Subsequent Payment Allocation Instruction Form for Premier Retirement and Premier Advisor (And 6 or 12 Month Dollar Cost Averaging (DCA) Program)

Transcription

1 Subsequent Payment Allocation Instruction Form for Premier Retirement and Premier Advisor (And 6 or 12 Month Dollar Cost Averaging (DCA) Program) Variable Annuities are issued by Pruco Life Insurance Company, in New York, by Pruco Life Insurance Company of New Jersey (these entities are referred to as Prudential below). Both 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 The Prudential Insurance Company of America (PICA) and its affiliates. Submit this completed form with an additional purchase payment. See section 5 to enroll in the 6 or 12 Month DCA Program. For use only with Premier Retirement and Premier Advisor. Instructions: All information must be typed or printed using blue or black ink. This form cannot be used to provide trade instructions. NOTE: Prudential reserves the right to limit, restrict, or suspend additional Purchase Payments based on product, benefit and/or state availability. SECTION 1 Annuity Number OWNER INFORMATION Owner Name (First, Middle, Last Name) Owner Social Security/Tax I.D. Number Telephone Number SECTION 2 ALLOCATION INSTRUCTIONS A. CHECK APPROPRIATE BOX BELOW If you elected one of the following: Highest Daily Lifetime Income 2.0 (HDI 2.0), Highest Daily Lifetime Income v2.1 (HDI v2.1) or Highest Daily Lifetime Income v3.0 (HDI v3.0) Suite of Benefits you may only invest among the available Subaccounts listed in Box 1 of section 2C. NOTE: With HDI v3.0 Suite of Benefits, 10% of each Purchase Payment will be automatically allocated to the Secure Value Account. You should be aware that the Purchase Payments allocated to your elected investment options will be adjusted proportionally based on the amount allocated to the Secure Value Account. If you elected, HD6 Plus (subsequent purchase payments available only if your Annuity was issued in Oregon) or HDI Suite of Benefits, Highest Daily Guaranteed Return Option II (HD GRO II), GRO Plus II, Highest Anniversary Value (HAV) or Combination 5% Roll-Up you may invest: Among the available Sub-accounts listed in Box 1 only in section 2C; or In the Custom Portfolios Program in section 3 If you elected Legacy Protection Plus Death Benefit, you may invest: Among the available Sub-accounts listed in Box 1 only in section 2C; or In the Custom Portfolios Program in section 4 If no Optional Benefit is elected, any sub-accounts and/or Long Term Market Value Adjustment (MVA) Options may be selected for allocation. Note: If you elected the 6 or 12 Month DCA program you must also complete section 5. The allocation instructions you provide will be used for the monthly transfers. $2,000 minimum required for DCA program. B. Long Term Market Value Adjustment (MVA) Options 3-year Fixed % 5-year Fixed % 7-year Fixed % 10-year Fixed % (Continued) ORD Ed. 12/17 p1 of 8

2 SECTION 2 ALLOCATION INSTRUCTIONS (CONTINUED) C. Sub-Account Allocations ASSET ALLOCATION PORTFOLIOS BOX 1 Traditional AST Balanced Asset Allocation AST Capital Growth Asset Allocation AST New Discovery Asset Allocation AST Preservation Asset Allocation AST Quantitative Modeling 1 AST T. Rowe Price Asset Allocation AST T. Rowe Price Growth Opportunities 2 Tactical AST Goldman Sachs Multi-Asset AST J.P. Morgan Global Thematic AST RCM World Trends Quantitative AST FI Pyramis Quantitative Portfolio* AST Legg Mason Diversified Growth 2 AST Prudential Growth Allocation Alternative AST Academic Strategies Asset Allocation AST Advanced Strategies AST BlackRock Global Strategies AST J.P. Morgan Strategic Opportunities AST Managed Alternatives 3 AST Wellington Management Hedged Equity DOMESTIC EQUITY Large Cap Growth AST Jennison Large-Cap Growth AST Loomis Sayles Large-Cap Growth AST MFS Growth AST T. Rowe Price Large-Cap Growth Large Cap Blend AST AQR Large-Cap AST Clearbridge Dividend Growth AST QMA Large-Cap AST QMA US Equity Alpha Large Cap Value AST Goldman Sachs Large-Cap Value AST Hotchkis & Wiley Large-Cap Value AST MFS Large-Cap Value AST T. Rowe Price Large-Cap Value Mid Cap Growth AST Goldman Sachs Mid-Cap Growth Mid Cap Value AST Neuberger Berman / LSV Mid-Cap Value AST WEDGE Capital Mid-Cap Value Small Cap Growth AST Small-Cap Growth AST Small-Cap Growth Opportunities Small Cap Value AST Goldman Sachs Small-Cap Value AST Small-Cap Value INTERNATIONAL EQUITY Developed Markets AST International Growth AST International Value AST J.P. Morgan International Equity AST MFS Global Equity 1 Available with Legacy Protection Plus death benefit. Not available with any optional living benefits, HAV or Combination 5% roll up death benefits. 2 Only available with the HDI v3.0 suite of benefits, Legacy Protection Plus or if no optional benefit is selected. 3 Not available with any optional living and/or death benefit and only available on Premier Advisor. *Pyramis is a registered service mark of FMR LLC. Used with permission. (Continued) ORD Ed. 12/17 p2 of 8

3 SECTION 2 ALLOCATION INSTRUCTIONS (continued) AST AQR Equity AST Parametric Equity ALTERNATIVES AST Cohen & Steers Realty AST Global Real Estate AST Morgan Stanley Multi-Asset 3 AST Neuberger Berman Long/Short 3 AST T. Rowe Price Natural Resources AST Wellington Management Real Total Return 3 FIXED INCOME Domestic AST BlackRock/Loomis Sayles Bond AST BlackRock Low Duration Bond AST Government Money Market AST Lord Abbett Core Fixed Income AST Prudential Core Bond AST Western Asset Core Plus Bond High Yield AST High Yield International AST Templeton Global Bond AST Western Asset Debt ADDITIONAL PORTFOLIOS AVAILABLE WITH THE PRUDENTIAL PREMIER ADVISOR ONLY. ProFund Portfolios % Large Cap Growth ProFund VP Large-Cap Growth Large Cap Value ProFund VP Large-Cap Value Mid Cap Growth ProFund VP Mid-Cap Growth Mid Cap Value ProFund VP Mid-Cap Value Small Cap Growth ProFund VP Small-Cap Growth Small Cap Value ProFund VP Small-Cap Value Specialty Portfolio ProFund VP Consumer Goods ProFund VP Consumer Services ProFund VP Financials ProFund VP Health Care ProFund VP Industrials ProFund VP Real Estate ProFund VP Telecommunications ProFund VP Utilities Total allocations for Sub-account(s) and/or Market Value Adjustment (MVA) Options must total 100% or the total amount of the purchase payment. Use dollar amounts or whole number percentages only. These Allocations will be used for Future Purchase Allocations and Auto Rebalancing for additional remittances, unless additional instructions are received. Special Programs may have specific Sub-account restrictions. See program enrollment forms for additional details. 3 Not available with any optional living and/or death benefit and only available on Premier Advisor. ORD Ed. 12/17 p3 of 8

4 SECTION 3 CUSTOM PORTFOLIOS PROGRAM INSTRUCTIONS Only for use with HD6 Plus 4 or HDI Suite of Benefits, HD GRO II, GRO Plus II, HAV or Combination 5% Roll-Up optional benefit. By allocating to the Sub-accounts in this section, you will be automatically enrolled in a quarterly rebalance program. You may not allocate to any Sub-account not listed below. Please see the prospectus for program details. A. FIXED INCOME PORTFOLIOS At least 20% must be allocated among these Fixed Income Portfolio Sub-accounts. Domestic AST BlackRock/Loomis Sayles Bond AST Lord Abbett Core Fixed Income AST Prudential Core Bond AST Western Asset Core Plus Bond B. ADDITIONAL PORTFOLIOS No more than 80% may be allocated among these Additional Portfolio Sub-accounts. DOMESTIC EQUITY Large Cap Growth AST Jennison Large-Cap Growth AST Loomis Sayles Large-Cap Growth AST MFS Growth AST T. Rowe Price Large-Cap Growth Large Cap Blend AST ClearBridge Dividend Growth AST QMA US Equity Alpha Large Cap Value AST Goldman Sachs Large-Cap Value AST Hotchkis & Wiley Large-Cap Value AST MFS Large-Cap Value AST T. Rowe Price Large-Cap Value Mid Cap Growth AST Goldman Sachs Mid-Cap Growth Mid Cap Value AST Neuberger Berman / LSV Mid-Cap Value AST WEDGE Capital Mid-Cap Value Small Cap Growth AST Small-Cap Growth AST Small-Cap Growth Opportunities Small Cap Value AST Goldman Sachs Small-Cap Value AST Small-Cap Value INTERNATIONAL EQUITY Developed Markets AST International Growth AST International Value AST J.P. Morgan International Equity AST MFS Global Equity AST Parametric Equity FIXED INCOME Domestic AST BlackRock Low Duration Bond AST Government Money Market High Yield AST High Yield International AST Templeton Global Bond ALTERNATIVES AST Cohen & Steers Realty AST Global Real Estate AST T. Rowe Price Natural Resources 4 Subsequent purchase payments available only for Annuities issued in Oregon. (Continued) ORD Ed. 12/17 p4 of 8

5 SECTION 3 CUSTOM PORTFOLIOS PROGRAM INSTRUCTIONS (continued) ASSET ALLOCATION PORTFOLIOS Traditional AST Balanced Asset Allocation AST Capital Growth Asset Allocation AST New Discovery Asset Allocation AST Preservation Asset Allocation AST T. Rowe Price Asset Allocation Tactical AST Goldman Sachs Multi-Asset AST J.P. Morgan Global Thematic AST RCM World Trends Quantitative AST FI Pyramis Quantitative Portfolio* AST Prudential Growth Allocation Alternative AST Academic Strategies Asset Allocation AST Advanced Strategies AST BlackRock Global Strategies AST J.P. Morgan Strategic Opportunities AST Wellington Management Hedged Equity ADDITIONAL PORTFOLIOS AVAILABLE WITH THE PRUDENTIAL PREMIER ADVISOR ONLY. ProFund Portfolios (%) Core Asset Class Portfolio ProFund VP Large-Cap Growth ProFund VP Large-Cap Value ProFund VP Mid-Cap Growth ProFund VP Mid-Cap Value ProFund VP Small-Cap Growth ProFund VP Small-Cap Value Specialty Portfolio ProFund VP Consumer Goods ProFund VP Consumer Services ProFund VP Financials ProFund VP Health Care ProFund VP Industrials ProFund VP Real Estate ProFund VP Telecommunications ProFund VP Utilities INVESTMENTS MUST TOTAL 100%. TOTAL INVESTMENT 100 % *Pyramis is a registered service mark of FMR LLC. Used with permission. ORD Ed. 12/17 p5 of 8

6 SECTION 4 CUSTOM PORTFOLIOS PROGRAM INSTRUCTIONS - LEGACY PROTECTION PLUS By allocating to the Sub-accounts in this section, you will be automatically enrolled in a quarterly rebalance program. Please see the prospectus for program details. A. FIXED INCOME PORTFOLIOS At least 30% must be allocated among these Fixed Income Portfolio Sub-accounts. Domestic AST BlackRock/Loomis Sayles Bond AST BlackRock Low Duration Bond AST Government Money Market AST Lord Abbett Core Fixed Income AST Prudential Core Bond AST Western Asset Core Plus Bond International AST Templeton Global Bond B. ADDITIONAL PORTFOLIOS No more than 70% may be allocated among these Additional Portfolio Sub-accounts. Asset Allocations listed in box 1 only in Section 2C may also be selected for this section. DOMESTIC EQUITY Large-Cap Growth AST Jennison Large-Cap Growth AST Loomis Sayles Large-Cap Growth AST MFS Growth AST T. Rowe Price Large-Cap Growth Large-Cap Blend AST AQR Large-Cap AST ClearBridge Dividend Growth AST QMA Large-Cap AST QMA US Equity Alpha Large-Cap Value AST Goldman Sachs Large-Cap Value AST Hotchkis & Wiley Large-Cap Value AST MFS Large-Cap Value AST T. Rowe Price Large-Cap Value Mid-Cap Growth AST Goldman Sachs Mid-Cap Growth Mid-Cap Value AST Neuberger Berman / LSV Mid-Cap Value AST WEDGE Capital Mid-Cap Value Small-Cap Growth AST Small-Cap Growth AST Small-Cap Growth Opportunities Small-Cap Value AST Goldman Sachs Small-Cap Value AST Small-Cap Value INTERNATIONAL EQUITY Developed Markets AST International Growth AST International Value AST MFS Global Equity AST AQR Equity AST Parametric Equity FIXED INCOME High Yield AST High Yield AST Western Asset Debt ALTERNATIVES AST Cohen & Steers Realty AST Global Real Estate AST T. Rowe Price Natural Resources INVESTMENTS MUST TOTAL 100%. TOTAL INVESTMENT 100 % ORD Ed. 12/17 p6 of 8

7 SECTION 5 6 OR 12 MONTH DOLLAR COST AVERAGING (DCA) PROGRAM (Minimum of $2,000) May not be available in all states. This section is only applicable if you wish to participate in the 6 or 12 Month DCA program. To enroll in the program check the applicable box below. Each time you make an additional Purchase Payment, you will need to elect a new 6 or 12 Month DCA Program for that additional Purchase Payment. If you do not provide such instructions, we will allocate that additional Purchase Payment on a pro rata basis to the Sub-accounts in which your Account Value is then allocated, excluding Subaccounts to which you may not electively allocate Account Value. You may not participate in both the 6 and 12 Month DCA programs at the same time. Indicate the percentage of the purchase payment to one of the programs below. 6 Month DCA MVA Option % of purchase payments (if not 100%, the remaining percentage will be applied directly to the allocation instruction provided in section 2 or if you are electing Custom Portfolios Program you must select funds in Section 3 only) or 12 Month DCA MVA Option % of purchase payments (if not 100%, the remaining percentage will be applied directly to the allocation instruction provided in section 2 or if you are electing Custom Portfolios Program you must select funds in Section 3 only) SECTION 6 ACKNOWLEDGEMENT TRANSACTION CONFIRMATIONS We may confirm regularly scheduled transactions, including, but not limited to, the Annual Maintenance Fee, electronic fund transfer, Systematic Withdrawal/ Required Minimum Distribution / 72(t) / 72(q) programs, auto rebalancing, the Custom Portfolios Program and Dollar Cost Averaging in quarterly statements instead of confirming those transactions immediately. I/we acknowledge by signing below that I/we have received the applicable product prospectus. I/we further acknowledge that I/we read and understand the program disclosure below. Prudential reserves the right to discontinue, modify or amend the 6 or 12 Month DCA program at any time. This program may not be available in all states. Any change to the program will not affect contract owners currently enrolled in the program unless required by law. See the prospectus for complete details. It s important to note that when electing the 6 or 12 Month DCA program in conjunction with the HD6 Plus 4, HDI, HDI 2.0, HDI v2.1 or HDI v3.0 Suite of Benefits, money could be transferred out of the DCA MVA Option and into the AST Investment Grade Bond Portfolio, if dictated by the predetermined mathematical formula employed under the HD6 Plus 4, HDI, HDI 2.0, HDI v2.1 or HDI v3.0 Suite of Benefits.This reduces the amount of Account Value earning a fixed rate of return, and the dollar amount of remaining program transfers. Withdrawals or transfers from an MVA Option made outside of this DCA Program are subject to an MVA, assuming no waiver of the MVA otherwise applies. 6 or 12 Month DCA transfers will begin on the date the DCA MVA Option is established and on each month following until the entire principal amount plus earnings is transferred. The credited interest rates are annualized rates the effective annual yield over one year. However, interest is credited on a daily basis on a declining balance due to the transfers of Account Value to the selected sub-account(s) during the program duration and/or transfers to the AST Investment Grade Bond Portfolio, if dictated by the predetermined mathematical formula employed under the HD6 Plus 4, HDI, HDI 2.0, HDI v2.1 or HDI v3.0 Suite of Benefits. Because the program transfers Account Value each month out of the DCA MVA Option, you earn interest on a declining balance rather than the full amount allocated initially to the program. All 6 or 12 Month DCA transfers will be confirmed on quarterly statements. We recommend that you review your statement promptly. If for any reason you believe the statement does not properly reflect the DCA transfers, contact the Annuities ServiceCenter immediately. In cases of multiple transfers/1035 exchanges, an allocation to a new DCA MVA Option is established for each purchase payment received if they are not received on the same day. Please note the interest rate on the DCA MVA Option may vary depending on the date the purchase payment is allocated to the annuity. Rate Lock is not available with the 6 or 12 Month DCA program. Dollar cost averaging does not assure a profit, or protect against a loss. Please see the prospectus for additional details about the 6 or 12 Month DCA Program. 4 Subsequent purchase payments available only for Annuities issued in Oregon. ORD Ed. 12/17 p7 of 8

8 SECTION 7 SIGNATURES I request that my Purchase Payment(s) be allocated according to the instructions indicated above. SIGN HERE Owner s signature Date of signature (Month / Day / Year) SIGN HERE Co-Owner s signature Date of signature (Month / Day / Year) SIGN HERE Party-In-Interest s signature Date of signature (Month / Day / Year) SIGN HERE Financial Professional s signature Date of signature (Month / Day / Year) 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 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 ORD Ed. 12/17 p8 of 8