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 MONY Life Insurance	 MONY Life Insurance	Express Mail:	Change of Beneﬁciary and/or
Company	Company of America	100 Madison St	Rightsholder (Owner)
P.O. Box 4830	P.O. Box 4720	Syracuse, NY 13202	Rightsholder (Owner)
P.O. Box 4830	P.O. Box 4720	Syracuse, NY 13202	(Page 1 of 6)
Syracuse, New York 13221	Syracuse, New York 13221		(Page 1 of 6)
			Form No. 10481 (10/2010)

INSTRUCTIONS FOR COMPLETING THIS FORM

Section 1. Designation of Beneﬁciary and Method of Payment

Payment will be made in one sum. Settlement Option is not available unless elected on Beneficiary, Rights and Settlement Option Request (Form 4113).

Complete the beneﬁciary designation (FIRST, SECOND), using the sample wordings on Page 2 as a guide for completing your designation. It is not necessary to designate a SECOND beneﬁciary, but the space is provided if you choose to do so. The relationship of the proposed beneﬁciary(ies), to the Insured person must be stated in Section 1.

Use the full legal name — Linda Smith, not Mrs. John Smith.

Current law requires us to request the name and address of each beneﬁciary (including the current list of living members in a group designation like “my children”) as well as the Relationship of each beneﬁciary named to the Insured. After completing the beneﬁciary designation in Section 1, you should provide this supplemental information below the name of each beneﬁciary noted on Page 4 in the space provided.

If you have named a person as beneﬁciary, the FINAL beneﬁciary will be the insured’s executors or administrators unless otherwise indicated. Is this your intent? Keep the rightsholder (owner) in mind. For example, if rights are vested in the Insured or the ﬁnal rights revert to the Insured, the FINAL beneﬁciary is generally the executors or administrators of the Insured’s Estate. If, however, ﬁnal rights are to be vested in someone other than the Insured (such as a spouse), the FINAL beneﬁciary is generally the executors or administrators of that person (surviving beneﬁciary).

Section 2. Designation of Rightsholder (Owner)

First Review Your Beneﬁciary Designation. Do you want to complete Section 1 in addition to Section 2?

To change the rightsholder (owner) on your policy, check the appropriate box. If rights are to be transferred to someone other than the Insured, complete 2. A and B. (See sample wordings on Page 2.)

Section 3. Signatures

To sign on behalf of a corporation:

1.An ofﬁcer other than the Insured and other than the secretary must sign and the signing ofﬁcer must specify his/her corporate title.

2.If the only two ofﬁcers in the corporation are the Insured and the secretary, please submit a statement to that effect or indicate that fact in Section 3. See below for additional signature requirements:

Professional Corporation (“PC”)	Ofﬁcer or Shareholder. Prefer someone who is both.
Registered Limited Liability
Partnership (“R.L.L.P.”)	Partner
Limited Liability Company (“L.L.C.”)	Member or Manager. Any other person would have to approve his/her
	authority under its opening agreement of Articles of Organization.
Professional Service L.L.C. (“P.S.L.L.C.”)	Same as L.L.C.

3.State the complete legal name of the Corporation as it appears in your Charter or Certiﬁcate of Incorporation. DO NOT use the corporate assumed name alone (its d/b/a).

4.The ﬁnal beneﬁciary and/or rightsholder (owner) will be the Corporation’s successors or assigns.

To sign for a partnership:

1. A general partner other than the insured must sign in the following manner: (state full name of the partnership)

by:		. A limited partner may not sign for a partnership.
	(member of the ﬁrm)

2.The ﬁnal beneﬁciary and/or rightsholder (owner) will be the Partnership’s successors or assigns. To sign on behalf of a tax-qualiﬁed plan:

1.The qualiﬁed trustee(s) must sign in the capacity of “trustee”, of the qualiﬁed/tax-sheltered plan, not individually.

2.State the full name of the tax-qualiﬁed plan as it appears in the plan.

GENERAL

A proposed Beneﬁciary Must Sign if designated to receive “as interest may appear” or in any way indicating the rightsholder’s (owner’s) indebtedness to the beneﬁciary, when that rightsholder is retaining any rights which would enable him at any time to eliminate the interest of the proposed beneﬁciary.

IMPORTANT: PLEASE READ THIS SPECIAL INSTRUCTION SHEET BEFORE COMPLETING THE FORM.

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(Page 2 of 6)

SAMPLE WORDINGS

If you need help in wording a designation or if your designation is too long for this form, send us details of the change desired and we will prepare the form for you based on our interpretation of the information, it will then be subject to your approval.

SAMPLE WORDINGS FOR COMPLETING FIRST AND SECOND BENEFICIARY DESIGNATIONS IN SECTION 1.

If you wish to designate . . .	Please use this language . . .
SINGLE BENEFICIARY
a person	— Spouse, Jane Doe
Insured’s estate	— Insured’s executors or administrators
corporation	— XYZ Corporation, or its successors or assigns.
partnership	— Smith and Jones, a partnership, or its successors or assigns.
GROUP (more than one person) BENEFICIARY
children	— children, John Doe, Susan Doe and Frank Doe (will not include any other children)
	— children of Insured including John Doe, Susan Doe and Frank Doe
	— children of marriage of Insured and spouse, Mary Doe
	— children of marriage of Insured and spouse, Mary Doe, including John
	Doe and Susan Doe
parents	— Father, James Doe and mother, Frances Doe
named brothers and sister	— Sister, Jane Doe, and brothers John Doe, Frank Doe.
(nieces and nephews, aunts and uncles, etc.)
TRUST BENEFICIARY
Trustee under written trust (living trust)	— John Jones (XYZ Bank) as trustee or his (its) successor trustee under an Agreement
Provide the names of Trustee(s), the name of	dated May 1, 1978 made by and between the Insured and said trustee.
living trust, date of living trust, the name(s) of
grantor(s). If all identifying trust information is
not provided, a Statement as to Trustee/
Beneﬁciary Form 3559 will be required.

Testamentary Trust (Trust created in a Will) The terms of trust must be fully contained in the Will and the Will must be probated to effectuate the trust.

—the trustee or successor trustee under a trust created under the Instrument probated as the Last Will and Testament of the Insured or, if the Insured shall die intestate or shall leave a will not creating a trust, the

Insured’s executors or administrators.

NOTE: If your Will speciﬁes that some portion (or all) of your estate must be distributed (“poured over”) to a trust that is already in existance, (a living trust), then you can designate the trustee under the written trust agreement as the beneﬁciary, you need not designate the executor or a trustee under a testamentary trust.

SAMPLE WORDINGS FOR COMPLETING RIGHTSHOLDER (OWNER) DESIGNATIONS

IN SECTION 2.A and 2.B, IF APPLICABLE.

	If you wish to designate . . .	Please use this language . . .
	SINGLE RIGHTSHOLDER
	a person	— Jane Doe, spouse
	corporation	— Jane Doe, spouse
	corporation	— XYZ Corporation, or its successors or assigns.
	partnership	— XYZ Corporation, or its successors or assigns.
	partnership	— Smith and Jones, a partnership, or its successors or assigns.

	TRUST RIGHTSHOLDER
	Usually no other rightsholder, and no FINAL	— John Jones (or XYZ Bank) as trustee or his (its) successor trustee under an Agreement
	rightsholder, needs to be named after this (an	dated May 1, 1978 made by and between the Insured and said trustee.
	irrevocable trust) designation; but, if there is a
	need to do so, (a revocable trust) complete the
	FINAL rights (Section 2B) or send us full details
	and we will propose a designation for you.

GROUP (more than one person) RIGHTSHOLDER

Group rightsholders must act jointly and ownership interests cannot be apportioned.

children	— Insured’s children
	— children, Jane Doe, John Doe and Mary Doe
	— children of marriage of Insured and spouse, Mary Doe
	— children of marriage of Insured and spouse, Mary Doe, including John
	Doe and Susan Doe
parents	— Mother, Jane Doe and Father, James Doe -OR-
	Mother and Father of Insured, Jane and James Doe, respectively.

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Continued Next Page

(Page 3 of 6)

SAMPLE WORDINGS CONTINUED ..........

SINGLE PRIMARY RIGHTSHOLDER AND SINGLE CONTINGENT RIGHTSHOLDER

spouse, followed by child	— Spouse, Mary Doe, if living, if not, daughter, Jane Doe
SINGLE PRIMARY RIGHTSHOLDER AND GROUP CONTINGENT RIGHTSHOLDER
spouse, followed by unnamed children	— Spouse, Mary Doe, if living, if not, Insured’s children
spouse, followed by named children	— Spouse, Harry Doe, if living, if not, son, Frank Doe and daughter, Jane Doe
GROUP PRIMARY RIGHTSHOLDERS AND SINGLE CONTINGENT RIGHTSHOLDER
children, followed by spouse	— Insured’s children, if none is living, spouse, Mary Doe

General Information for Change in Ownership

•If the new Owner is a U.S. citizen, they must have a primary residence in the United States. If the person is a U.S.

Citizen but lives abroad, the change of ownership will require the approval of the AXA Equitable Anti-Money Laundering Office (AMLO).

•If the new Owner is not a U.S. citizen, they must have a primary resident address in the U.S. and have an unexpired visa or Green Card. Copies of the unexpired visa or Green Card must be submitted with this request. We will accept an unexpired visa in the following visa categories: A, E, G, H, I, K, L, N, NATO, P, R, S, T, TN, TD, U TPS or V. We will also need a copy of an unexpired visa and I-94 document.

•A Non-U.S. citizen that has a visitor’s visa, an expired Green Card or visa, no visa or has a visa in the following categories: B, C, D, F, J, M, Q, TWOV, will not be accepted as a new Owner and the ownership change must be declined under the AXA Financial Anti-Money Laundering policy.

•For Legal Resident Aliens: A copy of the unexpired Green Card or acceptable visa and I-94 form will be required to be submitted with the change of ownership request.

•For Trusts: Taxpayer Identification Number of the Trust and a copy of a Trust certification or significant pages and signature page of the Trust Agreement that proves the existence of the Trust, the name and date of the Trust Agreement,

as well as the name of the Trustee(s).

•For Partnerships: Pertinent page from the Partnership agreement that proves the Partnership exists and indicates the names of the Partners.

•For Private Corporations: Articles of Incorporation or copy of business license and documentation indicating the acting party has the authority to act on behalf of the Corporation.

•For Publicly Traded Corporations: No additional requirements need to be submitted.

•All non-resident individual and foreign business (Corporation, Trust, Partnership) new Owners require the approval of the AXA Equitable AMLO. In addition to the requirements outlined above, the AMLO also requires these new Owners to have a U.S. Bank account.

General Information for New Owner(s) concerning Taxpayer Identification Number

•Federal Law requires you to provide to us the correct Taxpayer Identification Number which matches your name.

•If you fail to provide the correct Taxpayer Identification Number, tax withholding may be required and penalties may apply.

•Your Taxpayer Identification Number is your Social Security Number if you are an individual and a U.S. person. A

U.S. person is a U.S. citizen, or a non-citizen of the United States who is a U.S. resident for tax purposes. If you are a foreign individual who is not eligible to apply for a Social Security Number, your Taxpayer Identification Number is your Individual Taxpayer Identification Number or “ITIN” issued by the IRS. If you are an entity (U.S. or foreign), your Taxpayer Identification Number is the Employer Identification Number or “EIN” issued by the IRS.

•In the case of a minor, the minor.s Social Security Number must be provided. If the minor does not have a Social

Security Number, the natural guardian for the minor owner may obtain one by applying to the Social Security Administration on Application Form SS-4. If the newly acquired number is not received by AXA Equitable/AXA Life and Annuity/MONY Life Insurance Company of America within 60 days, AXA Equitable/AXA Life and Annuity/MONY Life Insurance Company of America is required by law to withhold on any taxable interest being credited to the policy/ contract.

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(Page 4 of 6)

General Information on USA PATRIOT Act – Customer Identification Program

•Section 326 of the USA PATRIOT Act outlines important information about procedures for opening new accounts

•To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

•To comply with Section 326, AXA Equitable/AXA Life and Annuity/MONY Life Insurance Company of America will ask for your name, address, date of birth, and other information necessary to allow us to identify you when opening an account. We may also ask to see your driver.s license or other identifying documents.

You May Use This Form:

To change either the beneficiary or the rightsholder (or both).

For any number of policies, provided you are requesting an identical change for each policy.

To change the beneficiary for proceeds payable at the Insured’s death only for Family Plan policies issued prior to 1968. The beneficiary of the proceeds payable upon the death of the insured wife and insured children will remain as stated in the policy or previous family plan endorsement.

You may NOT use this form:

To change the beneficiary on any MONY Employee or FU Pension or Benefit Plans, Disability Insurance Policies. Send us details of changes required for such policies and we’ll prepare a request for the rightsholder’s signature.

For settlement options on non - qualified policies. Use BENEFICIARY, RIGHTS and SETTLEMENT OPTION REQUEST (Form 4113), which may be obtained from your MONY Field Underwriter. (Settlement Options are not available on qualified policies.)

-OR-

To release an assignment. Assignment of Policy/Release of Assignment (Form 3600) is required and may be obtained from your MONY Field Underwriter.

TAX CONSEQUENCES

An attorney should be consulted about possible tax consequences in the following instances:

(a)if the rightsholder is not the Insured and is not the beneficiary; (b) if the rightsholder designates joint rights to two or more individuals, as a gift; (c) if the rightsholder is a corporation and is not a beneficiary; (d) if rights are changed on an annuity issued after April 22, 1987; (e) a transfer to a person two or more generations younger than the transferor (generation skipping); (f) if the policy has a loan and the rights are being transferred as a gift.

INFORMATION ON DIVORCE

If you are required to designate an ex-spouse or children as beneficiary(ies) pursuant to a divorce decree or order, then the decree should be submitted to us. We will try to conform the beneficiary designation to the terms of the decree. An endorsement will be sent to you and will be deemed to be accepted by you unless you notify us of your rejection. If you currently have your ex-spouse listed as beneficiary, then you should either change the beneficiary to reflect your new choice of beneficiary or to reconfirm your desire to designate the ex-spouse despite the divorce. In most states, a divorce does not automatically extinquish the rights of an ex-spouse as beneficiary. Therefore an Insured who inadvertently leaves his/her ex-spouse as beneficiary after a divorce may cause payment of the death benefits to the ex-spouse even though such payment is contrary to his/her intent. If your ex-spouse

is the beneficiary and you do not want him/her to be a beneficiary, then you should submit a change of beneficiary request.

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MONY Life Insurance	MONY Life Insurance	Express Mail:	CHANGE FORM
MONY Life Insurance	MONY Life Insurance	Express Mail:
Company	Company of America	100 Madison St	(RIGHTS, BENEFICIARY,
P.O. Box 4830	P.O. Box 4720	Syracuse, NY 13202	METHOD OF PAYMENT)
Syracuse, NY 13221	Syracuse, NY 13221		(Page 5 of 6)
	(Not licensed in WY and NY)		(Page 5 of 6)
	(Not licensed in WY and NY)		Form No. 10481 (Rev. 10/2010)
			Form No. 10481 (Rev. 10/2010)

Agency

Code

Policy Numbers

Insured’s Name (as it appears on policy)

If Insured’s name has changed, state new name and reason for change :

If more space is required, please print “See Attached”. The form and attachment(s) must include the policy number(s), have the same date, and be signed by the owner. Joint beneﬁciaries will receive equal shares proportionate to the number of those beneﬁciaries who survive the Insured. Proceeds will be payable in one sum.

1. PRIMARY

Are any named beneﬁciaries a Viatical or Life Settlement Company?

 Yes

 No

BENEFICIARY(IES)

if living, if not

(Relationship(s)

(Names of First Beneﬁciary(ies)

(Date(s) of Birth)

Please type or print full

name and indicate the

Phone number:

relationship to the

insured person

Beneﬁciary(ies) Address:

Beneﬁciary(ies) Social Security # :

CONTINGENT

BENEFICIARY(IES)

(Relationship(s)

(Names of First Beneﬁciary(ies)

(Date(s) of Birth)

if living, if not

Please type or print full

Phone number:

name and indicate

relationship to the

Beneﬁciary(ies) Address:

Beneﬁciary(ies) Social Security # :

insured person.

FINAL

If no beneﬁciary named above is living at the Insured’s death, the beneﬁciary is the Insured’s executors or administrators,

BENEFICIARY

unless checked:

 The executors or administrators of the survivor of all beneﬁciaries (the last designated beneﬁciary to die)

To be completed for

Is this ownership change in connection with a viatical or life settlement transaction?

Yes

No

change of Rights

Is the new owner a US citizen or a legal entity established under US law?

Yes

No

(owner)

If the new owner is a nominee, ﬁduciary or intermediary for a beneﬁcial owner,

2. RIGHTS

is the beneﬁcial owner a US citizen or a legal entity established under US law?

Yes

No

Rightsholder,

Please change the Policy(ies) so that all rights provided in “Rights (Ownership) Under Policy” (refer to #5 on Page 6)

Contract

belong exclusively to (if naming joint rightsholders, the following information needs to be provided for all named rightsholders):

holder (Owner) on

 Insured/Annuitant

 Individual

Trust

 Partnership

 Corporation  Other

record remains

Full Name of Proposed Rightsholder(s)

unchanged Unless

Relationship to Insured/Annuitant

Date of Birth

this section is

Legal Residence (Full Street, City, State, Zip)

completed.

Mailing Address (if different from Legal Address)

Where two or more

Phone number

New Rightsholder Occupation and Type of Business

Rightsholders are

Soc Sec #/TIN (IRS Form W-9 signed by new rightsholder must be included)

Designated, those

All non-resident individual and foreign business new rightsholders must have a US Bank

Living shall act jointly

Account: Name of Bank

Account Number

Unless otherwise

FINAL RIGHTSHOLDER (IF ALL PERSONS DESIGNATED IN a. PREDECEASE THE INSURED):

indicated.

 The Insured / Annuitant - Final Rightsholder will be the Insured if no box is checked.

 The executors and administrators of the rightsholder, if two or more rightsholders, the

executors or administrators of the survivor of said rightsholders (the last to die).

IRS Form W-9 must be

IF AN

 The contractholder’s spouse. Only check this box if contract is an Annuity (see note).

ANNUITY

NOTE ON ANNUITIES: If the contract has a Contingent Annuitant Provision, and if the primary Annuitant

Completed by the

is the Contractholder at the time of death, the Successor Contractholder must be designated as the

NEW RIGHTSHOLDER

Primary Contractholder’s Spouse for the Contingent Annuitant Provision to continue the contract. At the

and Submitted to the

death of the Primary Contractholder, the contract MUST be surrendered and the proceeds paid out if the

Company with new

Contractholder’s Spouse DOES NOT then become the Contractholder.

If the policy(ies) provide for an endowment or life income at annuity commencement. The right to receive

Rightsholder’s TIN

such endowment or life income at annuity commencement belongs exclusively to the Insured/Annuitant.

3.SIGNATURES The undersigned Rightsholder (Owner) requests the Company to accept and record the designations above, to add the provisions on

page 6 of this form his/her/its policy/contract (if necessary to update it), to issue an endorsement consistent with the above designations or to accept

this form as an endorsement (whichever it deems appropriate), and to accept any material changes above that I have initialed or otherwise ratiﬁed. If

signing on behalf of a corporation or partnership, see “Instructions” Page 1, Section 3 - “Signatures”.

Signature

Witness

Date

of Owner FIRST NAME

INITIAL

LAST NAME

If Rightsholder (Owner) resides in Massachusetts, a Witness is mandatory

and a named beneﬁciary may not be a witness.

Additional

Signature FIRST NAME

INITIAL

LAST NAME

Rightsholder’s (Owner) Daytime Phone Number

FOR HOME OFFICE USE: Form Recorded and Endorsement Waived:

Date

MONY Life Insurance Company

For Agency Use Only:

 Pending Transaction: contact

 Policyowner

 FU

 Agency F.U. Full Address if not at Agency of Record

 Completed Transaction: contact

 Policyowner

 FU

 Agency

Print F.U. or ASA Name

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GENERAL PROVISIONS

(Page 6 of 6)

1.DEFINITIONS

(a)“WE”, “US”, “OUR” and “Company” refer to The MONY Life Insurance Company or any of its insurance subsidiaries.

(b)“insured wife” and “insured child” —For family plan policies, wherever these words appear in this form, the section of the Policy entitled “deﬁnition of insured wife and insured child” will also apply to any endorsement.

3. TRUST PROVISIONS IN LIVING TRUSTS AND WILLS

A written trust or will cannot change the terms of your policy or otherwise bind the Company. Further, the Company cannot determine at any time whether a trust or will is valid. Accordingly, the Company cannot assume any responsibility for the trustee’s performance or failure to perform any trust duties and the Company will not have any further obligations under a policy if it has made a payment to (or honored a speciﬁc request by) a trustee.

(c)HOME OFFICE. Our Operations Center in Syracuse, New York and our World Headquarters in New York, New York are included within the meaning of Home Ofﬁce.

(d)RELATIONSHIPS. All relationships used in the beneﬁciary and rights designations refer to the Insured unless otherwise indicated.

(e)“Policy”, “Insured” and “Policyholder”. For annuities, wherever these words appear in this form, they mean “Contract”, “Annuitant” and “Contractholder”, respectively. For Group Universal Life, whenever Policy and Policyholder appear in

this form they mean Certiﬁcate and Certiﬁcateholder, respectively.

(f)RIGHTSHOLDER (OWNER) A person who can exercise rights is a rightsholder. In contrast, a person designated as contingent rightsholder can only act upon the death of the primary rightsholder and is not considered a rightsholder until the happening of that event. Wherever “Rightsholder” appears on this form, it means “Rightsholder”, “Owner” and “Policyholder”.

2.DETERMINATION OF BENEFICIARY. The beneﬁciary in Section 1 will become entitled to the amount payable (proceeds) in the order and proportion stated. For proceeds payable at the Insured’s death:

Payment made in one sum: Unless otherwise stated, a beneﬁciary will not be considered “living” unless the beneﬁciary is living on the earlier of (a) the day due proof of the Insured’s death is received by us at our Home Ofﬁce and (b) the 14th day after the Insured’s death. The share of the death proceeds of any beneﬁciary who is not living on the earlier of these two dates will be payable to the remaining beneﬁciaries in the manner provided.

4. POLICY ASSIGNMENT

The interest of any beneﬁciary or other person will be subordinate to any assignment whenever made. We may rely solely on the assignee’s statement as to the amount of its interest in the death beneﬁt proceeds, which will be payable in one sum.

5. RIGHTS (OWNERSHIP) UNDER POLICY

Subject to the rights of any assignee, during the Insured’s lifetime and prior to the date of any endowment proceeds or life income at maturity becoming payable, the right to change the beneﬁciary, the right to assign, the right to receive any endowment proceeds or life income at maturity or to change the payee thereof, and all other rights, beneﬁts, options, and privileges conferred by the Policy or allowed by the Company belong exclusively as designated in the application for this Policy unless otherwise provided by endorsement or as designated in Section 2 on Page 5.

6. CHANGES IN BENEFICIARY AND RIGHTSHOLDER (OWNER)

These changes may be made during the Insured’s lifetime by written request to us at our Home Ofﬁce. The Policy need not be presented for endorsement unless requested by us. Any such change will take effect as of the date the notice was signed, upon acceptance and recording at the Home Ofﬁce, subject to any payment made by us or action taken by us before receipt of the request at our Home Ofﬁce.

7.SETTLEMENT OPTIONS

Use BENEFICIARY, RIGHTS AND SETTLEMENT

OPTION REQUEST (Form 4113) which may be obtained from your MONY Field Underwriter. (Settlement Options are not available for Qualiﬁed policies).

FOR HOME OFFICE USE ONLY

Endorsement No.

Endorsement to Agency

DO NOT DESTROY

PD 99

10481

Endorsement sent to

File with App #

10660

12388

PI 10

Policy/Statement Returned

Servicer’s Name

11330 LA

12491

11197 LA

BART

Agy

FU #

Date

E14751

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