PRUCO LIFE INSURANCE COMPANY, STRATEGIC PARTNERS(SM) FLEX ELITE
a Prudential Financial company VARIABLE ANNUITY APPLICATION
Flexible Payment Variable Deferred Annuity
ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THE CONTRACT ARE VARIABLE
AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
On these pages, I, you, and your refer to the contract owner. We, us, and our
refer to Pruco Life Insurance Company.
1 CONTRACT OWNER INFORMATION
Contract number (if any)
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[ ] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other
TRUST: [ ] Grantor [ ] Revocable [ ] Irrevocable
TRUST DATE (mo., day, yr.)
---- ---- --------
If a corporation or trust is indicated above, please check the following as it
applies. If neither box is checked, we will provide annual tax reporting for the
increasing value of the contract.
[ ] Tax-exempt entity under Internal Revenue Code 501
[ ] Trust acting as agent for an individual under Internal Revenue Code 72(u)
Name of owner (first, middle initial, last name)
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Street Apt.
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City State ZIP code
- ------------------------------------------- ---- ---------- ------
Social Security number/EIN Date of birth (mo., day, year) Telephone number
- -------------------------- ---- ---- -------- ---- ---- --------
A. [ ] Female B. [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. person (including resident alien). I am a citizen of
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Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY).
2 JOINT OWNER INFORMATION (if any) Do not complete if you are opening an IRA.
Unmarried persons who wish to own the contract jointly should consult with their
tax adviser.
Name of joint owner, if any (first, middle initial, last name)
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Street (Leave address blank if same as owner.) Apt.
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City State ZIP code
- ------------------------------------------- ---- ---------- ------
Social Security number/EIN Date of birth (mo., day, year) Telephone number
- -------------------------- ---- ---- -------- ---- ---- --------
A. [ ] Female B. [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. person (including resident alien). I am a citizen of
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3 ANNUITANT INFORMATION Do not complete if you are opening an IRA.
This section must be completed only if the annuitant is not the owner or if the
owner is a trust or a corporation.
Name of annuitant (first, middle initial, last name)
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Street (Leave address blank if same as owner.) Apt.
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(continued)
Pruco Corporate Office:
Pruco Life Insurance Company, Phoenix, AZ 85014 0RD99723 Ed. 1/2004
ORD 99723 FlexElite Kit order no: ORD01163
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3 ANNUITANT INFORMATION (continued)
City State ZIP code
- ------------------------------------------- ---- ---------- ------
Social Security number Date of birth (mo., day, year) Telephone number
- -------------------------- ---- ---- -------- ---- ---- --------
A. [ ] Female B. [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. person (including resident alien). I am a citizen of
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4 CO-ANNUITANT INFORMATION (if any) Do not complete if you are opening an IRA or
if the contract will be owned by a corporation or trust.
Name of co-annuitant (first, middle initial, last name)
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Social Security number Date of birth (mo., day, year) Telephone number
- -------------------------- ---- ---- -------- ---- ---- --------
A. [ ] Female B. [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. person (including resident alien). I am a citizen of
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5 BENEFICIARY INFORMATION Please add additional beneficiaries in section 15.
[X] PRIMARY CLASS
Name of beneficiary (first, middle initial, last name) If trust, include name of
trust and trustee's name.
- --------------------------------------------------------------------------------
TRUST: [ ] Revocable [ ] Irrevocable
Trust date (mo., day, yr.)
---- ---- --------
Beneficiary's relationship to owner
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Social Security number
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CHECK ONLY ONE: [ ] Primary class [ ] Secondary class
Name of beneficiary (first, middle initial, last name) If trust, include name of
trust and trustee's name.
TRUST: [ ] Revocable [ ] Irrevocable
Trust date (mo., day, yr.)
---- ---- --------
Beneficiary's relationship to owner
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Social Security number
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6 ELECTION OF BENEFITS
This section contains various options available under your annuity contract. You
can choose any of the following benefits: (1) a Death Benefit; (2) the Earnings
Appreciator Benefit; (3) the Guaranteed Minimum Income Benefit; and (4) the
Income Appreciator Benefit. Prior to electing any of these benefits, you should
review the prospectus for a complete explanation of the features and their
costs.
A. Check one of the following four death benefit options:
[ ] Base Death Benefit
[ ] Guaranteed Minimum Death Benefit (GMDB) with a Roll-Up option
[ ] GMDB with an annual Step-Up option
[ ] GMDB with a Roll-Up and an annual Step-Up option
Indicate below if you want to elect the Earnings Appreciator supplemental
death benefit. ONCE ELECTED IN ND, THIS BENEFIT CANNOT BE REVOKED.
[ ] Yes, I would like to elect the Earnings Appreciator Benefit.
B. Check all that apply. ONCE ELECTED, THE GUARANTEED MINIMUM INCOME BENEFIT
(GMIB) CANNOT BE REVOKED.
[ ] Yes, I would like to elect the GMIB. THIS OPTION IS NOT AVAILABLE IN ND
AND OR.
[ ] Yes, I would like to elect the Income Appreciator Benefit.
ORD 99723 Page 2 of 7 Ed.1/2004
7 TYPE OF PLAN AND SOURCE OF FUNDS (minimum of $10,000)
PLAN TYPE.
Check only one: [ ] Non-qualified [ ] Traditional IRA [ ] Roth IRA/Custodial
[ ] Custodial account (PSI only)
SOURCE OF FUNDS. Check all that apply:
[ ] Total amount of the check(s) included with this
application. (Make checks payable to Prudential.) $ , , .
---- ---- ---- ----
[ ] IRA Rollover $ , , .
---- ---- ---- ----
If Traditional IRA or Roth IRA new contribution(s) for the current and/or
previous year, complete the following:
$ , . Year $ , . Year
---- -------- ---- -------- ---- -------- ---- --------
[ ] 1035 Exchange (non-qualified only),
estimated amount: $ , , .
---- ---- ---- ----
[ ] IRA Transfer (qualified), estimated amount: $ , , .
---- ---- ---- ----
[ ] Direct Rollover (qualified), estimated amount: $ , , .
---- ---- ---- ----
[ ] Roth Conversion IRA, establishment date:*
---- ---- --------
month day year
* This is the date you originally converted from a traditional IRA to a Roth
Conversion IRA. (If omitted, the current tax year will be used.) This is
required for the IRA five-tax year, holding period requirement.
A CONVERSION FROM A TRADITIONAL IRA TO A ROTH CONVERSION IRA WILL RESULT IN A
TAXABLE EVENT WHICH WILL BE REPORTED TO THE INTERNAL REVENUE SERVICE.
8 PURCHASE PAYMENT ALLOCATION(S)
Please write in the percentage of your payment that you want to allocate to the
following options. The total must equal 100 percent. IF CHANGES ARE MADE TO THE
ALLOCATIONS LISTED BELOW, THE APPLICANT MUST INITIAL THE CHANGES.
OPTION OPTION
INTEREST RATE OPTIONS CODES % VARIABLE INVESTMENT OPTIONS (continued) CODES %
- --------------------- ------ --- --------------------------------------- ------ ---
1 Year Fixed-Rate Option 1YRFXD SP AIM Aggressive Growth Portfolio AIMAG
Dollar Cost Averaging (DCA) 6 Month* DCA6 SP AIM Core Equity Portfolio AIMCEP
Dollar Cost Averaging (DCA) 12 Month* DCA12 SP Alliance Large Cap Growth Portfolio LARCP
2 Year Market Value Adjustment Option** 2YRMVA SP Technology Portfolio ALLTC
3 Year Market Value Adjustment Option** 3YRMVA SP Balanced Asset Allocation Portfolio BALAN
4 Year Market Value Adjustment Option** 4YRMVA SP Conservative Asset Allocation Portfolio CONSB
5 Year Market Value Adjustment Option** 5YRMVA SP Davis Value Portfolio VALUE
6 Year Market Value Adjustment Option** 6YRMVA SP Deutsche International Equity Portfolio DEUEQ
7 Year Market Value Adjustment Option** 7YRMVA SP Growth Asset Allocation Portfolio GRWAL
8 Year Market Value Adjustment Option** 8YRMVA SP INVESCO Small Company Growth Portfolio VIFSG
9 Year Market Value Adjustment Option** 9YRMVA SP Jennison International Growth Portfolio JENIN
10 Year Market Value Adjustment Option** 10YMVA SP Large Cap Value Portfolio LRCAP
VARIABLE INVESTMENT OPTIONS SP MFS Capital Opportunities Portfolio MFSCO
Prudential Equity Portfolio STOCK SP Mid Cap Growth Portfolio MFSMC
Prudential Global Portfolio GLEQ SP PIMCO High Yield Portfolio HIHLD
Prudential Jennison Portfolio GROWTH SP PIMCO Total Return Portfolio RETRN
Prudential Money Market Portfolio MMKT SP Prudential U.S. Emerging Growth Portfolio EMRGW
Prudential Stock Index Portfolio STIX SP Goldman Sachs Small Cap Value Portfolio SMDVL
Prudential Value Portfolio HIDV SP Strategic Partners Focus Growth Portfolio STRPR
SP Aggressive Growth Asset Janus Aspen Series Growth Portfolio-
Allocation Portfolio AGGGW Service Shares JANSR
TOTAL 100%
*THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $2,000.
**THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $1,000.
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9 DOLLAR COST AVERAGING PROGRAM
If you elect to use more than one Dollar Cost Averaging option, you must also
complete a Request for Dollar Cost Averaging Enrollment or Change form (ORD
78275).
[ ] DOLLAR COST AVERAGING: I authorize Prudential to automatically transfer
funds as indicated below.
TRANSFER FROM: (You cannot transfer from the 1 Year Fixed-Rate Option or any
of the Market Value Adjustment options.)
*If you selected the DCA6 or DCA12 option in section 8, only complete the
TRANSFER TO information.
Option code: $ , , . OR %
--------------- ---- ------ ------ ---- ------
TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly
TRANSFER TO: (You cannot transfer to the DCA Interest Rate options or any of
the Market Value Adjustment options.) The total of the two columns must
equal 100 percent.
OPTION CODE PERCENT OPTION CODE PERCENT
% %
------------------ ------ ------------------ ------
% %
------------------ ------ ------------------ ------
% %
------------------ ------ ------------------ ------
10 AUTO-REBALANCING
[ ] AUTO-REBALANCING: I want to maintain my allocation percentages. Please have
my portfolio mix automatically adjusted as allocated in section 8 under my
variable investment options.
Adjust my portfolio: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly
Please specify the start date if different than the
contract date:
---- ---- --------
month day year
11 TELEPHONE TRANSFERS
We will accept your transfers and reallocations over the telephone. Please
indicate below if you wish to extend authority as follows.
[ ] I authorize Prudential to accept telephone transfers and reallocation
instructions from my Registered Investment Adviser.
12 REPLACEMENT QUESTIONS AND DISCLOSURE STATEMENT
YOU MUST CHECK ONE OF THE FOLLOWING TWO CHECK BOXES.
[ ] I do have existing life insurance policies or annuity contracts. (FOR STATES
THAT HAVE ADOPTED THE NEW NAIC REGULATIONS *: The Important Notice Regarding
Replacement form (COMB 89216) must be completed even if your new annuity is
not replacing an existing policy or contract.)
* Note: See the state replacement highlighter for applicable states or the
attached list of state product restrictions.
[ ] I do not have existing life insurance policies or annuity contracts.
WILL THE PROPOSED ANNUITY CONTRACT REPLACE ANY EXISTING INSURANCE POLICY(IES) OR
ANNUITY CONTRACT(S)?
[ ] Yes [ ] No (If "Yes," provide the following information for each policy or
contract and attach all applicable Prudential disclosure and
state replacement forms.)
Company name
- --------------------------------------------------------------------------------
Policy or contract number Year of issue (mo., day, year)
- ------------------------- ---- ---- --------
Name of plan (if applicable)
- ----------------------------
FOR VIRGINIA ONLY:
X
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Contract owner's signature and date month day year
REPRESENTATIVE'S QUESTION
THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE.
Do you have, from any source, facts that any person named as the owner or joint
owner above is replacing or changing any current insurance or annuity in any
company?
[ ] Yes [ ] No (You must check "Yes" if the customer has responded "Yes" to the
replacement question above. If "Yes," please provide details in
section 15, ADDITIONAL REMARKS.)
FOR VIRGINIA ONLY:
X
------------------------------------------------ ---- ---- --------
Representative's signature and date month day year
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13 SIGNATURE(S)
If applying for an IRA or Roth IRA, I acknowledge receiving an IRA disclosure
statement and understand that I will be given a financial disclosure statement
with the contract. I understand that tax deferral is provided by the IRA, and
acknowledge that I am purchasing this contract for its features other than tax
deferral, including the lifetime income payout option, the Death Benefit
protection, the ability to transfer among investment options without sales or
withdrawal charges, and other features as described in the prospectus.
No representative has the authority to make or change a contract or waive any of
the contract rights.
I understand that if I have purchased another non-qualified annuity from
Prudential or an affiliated company this calendar year that they will be
considered as one contract for tax purposes.
I believe that this contract meets my needs and financial objectives.
Furthermore, I (1) understand that any amount of purchase payments allocated to
a variable investment option will reflect the investment experience of that
option and, therefore, annuity payments and surrender values may vary and are
not guaranteed as to a fixed dollar amount, and (2) acknowledge receipt of the
current prospectus for this contract and the variable investment options.
[ ] If this contract has a joint owner, please check this box to authorize
Prudential to act on the instruction(s) of either the owner or joint owner
with regard to transactions under the contract.
[ ] If this application is being signed at the time the contract is delivered, I
acknowledge receipt of the contract.
[ ] Check here to request a Statement of Additional Information.
MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE REQUIRED MINIMUM
DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE PAID TO PRUDENTIAL:
I understand it is my responsibility to remove the minimum distribution from the
purchase payment PRIOR TO sending money to Prudential with this application.
Unless we are notified otherwise, Prudential will assume that the owner has
satisfied their required minimum distributions from other IRA funds.
By signing this form, the trustee(s)/officer(s) hereby represents that the
trustee(s)/officer(s) possess(es) the authority, on behalf of the non-natural
person, to purchase the annuity contract and to exercise all rights of ownership
and control over the contract, including the right to make purchase payments to
the contract.
We must have both the owner's and annuitant's signatures even if this contract
is owned by a trust, corporation, or other entity. If the annuitant is a minor,
please provide the signature of a legal guardian or custodian.
THOSE AMOUNTS ALLOCATED TO ANY MVA OPTION WILL BE SUBJECT TO A MARKET VALUE
ADJUSTMENT IF WITHDRAWN OR TRANSFERRED AT ANY TIME OTHER THAN DURING THE 30-DAY
PERIOD FOLLOWING THE INTEREST CELL'S MATURITY. A MARKET VALUE ADJUSTMENT CAN BE
A POSITIVE OR NEGATIVE ADJUSTMENT. THERE IS NO MARKET VALUE ADJUSTMENT AT DEATH.
I hereby represent that my answers to the questions on this application are
correct and true to the best of my knowledge and belief. I have read the
applicable fraud warning for my state listed in section 17. ALL PAYMENTS AND
VALUES PROVIDED BY THE CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE
VARIABLE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. I
acknowledge receipt of current product and fund prospectuses.
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SIGNED AT (CITY, STATE)
X
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Contract owner's signature and date month day year
X
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Joint owner's signature (if applicable) and date month day year
X
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Annuitant's signature (if applicable) and date month day year
X
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Co-annuitant's signature (if applicable) and date month day year
OWNER'S TAX CERTIFICATION
Under penalty of perjury, I certify that the taxpayer identification number
(TIN) I have listed on this form is my correct TIN. I further certify that the
citizenship/residency status I have listed on this form is my correct
citizenship/residency status. I [ ] HAVE [ ] HAVE NOT (check one) been notified
by the Internal Revenue Service that I am subject to backup withholding due to
underreporting of interest or dividends.
X
------------------------------------------------------ ---- ---- --------
Contract owner's signature and date month day year
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14 REPRESENTATIVE'S SIGNATURE(S)
This application is submitted in the belief that the purchase of this contract
is appropriate for the applicant based on the information provided and as
reviewed with the applicant. Reasonable inquiry has been made of the owner
concerning the owner's overall financial situation, needs, and investment
objectives.
The representative hereby certifies that all information contained in this
application is true to the best of his or her knowledge.
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Representative's name (Please print) Rep's contract/FA number
X
--------------------------------------------------- ---- ---- --------
Representative's signature and date month day year
--------------------------------------------------- ---------------------
Second representative's name (Please print) Rep's contract/FA number
X
--------------------------------------------------- ---- ---- --------
Second representative's signature and date month day year
- ----------------------------------------------------
Branch/field office name and code
- ----- ----- --------
Representative's telephone number
15 ADDITIONAL REMARKS
ANY REMARKS ENTERED INTO THIS SECTION MUST BE INITIALED AND DATED BY ALL PERSONS
WHO HAVE SIGNED THIS APPLICATION IN SECTIONS 13 AND 14.
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17 FRAUD WARNINGS
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. 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 policy holder or claimant for the purpose of defrauding or
attempting to defraud the policy holder 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.
CONNECTICUT: Any person who knowingly gives false or deceptive information when
completing this form for the purpose of defrauding the company may be guilty of
insurance fraud. This is to be determined by a court of competent jurisdiction.
NEW JERSEY: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to civil fines
and criminal penalties.
OKLAHOMA: WARNING -- Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an insurance
policy containing any false, incomplete or misleading information is guilty of a
felony.
PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim
containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
VIRGINIA: Any person who, with the intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
ALL OTHER STATES: Any person who knowingly gives false or deceptive information
when completing this form for the purpose of defrauding the company may be
guilty of insurance fraud.
STANDARD PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: PO BOX 7590
PHILADELPHIA, PA 19101
OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: 2101 WELSH ROAD
DRESHER, PA 19025
If you have any questions, please call the Prudential Annuity Service Center at
(888) 778-2888, Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern
time.
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