To the Family, Friends and Beneficiaries of our Valued Customer,

Transcription

1 Prudential Annuities A Business of Prudential Financial, Inc. P.O. Box 7960 Philadelphia, PA (888) To the Family, Friends and Beneficiaries of our Valued Customer, On behalf of Prudential, I would like to begin by offering my sincere condolences for your loss. While there are no words to ease your sorrow, please know that my thoughts are with you. I would also like to assure you that Prudential is ready to honor the commitment that was made to your loved one. I understand that it can feel overwhelming, under any circumstances, to navigate financial matters and decisions. As such, I would like to highlight some resources that you may find helpful: A financial professional can help you see the big picture and explain financial topics that may be complex or unclear. You may also want to consult with your tax advisor, who can help you navigate any tax considerations. Because each situation is unique, neither Prudential nor any of its representatives can offer tax or legal advice. Prudential customer service representatives can help you with any questions you may have regarding the annuity contract. Our representatives can explain what options are available and assist with the paperwork that is required Enclosed you will find a Quick Start Guide that highlights the key steps when submitting a claim. You will also find instructions on how to complete the paperwork and information about special beneficiary situations. It is important to me that you receive the highest level of service. If you need any assistance, please contact our Service Center at (888) Representatives are available to assist you Monday through Thursday between 8 a.m. and 7 p.m., and Friday between 8 a.m. and 6 p.m. ET. Sincerely, Jessica Conley Vice President, Annuities Services Prudential is committed to supporting you through life s critical moments. We have online resources to assist you during this difficult time. Please visit to learn more. Annuities are issued by The Prudential Insurance Company of America and Pruco Life Insurance Company (in New York by Pruco Life Insurance Company of New Jersey), or by Prudential Annuities Life Assurance Corporation. Annuities are distributed by Prudential Annuities Distributors, Inc. All are Prudential Financial, Inc. companies, and each is solely responsible for its own financial condition and contractual obligations. CondolenceCover-C052018

2 Quick Start Guide The Prudential Insurance Company of America Pruco Life Insurance Company of New Jersey Pruco Life Insurance Company Prudential Annuities Life Assurance Corp. Please use this guide as reference to assist with completing your claim. On these pages, I, you and your refer to the person making the claim. We, us, and our refer to the Prudential company that issued the policy. 1. Decide how to receive your funds In order to meet your needs, Prudential offers several payment options for you to receive your annuity claim benefits. Please go to the corresponding section of the form to make your selection. You only need to choose ONE option. A. Lump Sum - Allows the beneficiary to receive the proceeds in one lump payment. [Page 2] B. Continuation Options - Available to spouses as well as same sex civil unions, domestic partnerships or same-sex spouses not recognized by federal tax law. These options are not available with Beneficiary Annuities. [Page 3] C. Annuity Payout Options - Allow the beneficiary to receive the proceeds over a period of time. [Page 4] D. Additional Claim Options - Allow beneficiaries to use their proceeds to continue or purchase a Prudential annuity product for the purpose of deferring taxes (subject to eligibility requirements). [Page 5] 2. Return the signed claim form and supporting documentation Please mail pages 1-8 of your claim form, including an original death certificate with a raised state seal, and the contract(s), if available to: Note: If your Annuity product has a custodian owner, please complete the Custodial Annuity Death Benefit Claim Form instead of this form. This form, and the information contained within, is not intended as investment advice and is not a recommendation about managing or investing your retirement savings. Neither Prudential Annuities, nor the Prudential entity(ies) set forth on this form, are acting as your fiduciary as defined by any applicable laws and regulations. Please consult with your qualified investment professional about managing or investing your retirement savings. Annuities Service Center Investor Line: Financial Professionals: :00AM 7:00PM ET, Monday Thursday 8:00AM 6:00PM ET, Friday Fax: (800) Regular Mail Delivery Annuities Service Center P.O. Box 7960 Philadelphia, PA Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA Did you know? If the total death benefit value for all annuity contracts owned by the deceased nets to less than $50,000, you are an individual claiming for yourself and you want to take the lump sum distribution option, you may be eligible for paperless processing. Contact our Annuities Service Center at to speak with a Customer Service Representative. Annuities are issued by The Prudential Insurance Company of America (PICA), Pruco Life Insurance Company (in New York, by Pruco Life Insurance Company of New Jersey), located in Newark, NJ (main office), or by Prudential Annuities Life Assurance Corporation (PALAC), located in Shelton, CT. (main office), these entities are referred to as Prudential below. All are Prudential Financial, Inc. companies and each is solely responsible for its own financial condition and contractual obligations. The Rock Prudential Logo is a registered service mark of PICA and its affiliates.

3 Annuity Beneficiary Claim Form QUESTIONS: If you have questions when completing this form, please see Instructions on page 10 or contact the Annuities Service Center at REMEMBER: Each beneficiary or claimant must complete and submit a separate claim form. Only one original death certificate with a raised state seal is needed. 1. ABOUT THE BENEFICIARY If the beneficiary is a trust or other entity, please complete Section 9, Entity Beneficiary on page 9. Social Security Number (all 9 digits required) or Tax ID Date of Birth (mm/dd/yyyy) Name (First, Middle, Last ) Street Address City State Zip Home Phone Mobile Phone Address In the event we need additional information to complete the request, please indicate who Prudential should contact: Claimant Financial Professional Other Name Phone Number I am the (check one) Please see Special Beneficiary Situations section on page 10 for additional details: Beneficiary Person named to receive funds from the policy (If you have assigned any portion of the claim to a funeral home, please include a copy of the assignment form). Power of Attorney for the beneficiary Attach a copy of the power of attorney documentation. Representative of the deceased s estate Attach a copy of proof of appointment. Trustee Please complete the Entity Beneficiary Authorization form on page 9. Assignee Specify the dollar amount you are claiming: $ Other Please specify: Legal guardian for the beneficiary Attach a copy of court order naming you as guardian. If the beneficiary is a minor, provide: Social Security Number (all 9 digits required) or Tax ID Date of Birth (mm/dd/yyyy) Name (First, Middle, Last ) 2. ABOUT THE DECEASED Social Security Number (all 9 digits required) or Tax ID Date of Birth (mm/dd/yyyy) Date of Death (mm/dd/yyyy) Name (First, Middle, Last ) Page 1 of 15

4 3. ANNUITY CONTRACT INFORMATION Provide the annuity contract and/or variable life policy number(s) for which you are making a claim. Annuity Number(s) 4. HOW TO RECEIVE YOUR FUNDS Please consult your tax advisor prior to selecting your option to ensure it is appropriate for your particular circumstance. Please complete only ONE of the sections below (sections 4A through 4D). Refer to the annuity contract or product prospectus, if applicable for details as not all sections are available for all products. IMPORTANT: Please remember to include an original death certificate with a raised seal. 4 A. Lump Sum These options allow the beneficiary to receive the proceeds in one lump sum payment. There may be tax consequences associated with selecting these options. Choose A or B below: A. Lump Sum Check Receive the full benefit in a single lump sum check mailed to the address provided in section 1 of this form. B. Alliance Account This option allows the beneficiary to open an interest-bearing Alliance Account with draft writing privileges that allows full access to funds immediately. The Alliance Kit will be mailed to the address provided in Section 1 of this form. If this option is elected, earnings on the claim proceeds will be fully reportable at the time of election and any additional interest paid will be reportable in the year it is accrued. Note: The Alliance Account is not available on products issued by the Prudential Annuities Life Assurance Corporation ( PALAC ) carrier. In addition, the Alliance Account is not available if the annuity contract was issued in or the beneficiary resides in Kentucky, Minnesota, New York or Rhode Island. Other restrictions apply. Please see page 12 for more information on Alliance Account eligibility. For Financial Advisors Please check this box if you wish to deliver the Alliance Kit to the beneficiary. Please provide your name and address below. Name (First, Middle, Last ) Street Address City State Zip 4 B. Continuation Options Please select only ONE of the options below (options A through D). I request to continue the contract(s) for my benefit. Based on the contract, you may continue the annuity under your name if ONE of the following conditions is met: You are the sole beneficiary and spouse of the deceased and the deceased passed away prior to the beginning of the payout period of the annuity OR You and your deceased spouse are joint owners of the contract and each other s sole primary beneficiary. Choose A or B below: A. Spousal Continuance 1 (Available for spouses recognized by federal tax law) Please complete IRS Required Minimum Distribution (RMD) for IRA Contracts, if applicable: 1. I will be under age 70½ in the year in which I am requesting this ownership change; or 2. I have already or will attain age 70½ in the year in which I am requesting this ownership change. If you checked 2 above, you must also select one of the following: 1. Please send me a package that describes the RMD requirements for IRAs; or 2. I received independent tax advice regarding the RMD requirements for IRAs and the risk associated with deferring settlement of my contract. I agree I shall not bring claim against Prudential in the event I fail to satisfy the RMD required for my contract and sustain any adverse tax consequences as a result. Page 2 of 15

5 4. HOW TO RECEIVE YOUR FUNDS (continued) 4 B. Continuation Options (continued) B. Taxable Contract Continuation 1 (Available for same sex civil unions, domestic partnerships or same-sex spouses not recognized by federal tax law. In addition, if the contract is tax qualified (IRA/SEP/Roth/403(b)), it will be continued as a non-qualified annuity.) Required: If you elected Spousal or Taxable Contract Continuation above, please complete Section 5, Beneficiary Designation, and provide New Annuity date: (mm/dd/yyyy). If a new annuity date is not provided, the annuity date will default to the maximum annuity date allowed under the terms of the contract. The following continuation options allow the beneficiary to use their proceeds to continue or purchase a Prudential annuity product for the purpose of deferring taxes (subject to eligibility requirements). Choose C or D below: C. Beneficiary Continuation Option In lieu of this form, you must complete and return a Beneficiary Continuation Option Allocation Instruction form and Beneficiary Continuation Option Election form, located at This option is only available if the current contract is a Strategic Partners, Prudential Premier, Premier Retirement Variable Annuity, Premier Advisor Variable Annuity, any PALAC qualified contract (IRA, SEP, TDA) or a PALAC non-qualified ASAPII, ASAP III, AC2000, APEX II, ASL, ASL II, AS XT, AS XT6, AS2000, OAP, OAP 4, or OAP Plus. The Beneficiary Continuation Option is only available within a limited time period from the deceased s date of death as detailed on page 11, Tax Consequences and Tax Withholding. D. Continuation for Remaining Period Certain Payments You may elect to continue any remaining inheritance period or certain period. Please be aware that if there is no remaining period, the contract has ended and no death benefits are due. 1 Please review the instructions on page 11 for the definition of spouse for federal tax purposes. Page 3 of 15

6 4. HOW TO RECEIVE YOUR FUNDS (continued) 4 C. Annuity Payout Options Prudential also offers a number of deferred payment options, which pay out the proceeds over a period of time that you select (e.g., over your lifetime). If you select a deferred payment option, we will provide you with a written description of the terms of the installment payment option you selected. Please note: the right to withdraw additional funds is not available for most products. Please refer to the contract or product prospectus, if applicable for additional information. Certain options may not be available on all products. Select only ONE: Life Income Life Income with a Certain Period Fixed Period Fixed Amount (Spousal) Highest Daily Lifetime Seven Beneficiary Income Option (Spousal) Highest Daily Lifetime Seven Plus Beneficiary Income Option Payments to the beneficiary for life. Payments to the beneficiary for life with a certain period of guaranteed payments to you or your named beneficiary. Please indicate the number of years for the certain period: Payment for an elected number of years, not to exceed your life expectancy. Please indicate the number of years for the fixed period: Payments of a selected amount until the proceeds and interest earned are fully paid to you. Please indicate the fixed amount: $ Payments of the Annual Income Amount for a specified period of time. Select if spouse or non-spouse: Spouse Non-Spouse Payments of the Annual Income Amount for a specified period of time. Select if spouse or non-spouse: Spouse Non-Spouse Interest Payment Under this option, we will report the taxable amount of the death claim on an IRS Form 1099-R. For Qualified contracts (except Roth IRA) the distribution will be reported as fully taxable. For Roth IRA contracts the full distribution will be reported with the taxable amount as not determined. For Non-Qualified contracts the full distribution will be reported with the earnings as the taxable amount. The proceeds are then held at interest with the right to withdraw the unpaid balance. You can elect to receive interest payments or have it accumulate within the contract. The future interest will be reported in the year of payment or accrual. Hold interest to accumulate Interest will be paid to you annually unless a different frequency is checked PLEASE NOTE: If electing one of the above options, you must select frequency: Monthly Quarterly Semi-Annually Annually OTHER PAYMENT OPTIONS: To select another payment option, as allowed in the policy/contract, write your selection below: If death benefits are paid by way of a settlement or payment option and any amount remains payable upon your death, please indicate to whom you wish the remaining amount to be paid. Check one: Pay my estate. Pay the beneficiary(ies) as designated in Section 5, Beneficiary Designation. Page 4 of 15

7 4. HOW TO RECEIVE YOUR FUNDS (continued) 4 D. Additional Claim Options These options allow the beneficiary to establish a new annuity, an inherited annuity or move funds to an existing annuity. Select only ONE: A. Beneficiary Annuity Contract You must also complete and return a Beneficiary Annuity Application and other appli cable documents. The Beneficiary Annuity is only available for a contract that does not qualify for the Beneficiary Continuation Option (products listed in option C under 4B). A licensed Financial Representative must assist you when choosing this option. To locate a Financial Representative in your area, please visit our website at com. The Beneficiary Annuity Contract option is only available within a limited time period from the deceased s date of death as detailed on page 11, Tax Consequences and Tax Withholding. B. New Annuity Contract This option allows for the beneficiary to apply the proceeds to a new Prudential Annuity. Please note, an application will need to be completed. A licensed Financial Representative must assist you when choosing this option. To locate a Financial Representative in your area, please visit our website at C. Please send my death claim proceeds as a spousal rollover to my existing contract number D. Please send my death claim proceeds to the following financial institution: IMPORTANT: A Letter of Acceptance is required from the institution below. Please check this box to confirm the paperwork is forthcoming. Institution Name Account Number Street Address City State Zip Please select ONE option for your death claim proceeds: 1035 Exchange Trustee to Trustee Transfer Direct Rollover 5. BENEFICIARY DESIGNATION Complete ONLY if you elected a Continuation Option, the Continuation of Remaining Period Option, an Annuity Payout Option, or the Alliance Account. If a beneficiary designation is not made when applicable, any proceeds due at your death will be paid to your estate. The contingent beneficiary will be paid if no primary beneficiary survives the insured. Primary Beneficiary Please indicate their percentage % Social Security Number (all 9 digits required), Tax ID or EIN Date of Birth (mm/dd/yyyy) Name (First, Middle, Last ) Street Address City State Zip Relationship to You Telephone Address Page 5 of 15

8 5. BENEFICIARY DESIGNATION (continued) Beneficiary 2 Primary % Contingent % Social Security Number (all 9 digits required), Tax ID or EIN Date of Birth (mm/dd/yyyy) Name (First, Middle, Last ) Street Address City State Zip Relationship to You Telephone Address Beneficiary 3 Primary % Contingent % Social Security Number (all 9 digits required), Tax ID or EIN Date of Birth (mm/dd/yyyy) Name (First, Middle, Last ) Street Address City State Zip Relationship to You Telephone Address Page 6 of 15

9 6. TAX WITHHOLDING If this section is left blank, you are electing to NOT have Federal or State taxes withheld. However, you will still be liable for any applicable taxes. If this page is not returned or you do not make a valid withholding election, Prudential will be required to withhold federal and state taxes in accordance with law. Please note that federal and state income taxes may be withheld if you do not provide a US residential address or SSN/TIN in section 1 of this form. Or, specify the amount of federal and/or State income taxes you want withheld from the taxable portion of your distribution. Please complete either the Non-Periodic Payments or Periodic Payments section that corresponds with the option you have elected. Non-Periodic Payment Tax Withholding: Complete this section if you are electing a Lump Sum, Alliance Account, Taxable Contract Continuation, Interest Payment Option and New Annuity Contract. Federal Income Tax Election Withhold 10% Federal income taxes Withhold greater than 10% of Federal income taxes % or $ State Income Tax Election 2 Withhold state income taxes % or $ Periodic Payment Option Tax Withholding: Complete this section if you are electing a Continuation for Remaining Period Certain and Annuity Payout Options except Interest Payment Option. Federal Income Tax Election Marital Status: Married Single Total Allowances you are claiming: Additional dollar amount (optional) $ State Income Tax Election 2 Marital Status: Married Single Exemptions: Other (Please specify): Or Percentage: % Specific dollar amount (optional) $ 2 Must be at least the minimum required by your state of residence. If the amount you select is less Prudential will be required to withhold the default amount. In addition, Michigan residents must complete the following. Please choose one: Michigan law now requires 4.25% income tax withholding from pension and retirement benefits, unless your payments are not taxable, or you opt out. Please check the appropriate box below if you are a Michigan resident. Your pension or annuity payments are not taxable or you wish to opt out. Note: Opting out may result in a balance due on your MI-1040 as well as penalties and interest. % Total percentage you want withheld from your annuity payment(s) (must be at least 4.25%). If no selection is made, we will withhold 4.25% If you elect to have no income tax withheld from your withdrawal, or if you do not have enough income tax withheld from your withdrawal, you may be responsible for payment of estimated tax. You may incur penalties if your withholding and estimated tax payments are not sufficient. Please see the Tax Withholding section in the instructions on page 11. Page 7 of 15

10 7. TAX CERTIFICATION CLAIMANT S TAX CERTIFICATION (SUBSTITUTE W-9) To be completed only by U.S. persons (including U.S. citizens and resident aliens). If not a U.S. person, you are required to submit the applicable IRS Form W-8 series (BEN, BEN-E, ECI, EXP, or IMY). Under penalties of perjury, I certify that the taxpayer identification number listed on this form is my correct SSN/EIN and I am a U.S. citizen or other U.S. person (including resident aliens). I further certify that I am exempt from backup withholding and/or FATCA reporting unless I check the applicable box(es) below: I have been notified by the Internal Revenue Service that I am subject to backup withholding due to the failure to report all interest or dividends. Prudential is required to withhold income tax on any payments which include interest and dividends when the claimant is subject to back up withholding. I am subject to the reporting requirements of the Foreign Account Tax Compliance Act (FATCA). 8. SIGNATURE I have read and agree to sections 1 through 8, the Instructions and Disclosures, and the Claim Fraud Warnings included with this form. By signing this form, I represent that the information I have provided is true and complete. I understand that there may be tax implications as a result of this request. It is fraudulent to fill out this form with information I know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts. For the purpose of processing and payment of claims in an efficient and prompt manner, I authorize Prudential to consolidate and disclose completed claims forms and documents to appropriate associates for each and every one of Prudential Financial, Inc. s affiliates or business units for which a claim for payment or distribution is made. During the period from the notification of death until the Death Benefit is paid out in full, the amount of the Death Benefit is impacted by certain charges under the contract and may be subject to market fluctuations. Note: Depending on the product, a transfer to money market may not be available for the contract. Please refer to the product prospectus, if applicable and the Annuity contract for details, or visit prudentialannuities.com. FLORIDA RESIDENTS Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NEW YORK RESIDENTS 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to avoid backup withholding. SIGN HERE Beneficiary or Claimant Signature Date of Signature (mm/dd/yyyy) Print Name Relationship to the Deceased Page 8 of 15

11 9. ENTITY BENEFICIARY AUTHORIZATION Complete ONLY if Beneficiary is a Trust or Other Entity. Please check here if one or more of the beneficiaries of the trust is considered to be a skip person as defined by the Internal Revenue Code. (A skip person is a person who is two or more generations below the grantor of the trust or an unrelated person` who is at least 37½ years younger than the grantor). This is not a U.S. Entity (If this box is checked, the W8-BEN-E is also required in order to process your request.) Please indicate the type of Trust: Grantor Trust Irrevocable Non-Grantor Trust Other Name of Trust or Entity Street, City, State, ZIP Code Date of Trust Contract/Policy Number Tax ID Number The document and/or agreement creating and/or organizing the above entity, if applicable, is referred to herein as the Entity Agreement. Does the Entity Agreement authorize more than one individual to act on behalf of the entity? Yes (list below) No Authorized Individual/Trustee Name(s) Authorized Individual/Trustee Name(s) If there is more than one Authorized Individual/Trustee named in the Entity Agreement, does the Entity Agreement expressly provide that each of the Authorized Individuals/Trustees can act individually, independently, and without the consent of the other individuals authorized to act on behalf of the Entity? (This question does not apply to corporations.) An option must be selected in order for the claim to be processed. Yes No If Yes, by signing this Form the Authorized Individuals/Trustees hereby certify that Prudential may follow the instructions of any one Authorized Individual/Trustee. If no, Prudential will require the signatures of all Authorized individuals/trustees to claim a Death Benefit under the annuity. Certification, Indemnity, and Agreement: The Authorized Individuals/Trustees represent, warrant, and certify that, the representations made in this certificate are true, complete, and accurate, that the Entity is active and in compliance with state and federal laws, and that the Entity Agreement (as defined above) has not been revoked, modified or amended in any manner which would cause the representations contained in this certification to be inaccurate or incorrect. Prudential will rely on this certification and will not be held liable for any act taken by it pursuant to and in reliance upon this certificate and upon the representations made herein unless and until it receives a written amendment regarding the Entity Agreement, written notice of a change in Authorized Individual(s) /Trustee(s) or written notice of any events affecting the powers of the Authorized Individual/Trustee described above. The Authorized Individuals/Trustees agree to send written notice promptly to Prudential of any changes in Authorized Individuals/Trustees, of any amendment or modification to the Entity Agreement which would cause the representations contained in this certification to be or become inaccurate or incorrect, or of the occurrence of any event which would affect the Entity Agreement s revocability, the powers of the Authorized Individuals/ Trustees to act on behalf of the Entity, or any representations made in this certification. The Authorized Individuals/Trustees hereby agree, on behalf of themselves and the entity which they represent, to jointly and severally indemnify Prudential and each of its officers, directors, employees, and agents, from, and hold such persons harmless against, any claims, losses, judgments, surcharges, settlement amounts, or other liabilities or costs of defense or settlement (including attorney s fees) arising out of or related to any actual or alleged negligent, improper or unsuitable acts or omissions taken by Prudential upon the instruction of such Authorized Individuals/Trustees in connection with the contract referenced above. This indemnification is made by the Authorized Individuals/Trustees both in their capacities as Authorized Individuals/ Trustees for the Entity and in their individual capacities, and shall not be limited by any Authorized Individual s/trustee s provision to Prudential of independent documentation concerning the representations made herein. This section must be signed in order for the claim to be processed. SIGN HERE Authorized Individual/Trustee Signature Date of Signature (mm/dd/yyyy) SIGN HERE Authorized Individual/Trustee Signature Page 9 of 15 Date of Signature (mm/dd/yyyy)

12 TAX CONSEQUENCES, TAX WITHHOLDING, TAX CERTIFICATION Special Circumstances Tax Waiver/Consent Forms vary from state to state. Please call your State Department of Revenue (may also be referred to as the State Tax Department). 1. If the deceased was a resident of one of the following states, an additional approved Tax Waiver/Consent Form may be required: Alabama (only for Estates), Indiana, and Ohio (for claims in excess of $25,000). 2. If the death occurred in a country other than the United States: We require an original Report of Death of a U.S. Citizen Abroad from a U.S. Embassy of the country where the death occurred. 3. If a Beneficiary wants his or her Attorney-in-Fact (Power of Attorney) to complete the Beneficiary Claim Form on his or her behalf, Prudential requires that: The Power of Attorney document must be submitted with the Beneficiary Claim Form. When the Beneficiary Claim Form is completed by an Attorney-in-Fact, the form of signature must properly reflect the fiduciary relationship. Instructions on how to sign this form are provided in the signature section. Special Beneficiary Situations 1. When the Beneficiary is an Estate: The Beneficiary Claim Form must be completed by the estate s executor or administrator. A certified copy of the court appointment must be included. If the estate is eligible, you may submit a small estate affidavit in lieu of a certified copy of the court appointment. 2. When the Beneficiary is a Minor (under the age of 18): Every state has different requirements, which may vary depending on the amount of the benefits payable. If your state requires a legal guardian or custodian to accept payment on the minor s behalf: A Beneficiary Claim Form must be completed by the legal guardian or custodian of the minor s estate. A certified copy of the court appointment must also be submitted. 3. When the Beneficiary s name is different than the one listed in the annuity contract: If the Beneficiary s name has changed due to marriage, divorce, etc., include a copy of the legal document (Marriage Certificate, Divorce Decree, etc.) that documents the name change. 4. When the beneficiary designation is children or a similar designation, each beneficiary must provide a notarized affidavit which includes: Name, Address, Date of Birth, Relationship to Deceased (son, daughter), Names of all other siblings. 5. If the Beneficiary is deceased prior to submitting the claim: Include a Certified Copy of the Death Certificate for the Beneficiary. 6. When a Beneficiary is legally incompetent: Send a letter stating the Beneficiary is legally incompetent. In addition, indicate the name and address of the Beneficiary s Attorney-in-Fact under a Durable Power of Attorney. Follow all instructions for Power of Attorney as referenced in Special Circumstance No. 3 on this form. Follow all instructions as if the Beneficiary is a minor as referenced in Special Beneficiary Situations No. 2 on this form. 7. When the Beneficiary is a corporation or charitable organization: A certified copy of a corporate resolution (or its equivalent) indicating the representative is authorized to sign on behalf of the corporation or charitable organization. The corporate secretary must certify (with a raised seal) that the authority granted to the representative has not been revoked, modified or amended as of the date of the filing of the claim. The named representative must also complete and sign the Entity Beneficiary Authorization Form. Page 10 of 15 (Do Not Return this page with completed form)

13 TAX CONSEQUENCES, TAX WITHHOLDING, TAX CERTIFICATION (continued) Tax Withholding There may be tax implications as a result of this request(s), including requests to pay advisory fees, and the request(s) (including tax reporting and withholding) cannot be reversed once processed. Please consult tax and/or legal counsel before proceeding. Please refer to the annuity contract and prospectus, if applicable for provisions and tax considerations regarding withdrawals prior to submitting this form. For certain contracts the death benefit is payable upon the death of the annuitant. For such contracts, if a non annuitant owner, and the beneficiary are not the same person, the owner will receive Form 1099-R reporting the taxable income related to the distribution. However, the beneficiary, as the recipient of the death claim proceeds, is required to complete the income tax withholding election. If you purchased Non-Qualified Annuity Contracts from Pruco Life or an affiliated company in the same calendar year, they will be considered as one Annuity for tax purposes. If you take a distribution from any of these contracts, the taxable amount of the distribution will be reported to you and the IRS based on the earnings of all such contracts purchased during the same calendar year. For 401(a) and 403(b) tax deferred annuities the eligible rollover portion of your distribution is subject to a mandatory 20 percent federal income tax withholding unless directly rolled over to a traditional IRA, a 457 (governmental) or another plan qualified under Internal Revenue Code section 401(a). If your payment is from a section 403(b) or a section 401(a) qualified plan, and is an eligible rollover distribution, you will not be able to elect out of federal income tax withholding. Federal taxes will be withheld at a flat 20% rate, unless you elect to have your eligible rollover distribution directly rolled over to an IRA or to another qualified plan. Other alternatives and settlement options may require other tax forms. If needed, these will be sent to you. Federal Tax Implications For Federal tax purposes, the term spouse includes any individuals who are lawfully married under state law. Federal law does not recognize domestic partnerships or civil unions that are not designated as married under state law. Therefore, we cannot permit a civil union partner or domestic partner who is not recognized under state law as married to continue the annuity within the meaning of the tax law under the annuity s spousal continuance provision. An alternative distribution option referred to as Taxable Contract Continuation is available to domestic partners and civil unions. Eligibility Requirements for Beneficiary Continuation Option, Beneficiary Annuity Option, and Transfer/Exchange/Direct Rollover to an Inherited Annuity If you are selecting the Beneficiary Continuation Option, Beneficiary Annuity Option or are requesting a transfer/exchange or direct rollover please note the following: A) qualified death benefit proceeds, distributions required under section 401(a)(9) (B) of the Internal Revenue must begin by 12/31 of the year following the deceased s date of death. In order to proceed with your request, we must receive all the requirements 45 days prior to 12/31 cutoff. B) non-qualified death benefit proceeds, the distributions required under section 72(s) of the Internal Revenue Code must begin within one year of the deceased s date of death. In order to proceed with your request, we must receive all the requirements 45 days prior to the one year anniversary of the date of death. Taxpayer Identification Number (TIN) You must include a TIN for the beneficiary, this is: A Social Security number (SSN) if the beneficiary is an individual or the owner of a sole proprietorship; The employer identification number (EIN) if you represent a trust, estate, corporation, partnership, or tax-exempt organization; The TIN of the grantor/trustee if you represent a grantor trust, or that of the actual owner of a trust-like entity not recognized as a legal or valid trust under state law. If you are a guardian completing this form for someone else, including a minor, be sure to provide that person s SSN. Backup Withholding You must tell us if the IRS has notified you that you are subject to backup withholding because you didn t report all your taxable interest and dividends on your tax return. You are not subject to backup withholding if either (a) you did not receive such a notice from the IRS, (b) the IRS told you that you are no longer subject to a backup withholding order, or (c) you are exempt from such withholding. If you have been notified that you are subject to backup withholding, please check the box as indicated. Page 11 of 15 (Do Not Return this page with completed form)

14 TAX CONSEQUENCES, TAX WITHHOLDING, TAX CERTIFICATION (continued) Foreign Account Tax Compliance Act (FATCA) Any entity making a payment of U.S. source income must consider whether it is subject to FATCA. A payor must collect documentation about the payee s status or withhold at 30%. Nontaxable payments, such as income tax free death benefits from nonqualified life insurance contracts are not subject to FATCA. Citizenship You must indicate if you are not a U.S. person (including resident alien). In that case, you must state the country in which you are a citizen and submit the applicable IRS Form W-8(BEN, BEN-E, ECI, EXP, IMY). In most situations, the IRS Form W-8BEN will be the appropriate IRS Form W Prudential Financial, Inc. and its related entities. Prudential s Alliance Account is a registered trademark of The Prudential Insurance Company of America. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. HOW TO RECEIVE YOUR FUNDS - THE ALLIANCE ACCOUNT About the Alliance Account: Eligible(1) proceeds from your Prudential claim may be made available to you in an interest-bearing Prudential Alliance Account. With the Alliance Account you will have a flexible way to access your money. Simply by writing drafts, you can get the funds you need now for immediate expenses, then take as much time as you want to decide what to do with the rest. You may wish to access the money periodically, or all at once. Note: The Alliance Account is not available on products issued by the Prudential Annuities Life Assurance Corporation ( PALAC ) carrier. How It Works: The Alliance Account is an interest-bearing account with draft(2) writing privileges that allows full access to your funds immediately without any monthly fees. For complete information and eligibility requirements regarding the Alliance Account, please see the information below. The Alliance Account gives you flexibility and convenience with all these benefits. Easy and Immediate Access Upon approval of the death benefit claim, the full amount of the proceeds payable to you are paid via an interest-bearing Alliance Account established in your name. Advantages of the Alliance Account Convenience and Flexibility You can leave the funds in the account for as long as you wish or access any or all of your funds, at any time and at no cost. Your Money Continues to Grow The funds in your Alliance Account begin earning interest immediately and will continue to earn interest until they are withdrawn(3). Your Funds Are Secure The Alliance Account is a settlement option under the original annuity contract and is backed by the financial strength of The Prudential Insurance Company of America. See How the Alliance Account Works for details. No Usage Fees The Alliance Account has no monthly charges, per draft charges or draft reorder fees. Other fees may apply. See How the Alliance Account Works for details. Multiple Payments One Account If you are the beneficiary on more than one Prudential policy or already have an Alliance Account, proceeds will be paid into one account. A key benefit of the Alliance Account is that, as a settlement option, you may be able to pass the claim proceeds balance tax-free to your beneficiary. Page 12 of 15 (Do Not Return this page with completed form)

15 HOW TO RECEIVE YOUR FUNDS - THE ALLIANCE ACCOUNT (continued) Dedicated Customer Support You can speak directly with a customer service representative Monday through Thursday between 8 a.m. and 7 p.m., and Friday between 8 a.m. and 6 p.m. Eastern Time at Written inquiries can be sent to Prudential, P.O. Box 7960, Philadelphia, PA, You can also go online or call our automated voice-response system 24 hours a day to check your account balance, request additional drafts and more. (1). A claim is not eligible for an Alliance Account when: Benefits from all policies total less than $5,000. The beneficiary resides outside the US, is a minor, corporation, partnership, tax exempt entity, trust, or other ineligible third party. The person who owned the policy established specific provisions about death benefit payment. In these situations, the claim is paid by check or another option. The benefits are being claimed under a power of attorney, guardianship, or conservatorship. The annuity contract was issued by the Prudentlal Annuities Life Assurance Company ( PALAC ) carrier. The annuity contract was issued in or the beneficiary resides in Kentucky, Minnesota, New York or Rhode Island. (2). Alliance drafts are considered checks under federal law for certain purposes. (3). See How Interest Is Earned under How the Alliance Account Works for more details. How the Alliance Account Works Your Funds: All funds are held within Prudential s general account. It is not FDIC insured because it is not a bank account or a bank product. Funds held in the Alliance Account are guaranteed by State Guaranty Associations. Please contact the National Organization of Life and Health Insurance Guaranty Associations ( to learn more about coverage limitations on your account. State guaranty fund coverages are not determined by the insurance company. How Interest Is Earned: The funds in the Alliance Account begin earning interest immediately and will continue to earn interest until all funds are withdrawn. Interest is accrued daily, compounded daily and credited every month. The interest rate may change without notice, but not more than once a month and will vary over time. The interest rate credited to your Alliance Account is adjusted by Prudential at its discretion and may be more or less than the rate Prudential earns on the funds in the account. Currently, the interest rate is based upon a nationally recognized index of average taxable retail money market fund crediting rates, with certain minimums. In the future, we may change the index, however, the minimum interest rate that will be paid on this account will be no lower than 0.5% annually. The current rate can be obtained by contacting our customer service center at The interest earned on the Alliance Account may be taxable. You should consult with a tax, investment or other financial advisor for tax information or other available investment options. Neither we nor our representatives can provide tax advice. Account Statements: You will receive regular (either monthly or quarterly) statements showing your current balance, the interest you earned, the drafts you have written, your current interest rate, and any other account activity. The frequency at which the statements are mailed to you is determined by the activity in your Alliance Account. Special Service Fees: There are fees for special services, which are subject to change, and include stop payments ($12.00 per draft/$25 maximum for 3 or more per day); cashed draft copy or statement copy ($2.00 per); drafts returned for insufficient funds ($10.00 per draft) and overnight delivery (based on carrier s charge). Page 13 of 15 (Do Not Return this page with completed form)

16 HOW TO RECEIVE YOUR FUNDS - THE ALLIANCE ACCOUNT (continued) Minimum Balance: If the balance falls below $250, you will receive a check for the remaining balance plus interest at the end of the monthly cycle in which the balance fell below $250. You can close the Alliance Account at anytime by calling the Customer Service office. A check for the remaining balance and interest will be sent to you. Or, you can close the account by writing an Alliance draft for the balance and cashing it or depositing it at your own bank. Since interest accrues daily, a check for the remaining accrued interest will be sent to you. Inactive Accounts: State law requires that if there is no account activity and we have had no contact with you regarding your Alliance Account after a number of years (which time period varies by state), your Alliance Account may be considered dormant. If your Alliance Account becomes dormant, you will be mailed a check for the remaining balance plus interest, at your last address shown on our records. If you do not timely cash that check, your funds will be transferred to the state as unclaimed property. If your funds are transferred to the state, you may claim those funds from the state but you may be charged a fee by the state. Once your funds are transferred to the state, we no longer have any liability or responsibility with respect to your Alliance Account. FOR FURTHER INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE. The Bank of New York Mellon is the Administrator of the Prudential Alliance Account Settlement Option, a contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ Draft clearing and processing support is provided by The Bank of New York Mellon. Alliance Account balances are not insured by the Federal Deposit Insurance Corporation (FDIC). The Bank of New York Mellon is not a Prudential Financial company. Page 14 of 15 (Do Not Return this page with completed form)

17 CLAIM FRAUD WARNINGS The Fraud Warning Notification is required if you are a resident of, or if the contract was issued in, the following: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas, Louisiana, Texas and West Virginia: 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 fines and confinement in prison. California: For your protection California law requires the following: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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. Delaware, Idaho, Indiana and Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a 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. Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits. Maryland and Rhode Island: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey and 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. Ohio: Any person who, with 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 is guilty of insurance fraud. Oregon: It is fraudulent to fill out this form with information I know to be false or omit important facts with the intention to defraud. Criminal and/or civil penalties may result from such acts. An insurer may deny a claim on the basis of misstatements, misrepresentations, omissions or concealments if such misinformation is material to the contract, the insurer relies on the misinformation, and the information is either material to the risk assumed by the insurer or the misinformation was provided fraudulently. 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 the state law. All Other States: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit may be guilty of a crime and subject to fines and confinement in prison. Page 15 of 15 (Do Not Return this page with completed form)