
Participant within 12 months from the date such Contributions were made
and no earnings attributable to such Contributions are included in such
repayment;
(g) Refunds of Contributions which are remitted by the Employer on
behalf of the Participant but which are disallowed to the Employer as a
deduction for federal income tax purposes, provided such Contribution,
less any loss allocable thereto, are refunded to the Employer on behalf
of the Participant within 12 months after the disallowance of the
deductions has occurred and no earnings attributable to such
Contributions are included in such repayment; and
(h) The amount withdrawn is defined as a "hardship withdrawal" pursuant
to Treas. Reg. 1.401(k)- 1(d)(2).
The amounts described in said items (c) through (g) will be as determined by the
Employer and reported to the Equitable.]
Participation in the Contract will become effective only upon acceptance, by the
signature below, of a duly authorized signatory on Equitable's behalf.
PARTICIPANT
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Print Name of Participant City State
BY
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Signature of Participant Date
PF 10,798A-MP-OH Page 4 of [55]
ACCEPTED FOR EQUITABLE
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Print Name of Authorized Signatory ----------------------------------
Signature of Authorized Signatory
EFFECTIVE DATE: CLIENT NO.
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A copy of this Application and the Contract should be retained in the
Participant'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 the Equitable and a copy returned to the
Participant after Equitable's acceptance thereof. Initial contributions will be
accepted by Equitable only after installation documents have been approved by
the Equitable Processing Office.
67697
PF 10,798A-MP-OH Page 5 of [55]