Mony Form Ml200 – Fill Out and Use This PDF

			FORM # ML200 (10/2004)
FIELD UNDERWRITER/REG. REP.		AGENCY	MONY-MATIC PLAN NO.
	CONSOLIDATION/		BANK ACCOUNT NO.
NEW		ADD AND BANK CHANGE
INDICATE	SPLIT
EFFECTIVE DATE
ADD	BANK CHANGE
NAME AS SHOWN ON CHECKING ACCOUNT (Please Print)				MONY-matic
			POLICY / CONTRACT
				PREMIUM
			NUMBER
				AMOUNT
CHECK HERE IF NEW ADDRESS			1)
STREET ADDRESS
			2)
CITY OR TOWN	STATE OR PROVINCE		ZIP CODE
			3)
FOR CANADIAN CASES ONLY
SAVINGS	CHECKING		4)
BANK NAME
			5)
STREET ADDRESS
			6)
CITY OR TOWN	STATE OR PROVINCE		ZIP CODE

NOTE: DESIGNATE CONTROL POLICY WITH *

I have read and fully understand the agreement on page 2 of this form. By signing it, I accept the conditions stated in that agreement. If I now have or hereafter add to this Plan a policy or contract issued by MONY Life Insurance Company of America ("MLOA"), then I understand and agree that MONY will collect, hold separate and then remit premiums paid thereon to MLOA. I understand that "premium reduction" is not available as a dividend option for any participating policies that are on MONY-matic and that the dividend option will be changed automatically from premium reduction to the option specified in the policy.

HOME OFFICE USE ONLY

Date Processed

Initials

Instructions: 1 Original and 1 Copy required; Original signed to PSU; Copy to Premium Payor.

Page 1 of 2

This is the premium payor’s/remitter’s request and authorization for payment of premiums to MONY indicated on page 1 by checks or other orders drawn by MONY on the premium payor’s/remitter’s account under the MONY-matic Monthly Premium Plan (hereinafter referred as to the “Plan”), subject to the following conditions:

(1)The name of the premium payor’s bank and the policies/contracts for which premiums are to be paid under the Plan are shown on page 1. If a policy/contract having a new number is issued in place of any policy listed, or if, for any reason, any listed policy/contract is rewritten under a new number, this request shall apply in the same manner to such new number.

(2)Such checks or other drawn by MONY shall be drawn on or after the 15th day of each month covering the monthly premiums payable in such month under all the policies listed. While premiums are paid under the Plan MONY will not mail notices of premiums payable on any such policies. The cancelled checks or other orders drawn by MONY will constitute receipt of payment of premiums. In case of Flexible Premium Adjustable Life and Variable Policies and Variable Annuity Contracts, premiums shall be deemed payable when scheduled.

(3)If any policy listed provides for payment or premiums on a frequency other than monthly, it is hereby requested that the premium frequency of such policy be changed to monthly.

(4)The privilege of paying premiums under the plan will terminate:

(a)If any such checks or any other orders drawn by MONY are dishonored. Such termination shall be effective as of the last day of the month preceding the month in which the checks or other orders drawn by MONY so dishonored are dated, unless the Plan is reinstated upon written notice given by MONY to the premium payor. Checks or other orders drawn by MONY shall be deemed to have been dishonored if they are not paid on presentation or if MONY has refunded amount of such checks or other orders drawn by MONY to bank named above pursuant to request of such bank.

(b)At the election of MONY upon at least two (2) months written notice to the premium payor.

(c)At the election of the premium payor/remitter only at least thirty (30) days written notice to MONY. For those policies that are not Flexible Adjustable Life, Variable Life, or Variable Annuity, on and after any such termination, the amount of premium for policies which were under the Plan shall be at regular rates applicable to them without any lower rate provided for under the Plan and the frequency (shall be monthly until changed as provided in written notice has been mailed to the last known address) of the insured and of any assignee of record at least 31 days before such anniversary, the premium frequency for such policy shall be changed to annual so that premiums will be payable on that and each subsequent policy anniversary (unless by agreement another premium frequency change is made effective).

(5)PREMIUM Payor will give MONY at least thirty (30) days notice of intent to change banking arrangement.

(6)If the Plan includes policies with other than fixed guaranteed premium, it is understood that any change in the premium payable under the plan after the effective date indicated on page 1 will automatically effect a corresponding change in the amount drawn by MONY on the premium payor’s account.

(7)For Variable Annuity Contracts, premiums and policy shall mean payment and contract, respectively.

(8)FOR VARIABLE LIFE POLICIES AND VARIABLE ANNUITY CONTRACTS – BROKER DEALER IS MONY SECURITIES CORPORATION.

(9)Where the payor has designated remittance amounts pursuant to a billing concept election, premiums shall mean such amounts, as applicable.

(10)In order to effect and administer the EFT/MONYMatic transaction request, MONY may disclose the identity of its customer and his/her policy/contract number to the third party, if any, designated as premium payor. Furthermore, MONY’s customer (typically the policyowner) may become privy at the premium payor’s bank and account number. Copies of MONY’s Privacy Policy For Customers may be obtained at www.mony.com.

Form No. ML-200 (10/2004) Page 2 of 2