Click on the New Business tab. Click on Replacement Highlighters (located in the drop-down box). Important Notes About This Guide...

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1 CREATED EXCLUSIVELY FOR FINANCIAL PROFESSIONALS SERVICE Guide to Completing Life Insurance Applications PURPOSE OF THIS GUIDE This guide provides information that will help the user accurately complete the generic, individual long-form application packet. Unique applications exist for Juveniles age 0 to 17 as well as specific survivorship applications for use with SUL Protector. This guide helps ensure once-and-done transaction processing. Easy-to-follow instructions and reminders are included about the primary portions of the forms listed below. The information in this guide is not state specific, so be sure to familiarize yourself with any state variations which can be found on Replacements Information on completing replacements is not included in this guide. If you have questions regarding replacements, please refer to the Replacement Highlighters located on Pruxpress. To access the Replacement Highlighters on Pruxpress: Click on the New Business tab. Click on Replacement Highlighters (located in the drop-down box). TABLE OF CONTENTS Important Notes About This Guide... 2 Application Packet Checklist... 3 Requirements for Non-Face-to-Face Sales... 3 Application for Life Insurance (ORD 96200) Authorization to Release Information (ORD 96200C)... 8 Limited Insurance Agreement (ORD 96200A)...8 Agent s Report...9 Application Signature Requirements Obtaining and Submitting Additional Forms NOT FOR CONSUMER USE The Prudential Insurance Company of America, Newark, NJ. NR-13A51515 Ed. 10/2013 Exp. 03/31/2015

2 IMPORTANT NOTES ABOUT THIS GUIDE Obtaining forms Forms are accessible on-line via To access forms on the website, click on the Forms tab and then Launch Forms. Be sure to select the appropriate state-specific version(s). When completing forms Black ink is preferred as it photocopies the best. White-out is not allowed. To make corrections, draw a line through the mistake, write in the correct information, and have the appropriate party initial by the correct data. Selecting the appropriate issuing company At the top of many forms, you are asked to check the box for the appropriate company. Check: Pruco Life Insurance Company for all plans. Definition of terms Producer: Sales representative, agent, broker, writing representative, etc. Proposed Insured: Person who is being considered for insurance on their life. Policyowner: Purchaser of the policy(s); account owner (often the same person{s} as the proposed insured). Send completed forms to Prudential Financial, Attn: Life New Business 2101 Welsh Road/Suite DTY Dresher, PA

3 APPLICATION PACKET CHECKLIST Before submitting this application: Complete/include a cover letter summarizing the application and providing details that may help in the approval process, including: Amount (include information regarding pending applications with other companies and the ultimate total coverage with all companies, in force and pending). Purpose (financial justification) and coverage details (e.g., type of coverage, reason, etc.). Clearly labeled application(s) if submitting more than one application (e.g., is this an alternate, duplicate, etc.?). Clear definition(s) indicating if this is new or replacement* coverage. Specific details about policy change request(s) (e.g., is it clear what needs to be altered and/or is the increase amount clearly stated {if applicable}?). List all names on the application and provide complete addresses. Provide SSN or TIN A Tax Identification Number (TIN) may be either a Social Security Number (SSN) or an Employer Identification Number (EIN). Complete/include other applicable forms See list of possible additional forms on pages 11 and 12. Ensure signatures were obtained. Include Special Instructions with clear explanations. Leave the Important Notice About Your Application for Insurance with the primary proposed insured. Attach the check for prepayment Provided the proposed insured can certify the health attestations, and is less than or equal to 75 years old, a prepayment may be accepted on face amounts applied for up to and including $5,000,000, either as a single $5,000,000 application or as multiple applications totaling no more than $5,000,000 for both individuals on survivorship plans. NOTE: The total death benefit payable under all Limited Insurance Agreements (LIAs) combined is the amount applied for, up to a maximum of $1,000,000 (per insured). Include underwriting requirements APS ECG Exam Financial Information Lab Work Other REQUIREMENTS FOR NON-FACE-TO-FACE SALES The collection of the application information must be conducted by the producer with both the proposed insured and the owner, if the owner is other than the proposed insured. The producer securely sends the application package to the insured/owner to be signed, along with any required forms and illustration requirements where applicable. NOTE: The Agent s Report and Xpress Worksheet (as applicable) is NOT to be included in the application package. These items are to be completed by the producer. The insured/owner reviews and signs the application package, and sends it back to the producer. The producer reviews the application package to ensure it s in good order, signs the application package, and then submits it to the Brokerage General Agency for submission to Prudential. * Replacement coverage involves a transaction in which a new life insurance policy or a new annuity contract is to be purchased, and it is known or should be known to the proposing producer that by reason of the transaction, an existing life insurance policy or annuity contract has been or is to be lapsed, forfeited, surrendered or partially surrendered, assigned to the replacing insurer, or otherwise terminated. See the Replacement Highlighters available on Pruxpress.com for additional information on understanding replacements. 3

4 APPLICATION FOR LIFE INSURANCE (ORD 96200) PART ONE: SECTIONS A F Heading: Prudential Application for Life Insurance Check applicable box for the correct issuing company (Pruco). Enter policy number (if available). A: Proposed Insured B: Plan of Insurance C: Premium D: Owner E: Benefi ciary Details F: Insurance History Vague comments such as consultant as the occupation may prompt additional questions. Without complete and accurate information, application approval may be delayed or denied. The plan name is available on the illustration (e.g., Term Essential 20, etc.). Only complete this section if the policyowner is other than the proposed insured. If a trust is the owner, provide the name of the trust, the trustee(s) and the date. Also include whether the trust is revocable or irrevocable. Complete ALL information that is asked for. Check YES box if requesting to save age; otherwise, check NO. Residence address MUST be a street address; P.O. boxes are not permitted. If proposed insured is not a permanent, legal U.S. resident, ALL details regarding status must be provided. Occupation Provide nature of the business and specific duties. Check the plan name. If the specific plan requested is not listed, check the OTHER box and write the full plan name on the line. Check the applicable optional benefits and riders. If the specific benefit/ rider requested is not listed, check the OTHER box and write name on the line. Where applicable, check the death benefit option type and the definition of life insurance used. If the specific plan is not listed, write requested selections in SPECIAL REQUESTS (Section H). For non-term plans, enter the billed premium amount. Send Notices: Check if the notices are to be sent to the policyowner or someone else s attention. If other than the policyowner, identify the individual. Check if notices are to be sent to the policyowner s residence or another location. If a location other than the policyowner s residence is requested, identify the location. If the policyowner is an individual, be sure to include the full name, SSN or TIN, date of birth, and address of the policyowner. If more than one owner, include the additional owner s information in SPECIAL REQUESTS (Section H). Enter complete information on all beneficiaries, including checking whether the beneficiary is a primary or secondary beneficiary. Check YES or NO regarding whether the client has existing coverage. Check YES or NO if a replacement. When YES is selected for a replacement, also check YES or NO if a 1035 exchange is involved. Complete all requested information for each existing policy. Is the proposed insured attempting to reinstate or change a life or health policy? If YES, include the insurance company, the amount applied for, and the total amount of coverage to be placed. Is the proposed insured planning on transferring ownership of the policy to an investor or a life settlement company? If YES, provide full details. 4

5 APPLICATION FOR LIFE INSURANCE (ORD 96200) (continued) PART ONE: SECTIONS G H G: General Information H: Special Requests Be sure to provide specific details about aviation, avocation, other applications, criminal offenses, driving violations, and travel. IT IS CRITICAL TO FULLY AND ACCURATELY COMPLETE THIS SECTION. Aviation: If yes, complete the aviation questionnaire (ORD Aviation). Avocation/hobbies: If yes, complete the appropriate avocation form (ORD Diving, Mountain Climbing, Racing, General Avocation). Tobacco: Include all forms of tobacco and list the frequency of use and the dates last used. Driver s license: Complete in full. Criminal offense: If yes, provide details. Residence or travel outside of the U.S.: Provide details such as dates of trips, the countries visited, the frequency of travel, the purpose, the duration of stay, etc. Include all details to YES responses for Questions 4 6 on the lines in Question 7. Enter information on items such as: Explanation of the policy change. Request for additional policies. Beneficiary & owner information. APPLICATION FOR LIFE INSURANCE (ORD 96200) PART TWO: SECTIONS A B Complete all of Part Two if you are using another company s exam. A: Physician Information B: Physical Measurements You don t need to complete all of Part Two if the client is having a full exam on Prudential exam forms. It is still helpful, however, to complete Section A of Part Two (In case the exam results are delayed, Prudential will at least have this information to know whether an APS is required). You don t need to complete this section if a full Prudential exam has already been performed and you are submitting the results with the application. Complete the physician information in full. Enter the client s height and weight. Enter the full details regarding any change in weight greater than 10 pounds. 5

6 APPLICATION FOR LIFE INSURANCE (ORD 96200) (continued) PART TWO: SECTIONS C D C: Family History D: Medical Information Question #1 is frequently incomplete, which can cause a delay in the approval process. You are not required to complete this if a full Prudential exam has been completed. It is helpful, however, to still complete and submit the family history section even if the exam is complete. IT IS CRITICAL TO FULLY AND ACCURATELY COMPLETE THIS SECTION. Provide the specific details for immediate family members (parents and siblings) only for death or diagnosis of listed conditions before age 70. Provide the current age or age at time of death only for parents. Complete for ALL NEW BUSINESS. Watch for state-specific variables. If a portion of a question is NOT applicable in a certain state, only that component of the question should not be asked or answered. The remainder of the question should be asked and answered and not left blank. Use the following page (sample page shown below) of this form/ application to provide the specific details for any questions that were answered YES. 6

7 APPLICATION FOR LIFE INSURANCE (ORD 96200) (continued) The state where the application is physically signed and the policy will be delivered determines the state of sale and dictates which application version to use. The producer must be licensed in this state. Signatures Tax Certifi cation If the owner is a trust, the trust should be in effect prior to submitting the application. Form (COMB 86044) must be submitted if the owner is a trust. This line applies to both entities and individuals. Ensure that the box is checked when the policyowner verifies the accuracy of the SSN/TIN. This line applies to both entities and individuals. Ensure this box is checked ONLY when the policyowner is NOT subject to backup withholding. This line applies to both entities and individuals. An entity should consider itself a U.S. person if it is established as a United States domestic corporation. If this box is not checked, a W8 MUST be submitted for the policyowner. Enter the state where signed and the current date. Signature of the proposed insured. Signature of the policyowner. If the policyowner is an entity, list the name of the entity, obtain the signature of the entity representative, and list the title of the entity representative. Signature of the producer. The number shown on the application is my correct Social Security/ Tax ID number. The information entered in this section must match the information provided on pages 1 5 of the application. I am not subject to backup withholding under Section 3406(a)(1)(C) of the Internal Revenue Code. I am a U.S. person (including a U.S. resident alien). If not a U.S. person (including U.S. resident alien), submit the applicable Form W-8 (BEN, ECI, EXP, or IMY). In most cases, Form W-8BEN will be the appropriate form. 7

8 AUTHORIZATION TO RELEASE INFORMATION (ORD 96200C) & LIMITED INSURANCE AGREEMENT (ORD 96200A) Note When you print the application packet, you will find one copy of both the Authorization to Release Information and the Limited Insurance Agreement. Once finished, provide a copy of the Authorization to Release Information and the Limited Insurance Agreement (if a prepayment was taken) to the client. Submit the original(s) with the completed application. Authorization to Release Information Enter the name of proposed insured. Enter the policy number (if available). Proposed Insured MUST sign and date (parent/guardian when the proposed insured is under 18). Limited Insurance Agreement (LIA) Checks can be made payable to Prudential Insurance. Complete this section if prepayment can and will be collected. Note: prepayment cannot be collected on non-face-to-face sales. Enter the amount of insurance requested. If a term conversion, show the amount of the new policy in the amount of insurance requested. If requesting a flex face increase (VAL) or a layer/slice (VUL), show only the amount of the flex face increase or layer/slice requested. Enter the amount of prepayment. Enter the proposed insured s name. Prudential must receive payment, the LIA, and the request for coverage on the same day. Prepayments are not accepted after the application is submitted. Signatures If the owner is a business, a company officer must sign and include their title. Proposed insured must sign and date this section/form (if under 18, parent/guardian signs). If the policyowner is different from the insured, the policyowner must sign. If a trust is the owner, all trustees must sign unless otherwise stated in the trust or applicable state laws. They must also indicate trustee under trust agreement dated. The producer must sign. 8

9 AGENT S REPORT (this form MUST be submitted with the application in all cases) Name of Proposed Insured Purpose of Life Insurance Producer Information Suitability Declarations Source of Funds Underwriting Category Quoted Additional Coverage Frequently, the purpose of the insurance is not clear, which can cause a delay in processing the application. Applicable only to variable products. Enter name of the primary proposed insured. Check all that apply and explain. (The cover letter is a good place to include additional information about amounts, breakdowns, and purpose). Provide all requested information applicable. Answer all questions. Enter the source of BOTH the initial and future premiums. Check the applicable box. This needs to be answered only if a Pru/Pruco policy was issued within three months of the current application. Military Both questions MUST be answered on ALL cases. For any YES answers, provide appropriate disclosure forms at point of sale. Producer s Statement Remarks This section is often left blank yet remarks are helpful to expedite processing (e.g., a cross-reference to related applications on business partners, or stating who suggested coverage, etc.). Sign and date. For a non-face-to-face sale: Producer should select NO in section I, question 1 of the Agent s Report, noting the insured was NOT seen at the point of sale. Enter any/all unusual details or subjective information you learn about all the proposed insureds in this section. 9

10 APPLICATION SIGNATURE REQUIREMENTS FORM: Authorization to Release Information (ORD 96200C) Section Proposed Insured Policyowner(s) Trustees Offi cer Producer If age 18 or over; otherwise, parent/ guardian. Include date signed. FORM: Limited Insurance Agreement (ORD 96200A) Section Proposed Insured Policyowner(s) Trustees Offi cer Producer If age 18 or over; otherwise, parent/ guardian. Include date signed. If different from the proposed insured. If a trust is the owner, all trustees must sign unless otherwise stated in the trust or applicable state laws. Officer of company, if owner is a business or corporation. FORM: Application for Life Insurance (ORD 96200) Section Proposed Insured Policyowner(s) Trustees Offi cer Producer If different from the proposed insured. If the owner is an entity, give the entity s name. If a trust is the owner, all trustees must sign unless otherwise stated in the trust or applicable state laws. They must also indicate trustee under trust agreement dated. Officer (include title) of company, if owner is a business or corporation. 10

11 OBTAINING FORMS Forms may be accessed on-line via the Forms tab at Click on the Forms tab and then Launch Forms. Be careful to select the appropriate state-specific version(s). ADDITIONAL FORMS Form Name/Type Form Number When To Use Aviation Supplement ORD Aviation Required if the proposed insured has any duties aboard an aircraft, glider, balloon, or similar device. Diving Supplement ORD Diving Required if the proposed insured participates in scuba diving. Mountain Climbing Supplement Motorized Vehicle Racing Supplement General Avocation Supplement ORD Mountain Climbing ORD Racing ORD Avocation Required if the proposed insured participates in mountain climbing. Required if the proposed insured participates in any form of motorized vehicle racing. Required if the proposed insured participates in any hazardous activities other than scuba diving, mountain climbing, or racing. Business Supplement ORD Business Required when the owner or beneficiary of the policy is to be a business. Financial Supplement ORD Financial The financial supplement will now be required at face amounts of $5,000,000 or more up to age 70; at face amounts of $2,500,000 or more at ages 71-80; or face amounts of $1,000,000 or more at ages 81 and above. Child Rider Supplement ORD Child Rider Required when requesting a Child Rider. Policyowner Statement Supplement ORD Owner Statement Required for all non-variable plans when the age of the proposed insured is 70 or greater and the face amount is $1,000,000 or greater. Policy Change Supplement ORD Change Required only when: The existing policyowner of the policy being converted or changed is not the owner of the new or changed policy; or The rights restriction requires the beneficiary to sign all requests; or There is a collateral assignee. Indexed Universal Life Insurance Supplement ORD Indexed UL Required when requesting an indexed product (such as Index Advantage Universal Life). Variable Supplement ORD Variable Required when requesting a variable product (such as VUL II or VUL Protector). Absolute Assignment to Effect a Section 1035 Exchange CVAT or GPT Selection Form Request for Initial Premium (E-Pay) and/or to Establish Monthly Electronic Funds Transfer (EFT) ORD ORD ORD Complete only when requesting a 1035 Exchange from a non-prudential contract. Required when the application state is New York for any product that offers a choice of definition of life insurance: CVAT: Cash Value Accumulation Test GPT: Guideline Premium Test Complete if the policyowner wants to pay the initial premium from E-Pay and/or place the policy on the Electronic Funds Transfer (EFT) premium payment option. 11

12 ADDITIONAL FORMS (continued) Form Name/Type Form Number When To Use Illustration Certifi cation ORD A signed illustration is required to be submitted with the application to satisfy NAIC Regulations. The Illustration Certification Form may be submitted with the application for Universal policies if the illustration shown to the applicant differs from the policy applied for or a computer screen illustration was shown to the client. If an Illustration Certification is used, an illustration conforming to the policy as applied for must be provided to the applicant within 48 hours. Important Notice Regarding Replacements Living Needs Benefi t SM Get the Most Out of Your Life Insurance New York Defi nition of Replacement Pennsylvania Disclosure Statement Preliminary Statement of Policy Cost (Maine and New York) Premium Provisions of Indeterminate Premium Contracts (Montana and Texas) Trustee Statement and Agreement Form Disclosure for Military Sales COMB ORD COMB NY COMB PA ORD ORD ORD COMB ORD Form must be completed and submitted when: Replacing existing life or annuity coverage as required by state regulations. The proposed insured has existing individual life or annuity coverage (even if not replacing it) and the application state has adopted the NAIC s New Model Replacement Regulation. Additional replacement forms may also be required. If applying for the Living Needs Benefit (LNB), provide the primary proposed insured with a copy of the LNB brochure (found on Pruxpress). Required to be completed/signed by the owner when the application is signed in the state of New York. (Applies to all products.) Required for all products except VUL II. Producer completes the form and provides a copy to the proposed insured and submits a copy to the Home Office only if replacing an existing non-prudential policy. No signatures are required. Maine: ORD must be completed for all Term policies. New York: ORD must be completed and signed by both the owner and producer for all Term policies with a copy submitted to the Home Office with the application. Required for Term Essential in Montana and Texas. Form must be signed by the owner and a copy must be submitted to the Home Office with the application. Use for ownership in a trustee under a trust agreement. COMB is preferred over a trust document. Required when the military question on the Agent s Report is answered YES. The Living Needs Benefi t SM is an accelerated death benefit and is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for insurance of these types. There is no charge for this rider but, when a claim is paid under this rider, the death benefit is reduced for early payment, and a $150 processing fee ($100 in Florida) is deducted. If more than one policy is used for the claim, each policy will have a processing fee of up to $150 deducted ($100 in Florida). Portions of the Living Needs Benefit payment may be taxable, and receiving an accelerated death benefit may affect eligibility for public assistance programs. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefit and is considered terminally ill or chronically ill. We suggest that clients seek assistance from a personal tax advisor regarding the implications of receiving Living Needs Benefi t payments. This rider is not available in Minnesota to new purchasers over age 65 until the policy has been in force for one year, and the nursing home option is not available in Connecticut, Florida, Massachusetts, New York or the District of Columbia. This rider is not available in Washington state. In Oregon, term policies must include the waiver of premium benefit to be eligible for this rider. The Prudential Insurance Company of America, Newark, NJ. NOT FOR CONSUMER USE Prudential Financial, Inc. and its related entities. 12