Axa Distribution Form – Fill Out and Use This PDF

To receive all your funds in a single payment.

			About This Form
	If you need all your funds immediately to pay taxes, settle large debts or invest yourself, use this form.
	1 . P r o v i d e I n f o r m a t i o n A b o u t t h e D e c e a s e d
	Deceased’s Name (irst, middle initial, last)
	Date of Death (month/day/year)					Social Security or Taxpayer ID Number
	Street Address
	City, State, Zip
	Contract(s) or Certiicate Number(s):
	2 . P r o v i d e I n f o r m a t i o n A b o u t t h e B e n e f i c i a r y
	Are you a(n):	❑ Individual	❑ Minor			❑ Estate
		❑ Trust	❑ Corporation			❑ Partnership

Your Name (irst, middle initial, last)

Street Address

City, State, Zip

Date of Birth (month, day, year)			Beneiciary’s Social Security or Taxpayer ID Number
Daytime Telephone Number			Evening Telephone Number
Are you a U.S. citizen:	❑ Yes	❑ No	(If you are not a citizen, call 1-800-628-6673)

3 . T a x W i t h h o l d i n g

We must withhold income tax unless you are eligible to “elect out” of income tax withholding and do so below. To elect out of withholding, a US residence address and a correct Taxpayer Identiication Number must be provided, and the payment must be made in the US. Spousal beneiciaries of certain tax-qualiied plans are not eligible to elect out of mandatory 20% federal income tax withholding. For more information, see the Beneiciary Guide.

❑Withhold federal (and state, if applicable) income taxes from the taxable portion of my beneits.

❑In addition to the federal and state (if applicable) income taxes withheld from the taxable portion of my beneits, I would also like additional income taxes withheld:

Federal: $________________________ and State (if applicable) $________________________.

❑I DO NOT want federal and state (if applicable) income taxes withheld from the taxable portion of my beneits.

4 . P a y m e n t O p t i o n a n d D e l i v e r y

Payment Option

❑Send me a Lump Sum Check.

❑Establish an AXA Equitable Access Account on my behalf, if my distribution qualiies (Section 8 must be completed for this option).

Payment Delivery

❑Request delivery by mail to me

❑Request delivery by an AXA Equitable Financial Professional ___________________________________________________

(NAME OF FINANCIAL PROFESSIONAL — PLEASE PRINT)

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5 . P l e a s e R e a d a n d S i g n H e r e

Under penalties of perjury, I certify that (1) the number shown on this form is my correct Taxpayer Identiication Number, and

(2)I am not subject to backup withholding because (a) I have not been notiied that I am subject to backup withholding as a

result of failure to report all interest or dividends, or (b) the Internal Revenue Service has notiied me that I am no longer subject to backup withholding. (NOTE: Cross out Item (2) if you have been notiied by the IRS that you are currently subject to backup withholding because of underreporting interest or dividends on your tax returns.)

If the correct Taxpayer Identiication Number is not supplied or is left blank, federal and state income tax withholding may apply, despite any election to the contrary.

	Your Signature	Date
	6 . D e l i v e r y O p t i o n s

Unless otherwise instructed, distribution checks are mailed via First Class Mail. Expedited delivery is available for a fee of $35 for Express Mail and $90 for a wire transfer after your request has been processed. AXA Equitable has 5 business days to process your request. Please select one option below if you want to expedite delivery.

1. ❑ Please expedite delivery by using Express Mail for a fee of $35, (Cannot be a P.O. Box), or

2. ❑ Please expedite delivery by using a wire transfer for a fee of $90. Only available for net wire amounts of $10,000 or more to a Personal Bank Account.

Wire Transfer Details — to assist us in processing your transaction, please attach a voided check for wire transfers.

	7 . F o r A x A E q u i t a b l e u s e O n l y
	Agent Code	Delivery Code		Service Branch	Company Code
	Agency Name	Agency Alpha Code		Effective Date	Deposit Amount
	8 . A x A E q u i t a b l e A c c e s s A c c o u n t * I n f o r m a t i o n a n d S i g n a t u r e C a r d

Helping Meet Your Financial Needs

The AXA Equitable Access Account can help you address both short- and long-term inancial needs. With the AXA Equitable Access Account, you can withdraw funds to cover your immediate expenses, and at the same time, use it toward your future inancial needs.

How The Access Account Works

If you so elect, AXA Equitable will pay all or some of your life insurance proceeds through a convenient Access Account. The Access Account is a draft account established in your name and works in certain respects like an interest-bearing checking account. However, please keep in mind that you may only withdraw from the account. You may not make deposits into the account.

Beneits of The Access Account

With the Access Account, you can write one draft at any time to access the entire proceeds (including interest) or any remaining

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balance in the account. You may leave the funds in the Access Account and continue to earn interest. You can order additional drafts by sending in the form included in your draftbook, or you can simply call our toll-free number: (866) 494-4265.

You may withdraw any amount up to your balance, with a minimum draft amount of $250, and may write an unlimited number of drafts. There are no fees for drafts, draft-clearing, or monthly draft accounting services. The Access Account will be charged a fee of $25 for any stop payment order, if any draft is returned unpaid, or if you request a wire transfer of funds. Express mail fees are $15 for Monday through Friday delivery and $22 for Saturday delivery. The bank will retain cleared drafts for seven (7) years. Currently, Access Accounts are established and banking services provided by The Northern Trust Company, P.O. Box 92987, Chicago, IL 60675-2987, toll-free number (866) 494-4265. Access Accounts are subject to the rules of the bank.

Designating a Beneiciary

We encourage you to exercise your right to designate a beneiciary or beneiciaries to receive the balance in your account in the event of your death. Simply ill out the form on the back of the Supplementary Contract that you will receive after you elect the Access Account and send it to the address on the form.

If you do not designate a beneiciary for your funds, your estate will be the beneiciary. Please note that we cannot accept a beneiciary that is one of the following: minor; corporation; partnership; tax-exempt entity; estate; trust with more than two trustees; represented under a power of attorney; or resides outside the U.S.

Earning Interest on Your Proceeds

With the Access Account, you have the lexibility of using your proceeds while earning interest from the very day it is established. AXA Equitable will set the interest rate periodically, based upon our discretion and a review of current market interest rates. We reserve the right to change this procedure. The interest rate we apply will not be less than 0.25%. Interest is earned from the date the Access Account is established until the date the account is closed, compounded daily and credited at the end of the month, at which time we will mail you a monthly statement. Interest credited to the Access Account and the applicable rate will appear on your monthly statement. The monthly statement also shows withdrawals and any other inancial activity on your account. Interest earned may be taxable. An IRS Form 1099 will be issued annually for any interest credited to your account. Choosing an Access Account or other payout options may have tax implications. We recommend that you consult a tax advisor, an investment advisor, or any other inancial advisor regarding your particular circumstances and any potential tax liability.

Other Important Information

The principal and interest accrued under the Access Account are held by and are part of AXA Equitable’s general account. They are not held in a bank or other institution and are not insured by the Federal Deposit Insurance Corporation (FDIC) or other federal agencies. Funds held by insurance companies are guaranteed by the respective state guaranty association. For further information, contact the National Organization of Life and Health Insurance Guaranty Associations at www.nolhga.com. AXA Equitable will earn income on the funds held in the Access Account.

AXA Equitable’s obligation is satisied when the total amount of proceeds are deposited into the Access Account. AXA Equitable reserves the right to freeze or take back funds in the Access Account to set off any claim we may have against the account holder. AXA Equitable reserves the right to make changes in the terms and conditions of the Access Account. You will be notiied if changes are made.

If the balance in your account should fall below $1,000 as of the end of the month, the account will automatically be closed. A draft for the balance in the account plus accrued interest will be sent to you at the address we have on our records. Generally, if the Access Account has no customer-initiated activity for a period of one year or more, the account could be considered abandoned property under the unclaimed property laws of your state of residence. Such laws require us to report unclaimed property after a certain period of inactivity and then to turn the funds over to the state. Remember to keep your address current on your account.

For current Access Account interest rate information or to obtain additional information and answers to questions you may have about the Access Account, please call or write to the following: AXA Equitable Life Insurance Company, c/o The Northern Trust Company, P.O. Box 92987, Chicago, IL 60675-2987, toll-free number (866) 494-4265. DO NOT SEND CLAIM FORMS TO THE ABOVE ADDRESS.

Louisiana residents – for further information, please contact the Louisiana Department of Insurance at (800) 259-5300, P.O. Box 94214, Baton Rouge, LA 70804

Kentucky residents – FOR FURTHER INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE. West Virginia residents – for further information, you may refer to www.wvlifega.org.

Putting Your Proceeds to Work

Whenever you are ready, it is important to think about how to get the greatest possible beneit from your proceeds. Money, like most things of value, needs to be properly cared for. Even large sums of money may disappear quickly unless carefully managed. You may want to consider plans and products available to you as an AXA Equitable beneiciary.

Products and Services to Meet Your Future Needs

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AXA Equitable Life Insurance Company and its afiliate, AXA Advisors, LLC, offer a broad array of inancial products to help meet protection, retirement and investment needs. If you are interested in learning more about these products, or have any questions not answered by this booklet, there are numerous ways to contact us.

•Call our toll-free number at (800) 628-6673.

•Write to us at AXA Equitable Life Insurance Company, P.O. Box 4956, Syracuse, NY 13221.

•Log in to our Beneiciary Resource Center at http://www.axa-equitable.com/customer-service/beneiciary/overview.html, where you can search for a inancial professional and ind other useful information.

AXA Equitable Access Account helps provide access, convenience and inancial lexibility. Our business is to support individuals and businesses — small, mid-size and large — at every stage in their lives by providing products and services that help meet their insurance, personal protection, retirement savings and estate planning needs.

Please complete the information below. Print your name and address as you would like to have it printed on your drafts. Sign in the shaded section as you would normally sign a draft. This signature will be used to verify your drafts. If the signatures do not match, drafts will not clear.

Print Your Name (First/MI/Last)	Contract Number
Your Mailing Address
Social Security or Other Taxpayer ID Number	Daytime Telephone Number
Your Signature (as it should appear in your drafts)	Date

*Securities products and services are offered through AXA Advisors, LLC (Member FINRA). AXA Advisors is part of the global AXA Group. AXA Advisors afiliates include AXA Equitable Life Insurance Company.

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