EXHIBIT 1.A(5)(a)
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
GROUP INSURANCE CONTRACT
CONTRACT HOLDER: [PRUDENTIAL GROUP LIFE INSURANCE TRUST]
GROUP CONTRACT NO.: [GV-XXXXX]
Prudential will provide or pay the benefits described in the Group Insurance
Certificate(s) listed in the Schedule of Plans of the Group Contract, subject to
the Group Contract's terms. This promise is based on the Contract Holder's
application and payment of the required premiums.
All of the provisions of the Group Insurance Certificate(s), attached to and
made a part of the Group Contract, apply to the Group Contract as if fully set
forth in the Group Contract.
The Group Contract takes effect on the Contract Date, if it is duly attested
under the Group Contract Schedule. It continues as long as the required premiums
are paid, unless it ends as described in its General Rules.
The Group Contract is delivered in and is governed by the laws of the Governing
Jurisdiction.
[Secretary Chairman]
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GROUP CONTRACT SCHEDULE
CONTRACT DATE: [January 1, 19XX]
CONTRACT ANNIVERSARIES: [January 1 of each year, beginning in 19XX]
PREMIUM DUE DATES: [The Contract Date, and the first day of the month beginning
with February, 19XX]
Governing Jurisdiction: [State of Delaware]
[MINIMUM AGGREGATE FACE AMOUNT OF INSURANCE UNDER THE GROUP CONTRACT: $XXX,XXX
MINIMUM NUMBER OF CERTIFICATES IN FORCE UNDER THE GROUP CONTRACT: 25]
[INCLUDED EMPLOYERS
Each employer listed below has met the Rules for Inclusion and is an Included
Employer under the Group Contract as of the Inclusion Date shown below.
For the purpose of the Group Contract, an Employee will be considered an
Employee of only one subsidiary or affiliate of an Included Employer. That
Employee's service with any other subsidiary or affiliate of an Included
Employer will be treated as service with that one.
RULES FOR INCLUSION: The employer must:
(1) make a written request to Prudential to be included under the Group
Contract; and
(2) agree in writing to make required payments to the Contract Holder for the
insurance; and
(3) be approved by Prudential for inclusion under the Group Contract.
INCLUSION DATE: The date on which Prudential approves the Employer for
inclusion. But, if Prudential approves the Employer for inclusion before the
Contract Date, it is the Contract Date.]
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LIST OF INCLUDED EMPLOYERS
INCLUDED EMPLOYER INCLUSION DATE ANNIVERSARY DATE
[The A.B.C. Company January 1, 19XX January 1 of each year,
and these subsidiaries beginning in 19XX
or affiliates:
The U.V.W. Company
The X.Y.Z. Company
The D.E.F. Company January 1, 19XX January 1 of each year,
beginning in 19XX
The G.H.I. Company January 1, 19XX January 1 of each year,
beginning in 19XX]
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TABLE OF CONTENTS [(AS OF CONTRACT DATE): The Group Contract includes these
forms with an 89759 prefix: COV 10XX, GCS 10XX, SPR 10XX, GR 10XX, SCH 10XX, APP
10XX].
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Attest: ____________________________
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SCHEDULE OF PREMIUM RATES [#1]
[GV-XXXXX]
CLASSES OF [EMPLOYEES] TO WHICH THIS SCHEDULE APPLIES:
[All Employees of The A.B.C. Company]
[MONTHLY RATE PER EMPLOYEE]
[APPLICABLE COVERAGE EMPLOYEE INSURANCE DEPENDENTS INSURANCE
VARIABLE UNIVERSAL LIFE xxx% of the 1980 xxx% of the 1980
COVERAGE Commissioners Standard Commissioners Standard
Ordinary Mortality Table Ordinary Mortality Table
(Male - Age Last Birthday) (Male - Age Last Birthday)
per $1,000 of Face Amount per $1,000 of Face Amount
of Insurance by Attained of Insurance by Attained
Age* Age*
Additional Provisions for
Accidental Death and
Dismemberment Coverage $X.XX per $1,000 of $X.XX per $1,000 of
insurance insurance
Additional Provisions for
Motor Vehicle Accident Death
Coverage $Y.YY per $1,000 of $Y.YY per $1,000 of
insurance insurance
Additional Provisions for
Dependents Term Life Coverage $Z.ZZ
*In no event will the monthly rate be higher than 150% of the applicable amount
under the 1980 Commissioners Standard Ordinary Mortality Table (Male - Age Last
Birthday).
With respect to Premium Rate Changes for the Classes of Employees shown above,
Prudential will not make the changes permitted on a Premium Due Date for the
Variable Universal Life Coverage and any of the additional provisions that may
be a part of the Variable Universal Life Coverage before the end of the 12-month
period following the Included Employer's Inclusion Date.]
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GENERAL RULES
A. PAYMENT OF PREMIUMS - GRACE PERIOD.
Premiums are to be paid by the Contract Holder to Prudential. Each may be paid
at [the Prudential Office listed below] or to one of its authorized agents. For
each Included Employer, the first premium is due and payable on that Included
Employer's Inclusion Date. Subsequent premiums are due on each Premium Due Date
stated in the Group Contract Schedule. For each Included Employer, the Contract
Holder may pay each premium, other than the first, within [61] days of the
Premium Due Date without being charged interest. Those days are known as the
grace period. The Contract Holder is liable to pay premiums to Prudential for
each Included Employer for the time the Group Contract is in force for that
Included Employer.
[All notices and payments to Prudential under this Group Contract will be
deemed received when they are received at the following address:
The Prudential Insurance Company of America
00 Xxxxxxxxxx Xxx.
Roseland, New Jersey 07068]
B. PREMIUM AMOUNTS.
The premium due for an Included Employer on that Included Employer's Inclusion
Date is the sum of the contribution amounts made by the Included Employer's
Employees for Covered Persons under the Insurance. Those amounts are determined
from the premium rates then in effect, contributions permitted under the
Insurance and the [Employees] then insured. [If an employer becomes an Included
Employer on a date other than a Premium Due Date of the Group Contract, the
premium amounts will be pro rated for the number of days from the Inclusion Date
to the next Premium Due Date.]
C. CHANGES IN PREMIUM RATE, CHARGES AND INVESTMENT OPTIONS.
The premium rates, which include the Cost of Insurance [for the Variable
Universal Life Coverage and any of the additional provisions that may be a part
of the Variable Universal Life Coverage] in effect on an Included Employer's
Inclusion Date are shown in the Group Contract. The mortality and expense risk
charges and the Schedule of Charges and Expenses in effect on an Included
Employer's Inclusion Date, and the investment options available to an Included
Employer's Employees, are shown in the Certificate applicable to the Covered
Classes. Prudential has the right to make the following changes:
(1) Prudential may change the premium rates, which include the Cost of
Insurance [for the Variable Universal Life Coverage and any of the
additional provisions that may be a part of the Variable Universal Life
Coverage,] the mortality and expense risk charges and the Schedule of
Charges and Expenses, as of the following dates:
(a) any Premium Due Date; and
(b) any date that an employer becomes or ceases to be an Included
Employer; and
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(c) any date that the extent or nature of the risk under the Group
Contract is changed: (i) by amendment; or (ii) by reason of any
provision of law or any governmental program or regulation[; or (iii)
upon the determination, by Prudential, that the number of Certificates
in force with respect to an Included Employer at the beginning of a
month varies (positively or negatively) from the number of
Certificates in force with respect to that Included Employer as of the
beginning of the previous month by more than 10% or (iv) upon the
determination, by Prudential, that the aggregate Face Amount of
Insurance in force with respect to an Included Employer at the
beginning of a month varies (positively or negatively) from the
aggregate Face Amount of Insurance in force with respect to that
Included Employer as of the beginning of the previous month by more
than 10%.]
Unless an Included Employer's Schedule of Premium Rates or an amendment to
the Group Contract applicable to an Included Employer states otherwise,
Prudential will not make the changes permitted on a Premium Due Date before
the end of the 12-month period following the Included Employer's Inclusion
Date.
(2) Prudential may change any of the limits that apply to charges. These
changes may apply to contributions to investment options made both before
and after the change takes effect. With respect to each Included Employer,
the changes must be at least 90 days apart. Before Prudential makes any of
these changes, it will give the Included Employer at least 90 days advance
notice.
The variable investment options to which an Employee may make contribution
allocations is limited to the variable investment options chosen by that
Employee's Included Employer. The variable investment options which may be
chosen by an Included Employer include only those made available to the Included
Employer by Prudential. [An Included Employer may choose no more than 20
variable investment options and, once chosen, may not make any substitutions.
Selection of and changes to an Included Employer's variable investment options
may only be made in a manner and at times acceptable to Prudential.]
D. DIVIDENDS.
Prudential will determine the share, if any, of its divisible surplus allocable
to this Group Contract [with respect to each Included Employer] as of the
anniversary of each [Included Employer's Inclusion Date], if the Group Contract
stays in force by the payment of all required premiums to that date. The share
will be credited to this Group Contract as a dividend as of that date. If [an
Employer ceases to be an Included Employer] on a date other than [an anniversary
of that Included Employer's Inclusion Date,] the share, if any, will be
determined and credited to this Group Contract as of that date.
Each dividend will be paid to the Contract Holder in cash, unless the Contract
Holder asks that it be applied toward the premium then due.
Prudential's sole liability as to any dividend is as set forth above.
NON-PROFIT CLAUSE: This applies if the aggregate dividends under this Group
Contract and any other group contract(s) of the Contract Holder exceed the
aggregate payments toward their cost made from the [Included Employer's] own
funds. The Contract Holder will see that an amount equal to the excess is
applied for the benefit of insured persons.
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E. END OF THE GROUP CONTRACT OR OF AN INSURANCE FOR AN INCLUDED EMPLOYER.
DURING OR AT END OF GRACE PERIOD - FAILURE TO PAY EMPLOYER PAYMENT: If any
Employer payment required by the Contract Holder with respect to any premium due
for that Included Employer is not paid by the end of its grace period, this
Group Contract will end with respect to that Included Employer [when that period
ends.] But, the Included Employer may write to the Contract Holder, at least [90
days] in advance, to ask that the Group Contract be ended for that Included
Employer at the end of a period of time for which premiums have been paid. Then
this Group Contract for that Included Employer will end on the date requested.
[ON A PREMIUM DUE DATE - FAILURE TO MAINTAIN INSURING CONDITIONS: On any Premium
Due Date, Prudential may end the Group Contract if: (a) the number of
Certificates in force under the Group Contract falls below the minimum set forth
in the Group Contract Schedule; or (b) the aggregate Face Amount of Insurance
under the Group Contract falls below the minimum set forth in the Group Contract
Schedule. To do so, Prudential must give the Contract Holder and each Included
Employer notice at least 90 days in advance.]
[CEASING TO BE AN INCLUDED EMPLOYER: An employer may cease to be an Included
Employer because the Included Employer no longer meets the rules for inclusion
or for any other reason. Prudential may end an Included Employer's participation
in the Group Contract: (a) upon its determination that the number of
Certificates in force under the Group Contract with respect to that Included
Employer falls below 25; or (b) upon its determination that the aggregate Face
Amount of Insurance in force with respect to an Included Employer falls below
$X,XXX,XXX.XX. If this happens, the Group Contract will end for Employees of
that Included Employer at the end of the period for which premiums have been
paid with respect to Employees of that Included Employer. But the Group Contract
may permit coverage for such Employees to be continued subject to certain
rules.]
[ON A CONTRACT ANNIVERSARY: Prudential may end the Group Contract on any
Contract Anniversary. But notice of its intent to do so must be given to the
Contract Holder and to each Included Employer at least 31 days in advance.]
F. [EMPLOYEE'S] CERTIFICATE.
Prudential will give [each Included Employer] individual certificate(s) [to be
given to each insured Employee]. The certificate will describe the extent of the
[Employee's Insurance and Dependents Insurance] under this Group Contract. It
will include (1) to whom Prudential pays benefits, (2) any protection and rights
when insurance ends, and (3) claim rights and requirements.
G. RECORDS - INFORMATION TO BE FURNISHED.
[The Contract Holder, each Included Employer] or Prudential, as they agree, will
keep a record of the [Employees] covered under the insurance. It will contain
the key facts about their insurance.
At the times set by Prudential, [the Contract Holder or each Included Employer]
will send the data required by Prudential to perform its duties under the Group
Contract, and to determine the premium rates [and charges due.] All records of
[the Contract Holder and each Included Employer] which bear on the insurance
must be open to Prudential for its inspection at any reasonable time.
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Prudential will not have to perform any duty that depends on such data before it
is received in a form that satisfies Prudential. [The Contract Holder or the
Included Employer] may correct wrong data given to Prudential, if Prudential has
not been harmed by acting on it. A person's insurance will not be made invalid
by failure of [the Contract Holder or the Included Employer], due to clerical
error, to record or report the person for that insurance.
H. THE CONTRACT - INCONTESTABILITY OF THE CONTRACT.
The entire Group Contract consists of: (1) the forms shown in the Table of
Contents as of the Contract Date; (2) the Group Insurance Certificate(s) listed
in the Schedule of Plans, a copy of which is attached to the Group Contract; (3)
all modifications and endorsements to such Group Insurance Certificates which
are attached to and made a part of the Group Contract by amendment to the Group
Contract; (4) the [Contract Holder's] application, a copy of which is attached
to the Group Contract; (5) any amendments or endorsements to the Group Contract;
and (6) the individual applications, if any, of the persons insured. No
statement of the Contract Holder will be used in any contest of the insurance
under the Group Contract.
There will be no contest of the validity of the Group Contract, except for not
paying premiums, after it has been in force for one year.
The Group Contract may be amended, at any time, without the consent of the
insured [Employees] or of anyone else with a beneficial interest in it. This can
be done through a written request made by the Contract Holder and agreed to by
Prudential. But an amendment will not affect a claim incurred before the date of
change.
Only an officer of Prudential has authority: to waive any conditions or
restrictions of the Group Contract; or to extend the time in which charges may
be paid; or to make or change a contract; or to bind Prudential by a promise or
representation; or by information given or received. A Prudential agent is not
an officer.
No change in this Group Contract is valid unless shown in:
(1) an endorsement on it signed by an officer of Prudential; or
(2) an amendment to it signed by the Contract Holder and by an officer of
Prudential.
[But if the Group Contract is changed automatically as provided in Section I,
the change may be made in an amendment to the Group Contract that is signed only
by an officer of Prudential.]
[I. CONFORMITY WITH LAW.
To receive tax treatment accorded to life insurance under federal law, the
Insurance must meet the definition of life insurance as provided in the Internal
Revenue Code or successor law. To make sure the Insurance qualifies, Prudential
reserves the right: (a) to refuse contributions which would cause the Group
Contract to fail to definition of life insurance; and (b) to make changes in the
Group Contract or to make distributions from the Certificate Funds to
[Employees] to the extent needed to continue to qualify as life insurance.
If the provisions of the Group Contract do not conform to the requirements of
any state or federal law or regulation that applies to it, the Group Contract is
automatically changed to conform to the requirements of that law or regulation.]
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SCHEDULE OF PLANS [#1]
EFFECTIVE: [January 1, 19XX]
GROUP CONTRACT NO.: [GV-XXXXX]
This Schedule of Plans sets forth the Plan of Benefits that applies to each
Covered Class of an Included Employer under the Group Contract listed below as
of the Effective Date. The Plan of Benefits for a Covered Class is determined
by: (1) the Group Insurance Certificates that apply to the Covered Class; and
(2) any modification to those Certificates, provided the modification is listed
below or included in an amendment to the Group Contract. A copy of the
Certificate applicable to each Covered Class, and any modification to it, are
attached to the Group Contract and are made a part of it.
[1.] COVERED CLASS:
[All Employees of The A.B.C. Company]
PLAN OF BENEFITS THAT APPLIES TO THIS CLASS:
[The Variable Universal Life Coverage, including any of the additional
provisions that may be a part of the Variable Universal Life Coverage,
described in the Group Insurance Certificate:
(a) Prepared for Group Contract No. GV-XXXXX;
(b) With the Program Date of January 1, 19XX; and
(c) Bearing the code "VUL - 1-1-XX".]
[2. COVERED CLASS:
All Employees of The D.E.F. Company
PLAN OF BENEFITS THAT APPLIES TO THIS CLASS:
The Variable Universal Life Coverage, including any of the additional
provisions that may be a part of the Variable Universal Life Coverage,
described in the Group Insurance Certificate:
(a) Prepared for Group Contract No. GV-XXXXX;
(b) With the Program Date of January 1, 19XX; and
(c) Bearing the code "VUL - 1-1-XX".]
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MODIFICATION OF THE GROUP CONTRACT
[The Group Contract is modified to provide that:
With respect to the A.B.C. Company, the provisions titled CEASING TO BE AN
INCLUDED EMPLOYER appearing in Section E of the General Rules, is replaced by
the following:
CEASING TO BE AN INCLUDED EMPLOYER: An employer may cease to be an Included
Employer because the Included Employer no longer meets the rules for inclusion
or for any other reason. Prudential may end an Included Employer's participation
in the Group Contract: (a) upon its determination that the number of
Certificates in force under the Group Contract with respect to that Included
Employer falls below 30; or (b) upon its determination that the aggregate Face
Amount of Insurance in force with respect to an Included Employer falls below
$5,000,000. If this happens, the Group Contract will end for Employees of that
Included Employer at the end of the period for which premiums have been paid
with respect to Employees of that Included Employer. But the Group Contract may
permit coverage for such Employees to be continued subject to certain rules.]
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COMBINATION OF EXPERIENCE
Group Contract [GV-XXXXX, and Group Policy No. G-XXX
(Called "Group Contracts" below)]
[Eligible Class: All Employees of The A.B.C. Company.]
[With respect to The A.B.C. Company,] the Group Contracts [will be] treated as
one, [GT-XXXXX], for this purpose: to determine the share, if any, of
Prudential's divisible surplus allocable to the Group Contracts.
[Under that one, the financial experience of the coverage of this group will be
considered separately from that of all others:
All Employees of The A.B.C. Company classified as Hourly Employees.]
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APPLICATION TO
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA (PRUDENTIAL)
FOR GROUP CONTRACT NO. [GV-XXXXX]
APPLICANT: [PRUDENTIAL GROUP LIFE INSURANCE TRUST]
ADDRESS: [Wilmington, DE]
The Group Contract is approved and its terms are accepted.
This Application is made in duplicate. One is attached to the Group Contract.
The other is to be returned to Prudential.
It is agreed that this Application replaces any prior Application for the Group
Contract.
[PRUDENTIAL GROUP LIFE INSURANCE TRUST]
--------------------------------------------
(Full or Corporate Name of Applicant)
Dated at [Wilmington, DE] By [Xxxx Xxx, President]
----------------- ----------------------------------------
(Signature and Title)
On [January 1, 19 XX] Witness [Xxxxxxx Xxx]
----------------------- ----------------------------------
(To be signed by Resident Agent
where required by law)
[This copy is to be returned to Prudential.]
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AMENDMENT TO GROUP CONTRACT NO. [GV-XXXXX]
[EFFECTIVE DATE: June 1, 19XX]
[By their signatures below, the] Contract Holder and Prudential agree that the
Group Contract is changed as follows:
[1. The List of Included Employers in the Group Contract Schedule is replaced
by this list:
List of Included Employers
INCLUDED EMPLOYER INCLUSION DATE
The A.B.C. Company January 1, 19XX
and these subsidiaries
or affiliates:
The U.V.W. Company
The X.Y.Z. Company
The G.H.I. Company January 1, 19XX
The J.K.L. Company June 1, 19XX
2. Form 89759 SCH 1001 (Schedule of Plans) is attached to this Amendment. It
forms part of the Group Contract as of its Effective Date. The form
replaces, as of its Effective Date, form 89759 SCH 1001 (Schedule of Plans)
with an Effective Date of January 1, 19XX.]
[June 1, 19XX PRUDENTIAL GROUP LIFE INSURANCE TRUST]
---------------------------- --------------------------------------------
(Full or Corporate Name of Contract Holder)
[Witness Xxxxxxx Xxx] By [Xxxx Xxx, President]
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(Signature and Title)
[Roseland, NJ June 1, 19XX] THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
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[Attest: Xxxx Xxx By
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Assistant Secretary]
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