PRUDENTIAL IMMEDIATE INCOME ANNUITY REGULATION 60 FORMS PACKET

Transcription

1 PRUDENTIAL IMMEDIATE INCOME ANNUITY REGULATION 60 FORMS PACKET Annuities are issued by The Prudential Insurance Company of America

2 The Prudential Insurance Company of America Prudential Annuity Service Center P.O. Box Topeka, KS Telephone Fax Department of Financial Services of the State of New York For use with Prudential Immediate Income Annuity DEFINITION OF REPLACEMENT IN ORDER TO DETERMINE WHETHER YOU ARE REPLACING OR OTHERWISE CHANGING THE STATUS OF EXISTING LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS, AND IN ORDER TO RECEIVE THE VALUABLE INFORMATION NECESSARY TO MAKE A CAREFUL COMPARISON IF YOU ARE CONTEMPLATING REPLACEMENT, THE AGENT OR BROKER IS REQUIRED TO ASK YOU THE FOLLOWING QUESTIONS AND EXPLAIN ANY ITEMS THAT YOU DO NOT UNDERSTAND. AS PART OF YOUR PURCHASE OF A NEW LIFE INSURANCE POLICY OR A NEW ANNUITY CONTRACT, HAS EXISTING COVERAGE BEEN, OR IS IT LIKELY TO BE: (1) LAPSED, SURRENDERED, PARTIALLY SURRENDERED, FORFEITED, ASSIGNED TO THE INSURER REPLACING THE LIFE INSURANCE POLICY OR ANNUITY CONTRACT, OR OTHERWISE TERMINATED? (2) CHANGED OR MODIFIED INTO PAID-UP INSURANCE; CONTINUED AS EXTENDED TERM INSURANCE OR UNDER ANOTHER FORM OF NONFORFEITURE BENEFIT; OR OTHERWISE REDUCED IN VALUE BY THE USE OF NONFORFEITURE BENEFITS, DIVIDEND ACCUMULATIONS, DIVIDEND CASH VALUES OR OTHER CASH VALUES? (3) CHANGED OR MODIFIED SO AS TO EFFECT A REDUCTION EITHER IN THE AMOUNT OF THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT OR IN THE PERIOD OF TIME THE EXISTING LIFE INSURANCE OR ANNUITY BENEFIT WILL CONTINUE IN FORCE? (4) REISSUED WITH A REDUCTION IN AMOUNT SUCH THAT ANY CASH VALUES ARE RELEASED, INCLUDING ALL TRANSACTIONS WHEREIN AN AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE RELEASED ON ONE OR MORE OF THE EXISTING POLICIES? (5) ASSIGNED AS COLLATERAL FOR A LOAN OR MADE SUBJECT TO BORROWING OR WITHDRAWAL OF ANY PORTION OF THE LOAN VALUE, INCLUDING ALL TRANSACTIONS WHEREIN ANY AMOUNT OF DIVIDEND ACCUMULATIONS OR PAID-UP ADDITIONS IS TO BE BORROWED OR WITHDRAWN ON ONE OR MORE EXISTING POLICIES? (6) CONTINUED WITH A STOPPAGE OF PREMIUM PAYMENTS OR REDUCTION IN THE AMOUNT OF PREMIUM PAID? ORD NY Ed. 4/15 page 1 of 2

3 IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, A REPLACEMENT AS DEFINED BY NEW YORK INSURANCE REGULATION 60 HAS OCCURRED OR IS LIKELY TO OCCUR AND YOUR AGENT OR BROKER IS REQUIRED TO PROVIDE YOU WITH THE IMPORTANT NOTICE REGARDING REPLACEMENT OR CHANGE OF LIFE INSURANCE POLICIES OR ANNUITY CONTRACTS. YOU WILL ALSO RECEIVE A COMPLETED DISCLOSURE STATEMENT NO LATER THAN THE TIME YOUR NEW POLICY OR NEW CONTRACT IS DELIVERED. Date Signature of Applicant: Date Signature of Applicant: TO THE BEST OF MY KNOWLEDGE, A REPLACEMENT IS INVOLVED IN THIS TRANSACTION: Date Signature of Agent or Broker: ORD NY Ed. 4/15 page 2 of 2

4 New York Regulation 60 Authorization to Disclose Contract/Policy Information For use with Prudential Immediate Income Annuity Annuities are issued by The Prudential Insurance Company of America ( Prudential ). In accordance with New York State Department of Financial Services Regulation No. 60, N.Y. Comp. Codes R. & Regs. tit (1971) (amended 1998), please furnish, directly to Prudential, the information needed for completing the New York Disclosure Statement within 20 days of receipt of this form. This authorization is valid until revoked by the undersigned in writing. Please forward this information to Prudential via fax at or to the address indicated below. PLEASE COMPLETE FIELDS WITH AN ASTERISK SECTION 1 ABOUT THE APPLICANT Name of Owner* Social Security number/ein* Date of birth* Owner Street Address City State ZIP Code Name of Joint Owner (if applicable) Social Security number/ein Date of birth Name of Annuitant (if different than owner) Social Security number/ein Date of birth Name of Joint Annuitant (if applicable) Social Security number/ein Date of birth SECTION 2 EXISTING CONTRACT/POLICY INFORMATION NAME OF EXISTING CARRIER* Telephone number of existing carrier EXISTING CONTRACT NUMBER(s) Note-Contract number(s) must be provided for good order.* (Continued) ORD NY Ed. 2/18 page 1 of 3

5 SECTION 2 EXISTING CONTRACT/POLICY INFORMATION (continued) Contract(s)/Policy(ies) with existing carrier: Life insurance Annuity ( Deferred or Immediate ) PLEASE SELECT ONE OF THE OPTIONS BELOW* Full Replacement* Surrender Free Amount* Partial Replacement* $ (required if partial)* * May cause delay in processing if fields are not completed* SECTION 3 NEW PRUDENTIAL PRODUCT INFORMATION Plan Type Requested*: Non-Qualified IRA Roth IRA SEP IRA Payout Options: Period Certain Only, Payment for Years (5 to 25 Years. Must be in whole years.) Individual Life Only Individual Life with Cash Refund Individual Life with Installment Refund Individual Life with Period Certain for Years (5 to 25 Years. Must be in whole years.) The below Payout Options are only available if a Joint Annuitant is named. Joint Life Only Joint Life with 66 2/3% to Survivor Joint Life with 50% to Survivor Joint Life with Cash Refund Joint Life with Installment Refund Joint Life with Period Certain for Joint Life with Period Certain for Joint Life with Period Certain for Years (5 to 25 Years. Must be in whole years.) Years with 66 2/3% to Survivor (5 to 25 Years. Must be in whole years.) Years with 50% to Survivor (5 to 25 Years. Must be in whole years.) Payment Commencement: Payment Commencement Date must be within 13 months of contract issue. Payment Commencement Date: (1st to 28th of month) Frequency of Payment (cannot be changed once elected at time of application): Monthly Quarterly Semi-Annually Annually SECTION 4 ABOUT THE FINANCIAL PROFESSIONAL Financial Professional Name* Prudential ID Number Name of Firm* Telephone Number Financial Professional s Address* Financial Professional s Address I prefer to be contacted via: Telephone ORD NY Ed. 2/18 page 2 of 3

6 SECTION 5 SIGNATURE(S) This authorization is valid until revoked by the undersigned in writing. A copy of this authorization will be provided to the applicant upon request. SIGN HERE Applicant s Signature* Date of signature (Month / Day / Year) SIGN HERE Joint Applicant s Signature Date of signature (Month / Day / Year) SIGN HERE Financial Professional s Signature* Date of signature (Month / Day / Year) Please forward this information to Prudential via fax at *May cause delay in processing if fields are not completed* This form, and the information contained within, does not take into account the investment objectives or financial situation of any client or prospective clients. The information is not intended as investment advice and is not a recommendation about managing or investing your retirement savings. Clients seeking information regarding their particular investment needs should contact a financial professional. Annuities Service Center Financial Professionals: Fax :30AM -5:00PM CT, Monday-Friday Overnight Service, Certified or Registered Mail Delivery Prudential Annuity Service Center Mail Zone SW Sixth Ave Topeka, KS Standard Mail to: Prudential Annuity Service Center P.O. Box Topeka, KS ORD NY Ed. 2/18 page 3 of 3

7 Annuities Service Center P.O. Box Topeka, KS ANNUITIES: NOT FDIC OR GOVERNMENT AGENCY INSURED MAY LOSE VALUE NOT BANK OR CREDIT UNION GUARANTEED REGULATION 60 FORMS PACKET (2/18) ORD NY