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The Prudential Application for an Annuity Contract
[ ] The Prudential Insurance Company of America
[ ] Pruco Life Insurance Company, a subsidiary of
The Prudential Insurance Company of America
Corporate Offices, Newark, New Jersey
[ ] Qualified [ ] Non-Qualified Policy number |___|___|___|___|___|___|___|___|___|
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1. Proposed Annuitant (Owner, unless otherwise indicated in #3) Sex Date of Birth Age Social Security No.
Name -- first, initial, last (Print) M F Mo. Day Yr.
[ ][ ]
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Xxxxxxx Xx. Xxxxxx Xxxx Xxxxx Xxx Xxxxx xx Xxxxxxxxx
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2. Proposed Co-Annuitant (if any) (Do not complete if applying for a tax-qualified plan other than a Prudential Income Annuity)
Name -- first, initial, last (Print) Sex Date of Birth Age Social Security No. Relationship to
M F Mo. Day Yr. person named in 1.
[ ][ ]
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3. Contract Owner (if other than Proposed Annuitant) (Do not complete if applying for an XXX, SEP, or TDA contract)
Name -- first, initial, last (Print) Date of Birth Social Security
Mo. Day Yr. or Tax ID No.
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Relationship to the Xxxxxxxxx____________________________________________________________________________________________________
Xxxxxxx Xx. Xxxxxx Xxxx Xxxxx Zip
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4. Beneficiary: (Give name, age and relationship to person named in 1.) (Do not complete if applying for a Pension/Profit
Sharing Plan. The beneficiary for a contract owned by a trustee or an employer is the owner.)
a. Primary (Class 1):
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b. Contingent (Class 2) if any:
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5. Kind of Annuity (If a Variable contract is applied for, complete suitability form.)
a. Fixed Annuities: [ ] Prudential Income Annuity (PIA)
[ ] Fixed Interest Plan [ ] Discovery_____year(s) guarantee [______________________________________
b. Variable Annuities: [ ] Discovery Plus [ ] Variable Investment Plan [ ]______________________
c. Future Value Annuity [ ] 2 Yr. [ ] 3 Yr. [ ] 4 Yr. [ ] 5 Yr. [ ] 6 Yr. [ ] 7 Yr. [ ] 8 Yr. [ ] 9 Yr. [ ] 10 Yr.
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6. Purchase Payments Amount paid with application: $_________________ [ ] None (check `None' on Section 457 Plans)
Mode of Purchase Payment: [ ] Xxx. [ ] Semi-Xxx. [ ] Quar. [ ] Pay. Budg. [ ] Pru-Matic [ ] Gov't. Allot.
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7. Source of Funds (NOTE: Contract minimums must be met.)
XXX: Is any part of this purchase payment an XXX rollover? [ ] Yes [ ] No
Amount of Rollover: $______________ Regular Contribution: $_____________ Year_____________ $______________ Year_____________
Will the Purchase Payment be transferred from another financial institution? [ ] Yes [ ] No
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8. Complete this Section only if a Qualified Plan or Program is being applied for (Check One) Type:
[ ] XXX -- individual Retirement Annuity [ ] TDA -- Non-Profit Organization 501(c)(3)_____________________
[ ] SEP (Plan Name)_________________________________________ For TDA Billing:
[ ] Pension/Profit Sharing (Plan Name)______________________ Employer Name_________________________________________________
[ ] Section 457 (Plan Name)_________________________________ Employer Address______________________________________________
[ ] TDA -- Public School Employees-403(b)___________________ ______________________________________________________________
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Complete 9 for Prudential Income Annuity Only
9a. Kind of Payment Option__________________________________________________________________________________________________________
Frequency of annuity payment Amount of each annuity payment Date of first annuity payment
[ ] Mo. [ ] Quar. [ ] Semi-Xxx. [ ] Xxx. $
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b. Annuity payments payable to: Name_______________________________________________________________________________________________
No. Street City State Zip
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NOTE: The Prudential Income Annuity contract will take effect on the date the purchase payment is received in the Home
Office, even if the Annuitant or Co-Annuitant died after that date but before the contract is issued.
Proof of the date of birth of each proposed Annuitant, such as birth certificate, baptismal record, etc. must be
submitted with the application whenever a life annuity option is selected.
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XXX 00000-00 Litho in U.S.A.
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10. Will this annuity replace or change any existing insurance or annuity contract in any company on any Yes No
person named in 1 or 2? (If yes, for each such contract give the person's name, name of company, [ ] [ ]
plan, amount and contract numbers.)
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11. Special Requests
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OWNERSHIP: The owner of the contract will be as required by the applicable retirement plan. If there is no such plan,
the owner will be (1) the applicant if other than the proposed Annuitant, or else (2) the proposed Annuitant. In either
case, any limitations required by the retirement plan or program will be part of the contract. It is understood that the
purchase payment becomes the absolute property of the Company.
If this application is for an XXX, I have received an explanatory booklet, and I understand that I will be given a
financial statement with the contract.
__________________________________________________________________ _______________________________________________________________
Signature of Proposed Co-Annuitant Signature Proposed Annuitant
Dated at__________________________on_______________, 19___________ _______________________________________________________________
(City/State) Signature of Applicant (if other than proposed Annuitant)
(If owner is a firm or corporation, show that company' name)
Witness___________________________________________________________ By_____________________________________________________________
(Licensed Writing Representative must witness where (Signature and title of officer signing for that Company)
required by law.)
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XXX 00000-00
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Supplementary Information
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Instructions for the Writing Representative
o On IRA's contracts, the contract owner must be the Annuitant.
o If the product is a variable annuity, be sure you give the proposed Annuitant a prospectus.
o A completed Income Tax Withholding Election Form (ORD 84549B) must accompany this application. Also, Form ORD 84549A, the Income
Tax Withholding Notice must be given to the client.
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1. Proposed Annuitant's telephone no. Home( ) Business( )
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2. Does the purchase payment come from the proceeds of insurance contracts in this or another company? If yes, give: [ ] Yes [ ] No
a. Company name________________________________________________ b. Prudential/Pruco Life contract no.(s)_______________________
c. Amount $__________________________ d. Proceeds are from: [ ] Loan [ ] Dividends [ ] Surrenders [ ] Other (describe)
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3. Do you have, from any source, facts that any person named in 1 or 2 of the application may replace or change any current
insurance or annuity in any company? (Give details of yes, answers in "Remarks".) [ ] Yes [ ] No
_____________________________,19_______ ______________________________________________________________________________________
Date Signature of Writing Representative (Agent)
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Remarks:
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Credit % Contract number Name & Title Agcy. No./Rep. Init. Office code Detached Office
________ _______________ _____________________________________ ___________________ ___________ _______________________
________ _______________ _____________________________________ ___________________ ___________ _______________________
________ _______________ _____________________________________ ___________________ ___________ _______________________
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ORD 87348 92 Litho in U.S.A.
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The Prudential Receipt
[ ] The Prudential Insurance Company of America
[ ] Pruco Life Insurance Company, a subsidiary of
The Prudential Insurance Company of America
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We, the Company, received $________ on ___________, 19__ from __________________
This amount was paid when, on this date, an annuity application was signed in
which ____________________________ is named as the proposed Annuitant.
This receipt is issued on the condition that any check, draft or other order for
the payment of money is good and can be collected. All checks must be drawn only
to the Company and not to any other party.
If the application is rejected or if we issue a contract other than as applied
for and it is not accepted on delivery, we will refund the amount shown above.
_______________________________________________
No change may be made in the terms and conditions of this form. No statement
which claims to make such a change will bind the Company.
____________________________________ _____________________________________
Field Office Writing Representative (Agent)
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ORD 87348A-92 Litho in U.S.A.
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The Prudential Important Notice About Your
Application For An Annuity
The Prudential Insurance Company of America
Pruco Life Insurance Company
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Any information we obtain or have obtained about you will be treated as
confidential. However, we may give this information, as necessary, to persons
conducting mortality or morbidity studies and to affiliate companies for
marketing, servicing, underwriting or claim handling purposes. If you ask, we
will describe any other circumstance when we may obtain or disclose or may have
obtained or disclosed information about you without your prior authorization.
If you have any questions concerning any of the personal information which we
obtain or report, let us know. You have the right to see this information and to
correct, amend or delete any information which may be wrong. We will tell you
how to do this if you ask us.
Thank you for applying to us for an annuity.
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ORD 80067-92 Litho in U.S.A.
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Corporate Offices, Newark, NJ
The Prudential Insurance Company of America Pension Office
Pruco Life Insurance Company Service Offices
Note--Unless you get a contract, or your money back within eight weeks from the
date of this receipt, please notify the Company. Give the amount paid, date of
payment, name of person to whom paid, (Locations are shown above.)
_________________________________________
Received from the Company the sum of $_________________which is a refund of the
sum paid on this contract.
______________________________, 19__ __________________________________________
Date Signature
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