[LOGO] PRUDENTIAL APPLICATION FOR LIFE INSURANCE
OR POLICY CHANGE
[ ] The Prudential Insurance Company of America
[X] Pruco Life Insurance Company, A SUBSIDIARY OF
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
PART 1 POLICY NUMBER XX XXX XXX [ ]CHECK HERE IF POLICY CHANGE.
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A ABOUT THE 1. Name of primary proposed insured (OR CURRENT INSURED PERSON, IF
PRIMARY POLICY CHANGE) John Doe
PROPOSED --------------------------------------------------------------
INSURED (FIRST NAME, MIDDLE INITIAL, LAST NAME)
2. Social Security number XXX-XX-XXXX
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3. Sex [ ] female [X] male
4. Marital status [ ] single [X] married [ ] widowed
[ ] separated [ ] divorced
5. Date of birth 3/1/64
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month day year
6. Age 35
--
7. State of birth (COUNTRY IF NOT U.S.) (name of State)
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8. Billing address 123 Main Street, Any City, Any State XXXXX
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(STREET, CITY, STATE, ZIP)
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9. Home address _______________________________________________
(IF DIFFERENT) (STREET, CITY, STATE, ZIP)
_______________________________________________
10. Home telephone number (XXX) XXX-XXXX
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11. Business telephone number (XXX) XXX-XXXX
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12. Current employer ABC Company
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13. List all existing life insurance coverage. [ ] Check here if
none.
Year Type of To be
Company Amount Issued insurance replaced?
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[ ] Individual [ ] Yes
$ [ ] Group [ ] No
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[ ] Individual [ ] Yes
$ [ ] Group [ ] No
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[ ] Individual [ ] Yes
$ [ ] Group [ ] No
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[ ] Individual [ ] Yes
$ [ ] Group [ ] No
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[ ] Individual [ ] Yes
$ [ ] Group [ ] No
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B ALL OTHER Name relationship to primary sex date of birth age state of birth total life insurance
PROPOSED (FIRST, proposed insured (F/M) (M/D/Y) (COUNTRY IF NOT in all companies
INSUREDS INITIAL, LAST) U.S.)
(INCLUDE ___________________________________________________________________________________________________________________
APPLICANT IF ___________________________________________________________________________________________________________________
REQUESTING ___________________________________________________________________________________________________________________
APPLICANT'S ___________________________________________________________________________________________________________________
WAIVER OF ___________________________________________________________________________________________________________________
PREMIUM ___________________________________________________________________________________________________________________
[AWP] ___________________________________________________________________________________________________________________
BENEFIT) ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
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ORD 96200-98
PART 1 APPLICATION FOR LIFE INSURANCE OR POLICY CHANGE
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C COVERAGE 1. Plan of insurance Variable Universal Life
INFORMATION ------------------------------------------
if applicable to the plan, check one. [ ] Level Death Benefit
[X] Variable Death Benefit
2. Initial amount of insurance $100,000
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3. Supplementary benefits and riders
[ ] Waiver of Premium
[ ] Accidental Death Benefit $_________________
[ ] Applicant's Waiver of Premium
[ ] Option to Purchase Additional Insurance (OPAI) $__________
[ ] Automatic Premium Loan
[ ] Option to Purchase Paid-up Life Insurance Additions
(INCLUDE DETAILS IN SECTION G, SPECIAL REQUESTS)
[ ] Acceleration of Death Benefits
(Living Needs Benefit)
Other riders and benefits (INDICATE AMOUNT WHERE APPLICABLE)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
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D BENEFICIARIES 1. BENEFICIARY INFORMATION Relationship to primary
AND Name proposed insured Age
OWNERSHIP --------------------------------------------------
(IF TRUST, Primary Mary Doe Spouse 35
PROVIDE NAME (CLASS 1) --------------------------------------------------
OF TRUST, __________________________________________________
TRUSTEE AND Contingent Robert Doe Son 10
DATE OF (CLASS 2) --------------------------------------------------
TRUST) __________________________________________________
2. Is the policyowner someone other than the primary proposed
insured? [ ] Yes [X] No
(IF YES, PROVIDE INFORMATION REQUESTED BELOW.)
Name __________________________________Date of birth __/__/__
(FIRST NAME, MIDDLE INITIAL, LAST NAME) MONTH DAY YEAR
Address _____________________________________________________
(STREET, CITY, STATE, ZIP)
_____________________________________________________
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E PAYMENT 1a. Within the past 90 days, has any proposed insured been
INFORMATION hospitalized or been advised by a member of the medical
profession that he or she needs hospitalization for any
reason other than for normal pregnancy or well-baby care?
[ ] Yes [X] No
b. Within the past 12 months, has any proposed insured received
treatment or advice from a member of the medical profession
for heart disease, chest pain, stroke or cancer (except
skin)? [ ] Yes [X] No
2. Is a medical examination required on the primary proposed
insured? [ ] Yes [X] No
second proposed insured? [ ] Yes [X] No
3. Premium payment mode (COLLECT FULL MODAL PREMIUM IF PREPAID)
[X] Annual [ ] Semiannual [ ] Quarterly [ ] Monthly
[ ] Electronic Funds Transfer (EFT) [ ] Payroll Budget
[ ] Government Allotment
4. Amount of prepayment submitted with this application
$350.73 (INCLUDE ANY UNSCHEDULED PREMIUM PAYMENTS)
[ ] None (MUST BE NONE IF 1a OR 1b IS YES, EXCEPT FOR
GIBRALTAR [GIB] PRODUCTS)
5. Date prepayment collected, 7/1/99
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MONTH DAY YEAR
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F REPLACEMENT For any proposed insured, would this insurance replace or cause
a change in any existing insurance or annuity in any company?
(IF YES, ENCLOSE ALL REQUIRED REPLACEMENT FORMS.)
[ ] Yes [X] No
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G SPECIAL
REQUESTS
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ORD 96200-98
PART 1 APPLICATION FOR LIFE INSURANCE OR POLICY CHANGE
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H BACKGROUND 1. Has either the primary proposed insured or second proposed
ON PROPOSED insured (if any) ever used tobacco or other nicotine products
INSUREDS such as cigarettes, cigars, pipe, chewing tobacco, snuff,
nicotine gum or nicotine patch? (IF YES, PROVIDE DATE WHEN
LAST USED AND INDICATE ALL TYPES OF PRODUCTS.) [ ] Yes [X] No
DATE (MO., YR.) PRODUCT(S)
Primary proposed insured _______________ __________________
_______________ __________________
Second proposed insured _______________ __________________
_______________ __________________
2. What are the occupation and duties of the primary proposed
insured? Manager & Administrative Duties
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3. Within the last two years, has any proposed insured done or
does he or she plan to do the following:
a. operate or have any duties aboard an aircraft, glider,
balloon or similar device? [ ] Yes [X] No
(IF YES, COMPLETE AVIATION QUESTIONNAIRE.)
b. participate in hazardous sports, such as auto, motorcycle,
snowmobile or powerboat competitions/exhibitions, scuba
diving, mountain climbing, parachuting, skydiving or any
other such sport or hobby? (IF YES, COMPLETE AVOCATION
QUESTIONNAIRE.) [ ] Yes [X] No
4. Is any proposed insured applying for or requesting
reinstatement or policy change(s) of any other life or health
insurance policy? (IF YES, PROVIDE INSURANCE COMPANY, POLICY
PLAN AND AMOUNT.) [ ] Yes [X] No
______________________________________________________________
______________________________________________________________
5. Has any proposed insured been convicted of, or currently
charged with, the commission of any criminal offense - other
than the violation of a motor vehicle law - within the last
10 years? [ ] Yes [X] No
(IF YES, PROVIDE DETAILS.) ___________________________________
______________________________________________________________
6. a. Driver's license number and state of issue of primary
proposed insured _____________________________________________
XXXXX-XXXXX-XXXXX (name of State)
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b. In the last three years, has any proposed insured
(1) had a driver's license denied, suspended or revoked?
[ ] Yes [X] No
(2) been convicted of or cited for
(a) three or more moving violations? [ ] Yes [X] No
(b) driving under the influence of alcohol or drugs?
[ ] Yes [X] No
(3) been involved as a driver in two or more auto
accidents? [ ] Yes [X] No
(IF YES TO ANY OF THE ABOVE, PROVIDE DETAILS, INCLUDING
TYPE OF VIOLATION, ACCIDENT, OR REASON FOR DENIAL,
SUSPENSION OR REVOCATION.) ________________________________
______________________________________________________________
______________________________________________________________
7. Does any proposed insured plan to live or travel outside the
United States or Canada within the next 12 months? (IF YES,
LIST COUNTRIES AND PURPOSE AND DURATION OF EACH TRIP.)
[ ] Yes [X] No
______________________________________________________________
______________________________________________________________
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I ADDITIONAL COMPLETE ONLY IF THIS IS AN APPLICATION FOR ADDITIONAL COVERAGE
COVERAGE ON A PERSON ALREADY COVERED BY A PRUDENTIAL OR PRUCO POLICY WITH
AN APPLICATION DATE WITHIN THREE MONTHS OF THE DATE OF THIS
APPLICATION.
To the best of your knowledge, has the health or the mental or
physical condition of any person proposed for insurance changed
since the answers and statements were given in the application
included in policy number __________? [ ] Yes [ ] No
(IF YES, COMPLETE THE APPROPRIATE PART 2 MEDICAL INFORMATION
SECTION.)
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J CHANGES Changes made by the Company (NOT APPLICABLE IN NEW MEXICO OR WEST
VIRGINIA)
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ORD 96200-98
PART 2 MEDICAL INFORMATION APPLICATION FOR LIFE INSURANCE OR POLICY CHANGE
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K PHYSICIAN PRIMARY PROPOSED INSURED
INFORMATION
PHYSICIAN LAST CONSULTED
Name Dr. William Smith
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Address 23 Main Street
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(STREET, CITY, STATE, ZIP)
Any City, Any State XXXXX
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Telephone number (XXX) XXX-XXXX Date last seen 10-1-97
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Reason last seen Cold
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PRIMARY PHYSICIAN
Name Dr. William Smith
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Address 23 Main Street
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(STREET, CITY, STATE, ZIP)
Any City, Any State XXXXX
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Telephone number (XXX) XXX-XXXX Date last seen 10-1-97
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Reason last seen Cold
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SECOND PROPOSED INSURED OR APPLICANT FOR APPLICANT'S WAIVER OF
PREMIUM (AWP)
PHYSICIAN LAST CONSULTED
Name _________________________________________________________
Address _________________________________________________________
(STREET, CITY, STATE, ZIP)
_________________________________________________________
Telephone number (___)___________ Date last seen ________________
Reason last seen ________________________________________________
PRIMARY PHYSICIAN
Name _________________________________________________________
Address _________________________________________________________
(STREET, CITY, STATE, ZIP)
_________________________________________________________
Telephone number (___)___________ Date last seen ________________
Reason last seen ________________________________________________
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L PHYSICAL Height Weight
MEASUREMENTS -----------------------------------------------------------------
Primary proposed insured 5'11" 180
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Second proposed insured
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AWP applicant
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ORD 96200-98
PART 2 MEDICAL INFORMATION APPLICATION FOR LIFE INSURANCE OR POLICY CHANGE
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M CATEGORY II 1. Family record
CHANGES Current age or Year and cause
AND PLANS age at death of death
OTHER THAN -----------------------------------------------------------------
GIBRALTAR Father 65
(GIB) -----------------------------------------------------------------
Brother 30
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Brother
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Brother
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Current age or Year and cause
age at death of death
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Mother 65
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Sister 25
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Sister
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Sister
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2. Has anyone proposed for coverage been diagnosed with or
treated by a member of the medical profession for
a. chest pain or any disorder of the heart or
blood vessels? [ ] Yes [X] No
b. high blood pressure? [ ] Yes [X] No
c. cancer, tumor, leukemia, melanoma or
lymphoma? [ ] Yes [X] No
d. diabetes or high blood sugar? [ ] Yes [X] No
e. mental or psychiatric illness? [ ] Yes [X] No
f. Acquired Immune Deficiency Syndrome (AIDS)
or AIDS-Related Complex (ARC)? (MAINE: this
question may be answered No if an individual
has tested HIV positive and does not have
symptoms of the disease AIDS such as dry
coughs, skin lesions, weakness, fatigue,
weight loss or loss of appetite.) [ ] Yes [X] No
g. infection caused by the Human
Immunodeficiency Virus (HIV)? (NOT
APPLICABLE IN CALIFORNIA, CONNECTICUT AND
MAINE. WISCONSIN: AIDS virus HIV antibody
testing is limited to FDA-licensed enzyme
immunoassay and confirmatory HIV antibody
tests.) [ ] Yes [X] No
h. any sexually transmitted diseases? [ ] Yes [X] No
i. asthma or any disorder of the lungs? [X] Yes [ ] No
j. any disorder of the brain or nervous system? [ ] Yes [X] No
k. hepatitis or any disorder of the liver,
stomach or intestines? [ ] Yes [X] No
l. any disorder of the kidney or urinary tract? [ ] Yes [X] No
3. Is anyone proposed for coverage currently
taking prescription medication? [ ] Yes [X] No
4. Other than above, has anyone proposed for coverage
a. been a patient in a hospital or other
medical facility? [ ] Yes [X] No
b. in the last five years, had or been advised
to have surgery, medical tests (other than
HIV) or diagnostic procedures such as ECGs,
stress tests, X-rays, blood tests urine
tests, etc.? [ ] Yes [X] No
5. Has anyone proposed for coverage
a. used, or is he or she now using, cocaine,
amphetamines, marijuana, heroin, or other
drugs except as prescribed by a member of
the medical profession? [ ] Yes [X] No
b. had or been advised to have treatment or
counseling for alcohol or drug use? [ ] Yes [X] No
6. Does anyone proposed for coverage have any
disease, disorder or condition not previously
mentioned? [ ] Yes [X] No
7. Has anyone proposed for coverage had life or
health insurance declined, postponed or issued
with an increased premium? (MISSOURI: this
question may be answered No if an individual
has been declined for coverage.) [ ] Yes [X] No
8. Is anyone proposed for coverage currently
unable to perform his or her normal daily
activities or all normal occupational duties on
a full-time basis at the customary place of
employment? [ ] Yes [X] No
9. Has anyone proposed for coverage requested or
received disability or compensation benefits? [ ] Yes [X] No
(CONTINUED ON NEXT PAGE)
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ORD 96200-98
PART 2 MEDICAL INFORMATION APPLICATION FOR LIFE INSURANCE OR POLICY CHANGE
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M CATEGORY II 10. Details of "Yes" answers for questions 2-9
CHANGES Question number Indicate illness, hospitalization,
AND PLANS and name of proposed reason for checkup, medication and any
OTHER THAN insured advice or treatment given by a medical
GIBRALTAR professional
(GIB) -----------------------------------------------------------------
(CONTINUED) 2.i. John Cold
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Dates and Name, address and telephone
duration number of medical
of illness professionals and hospitals
10/97 Dr. Wm. Smith
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23 Main Street
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Any City, Any State
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XXXXX
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For additional medical details, use another application.
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ORD 96200-98
TERMS AND CONDITIONS
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The words "I" and "my" refer to the primary proposed insured and
policyowner or applicant, if other than the primary proposed insured. The
word "Company" refers to the company checked at the beginning of this
application.
Unless I have specified a policy date or special payment plan (e.g.,
government allotment, payroll budget) in this application, I understand
that if the initial premium is not paid with this request for coverage,
the policy will become effective when all of the following conditions are
met:
o the policy is issued, delivered and I accept it,
o the health of all persons proposed for insurance remains as stated in
the application and
o the first premium is paid in full and the check or other form of
payment is good and can be collected.
If the Company enters any change in section J, I approve the change by
accepting the policy unless the law requires written consent to changes.
No Company representative can make or change a policy, or waive any of the
Company's rights or requirements.
The Company will pay the beneficiary named in the application (or in the
policy if requesting a policy change and no beneficiary has been named in
the application) any applicable insurance benefit either at the death of
the primary insured or at the death of an insured child after the death of
the primary insured if there is no insured spouse.
For policy changes, the existing policyowner and beneficiary designation
will be used unless a new policyowner or beneficiary designation is
provided in this application.
The policyowner is either the primary proposed insured or the applicant
unless a different policyowner is named in the application. This is
subject to any provisions for the automatic transfer of ownership stated
in the policy.
If joint policyowners are named, in the event of the death of one
policyowner, the survivor(s) shall be the policyowner(s), unless otherwise
specified.
SIGNATURES
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I certify, affirm and understand the following:
o To the best of my knowledge and belief, the statements in this
application, as well as any forms that the Company designates to be
part of the application and that are attached to the policy, are
complete, true and correctly recorded.
o Except for failure to pay premium or fraud, the Company will not
contest the validity of this policy or change request after it has been
in force during the insured's lifetime for two years from the date it
takes effect.
o I will inform the Company of any changes in my or any proposed
insured's health, mental or physical condition, or of any changes to
any answers on this application, prior to or upon delivery of this
policy.
o If I have requested the Acceleration of Death Benefits (Living Needs
Benefit), I have read the disclosures in the brochure (ORD 87246).
o I have received and read the Terms and Conditions shown above and the
Important Notice About Your Application for Insurance.
o I believe this policy meets my insurance needs and financial
objectives. For a variable product: I acknowledge receipt of a current
prospectus for the policy. I understand that the policy's value and
death benefit may vary depending on the policy's investment experience.
o My original signature has been affixed to this application, the
original application will be retained by the Company and I will receive
a copy identical in form and substance to the original, attached to my
policy.
(CONTINUED ON NEXT PAGE)
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ORD 96200-98
SIGNATURES (CONTINUED)
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o NOT APPLICABLE IN ARIZONA, OREGON, AND VERMONT:
ANY PERSON WHO KNOWINGLY AND INTENTIONALLY GIVES FALSE OR DECEPTIVE
INFORMATION WHEN COMPLETING AN APPLICATION FOR INSURANCE OR FILING A
CLAIM, FOR THE PURPOSE OF DEFRAUDING AN INSURANCE COMPANY:
o may have committed fraud, or may have violated state law.
o ARKANSAS, HAWAII, MAINE and NEW MEXICO: may be subject to fines,
denial of insurance benefits, or confinement in prison,
o COLORADO: penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for
the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory
Agencies.
Signed at (Name or City, State) on 7/1/99
-------------------------------------- ----------
(CITY, STATE) MONTH DAY YEAR
SIGNATURE OF PRIMARY PROPOSED INSURED, IF AGE 8 OR OVER,
OR OF CURRENTLY INSURED PERSON, IF POLICY CHANGE X /s/ JOHN DOE
------------------------
SIGNATURE OF SPOUSE (APPLICABLE IN SOUTH CAROLINA,
IF PROPOSED FOR COVERAGE.) X
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SIGNATURE OF POLICYOWNER (IF DIFFERENT FROM THE
PRIMARY PROPOSED INSURED) OR OF EXISTING POLICYOWNER
IF A POLICY CHANGE. IF THE POLICY OWNER IS A FIRM OR
CORPORATION, GIVE THAT COMPANY'S NAME AND HAVE AN
OFFICER SIGN BELOW. X
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SIGNATURE AND TITLE OF OFFICER OF FIRM OR CORPORATION X
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SIGNATURE OF APPLICANT, IF DIFFERENT FROM PRIMARY
PROPOSED INSURED OR POLICYOWNER X
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SIGNATURE OF BENEFICIARY, IF POLICY CHANGE AND RIGHTS
ARE LIMITED X
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SIGNATURE OF WITNESS
(LICENSED WRITING REPRESENTATIVE MUST WITNESS.) X /s/ RICHARD ROE
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LICENSED WRITING REPRESENTATIVE'S CERTIFICATION
Do you have any information, other than that stated in this application, which
indicates that any proposed insured may replace or change any current insurance
or annuity in any company? [ ] Yes [ ] No
SIGNATURE OF WRITING REPRESENTATIVE X /s/ RICHARD ROE
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ORD 96200-98