Beneficiary Change and Predetermined Payout Election Form For PruSecure Fixed Indexed Annuity

Transcription

1 Beneficiary Change and Predetermined Payout Election Form For PruSecure Fixed Indexed Annuity Annuities are issued by Prudential Annuities Life Assurance Corporation (PALAC), located in Shelton, CT (main office), a Prudential Financial, Inc. company, which 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 and its affiliates. This form is used to name or change your beneficiary(ies) or any predetermined payout options for your beneficiary(ies). Please refer to your contract for additional information. Confirmation of your beneficiary(ies) and any applicable restrictions submitted with an annuity application will be sent to you separately from your Annuity contract. 1. OWNER INFORMATION New Annuity Existing Annuity Annuity Number Owner Name (First, Middle, Last Name) Joint Owner Name (First, Middle, Last Name) If we require additional information to complete this request, please indicate who Prudential should contact: Owner Financial Professional 2. REASON FOR THIS FORM MUST CHECK ONE If this change is a result of a divorce Prudential may require the Notification of Divorce and Division Form For PruSecure Fixed Indexed Annuities. Add/change beneficiary(ies) only. Please complete Section 3 and proceed to Signature Page.This will remove all existing beneficiaries and replace with those provided on this form unless otherwise indicated in the Section for Special Remarks. Add/change beneficiary(ies) with pre-determined payout options. Please complete Section 4 and then proceed to the Signature Page. This will remove all existing beneficiaries and/or pre-determined payout options and replace with those provided on this form unless otherwise indicated in the Section for Special Remarks. Page 1 of 8

2 3. BENEFICIARY DESIGNATIONS ONLY Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will Beneficiary Page 2 of 8

3 3. BENEFICIARY DESIGNATIONS ONLY (continued) Beneficiary IF YOU HAVE ADDITIONAL BENEFICIARIES, PLEASE ADD AND SUBMIT THEM ON A SEPARATE PIECE OF PAPER. STOP Section 4 should only be completed if you wish to elect a predetermined payout option for a beneficiary(ies). If you are not electing a predetermined payout, please complete Section 3 and the Signature page only. If you choose to elect a Predetermined Payout Option for any of your beneficiaries, please carefully review the following: The general provisions of your Annuity contract give the beneficiary(ies) choices ranging from an immediate lump sum distribution to a variety of income streams payable for a period of years not to exceed the beneficiary(ies) life expectancy. This form gives the Contract Owner(s) the ability to elect how their beneficiary(ies) will receive the death benefit value of the contract. These elections are irrevocable upon your death. Your beneficiary(ies) would still have the right to fully surrender their Beneficiary Annuity(ies). Please note that restrictions must be expressly indicated. If no restriction is noted, it is presumed that your beneficiary(ies) can elect any payout option available under your Annuity Contract. This form can be completed at any time prior to the Contract Owner s death. It can be submitted with an Application for a new contract, or as a beneficiary change request on an existing contract. This will revoke and replace any beneficiary designations previously received unless an irrevocable beneficiary designation is on file. Pre-determining the Death Benefit Distribution is only available for Individuals and/or Grantor Trust(s) designated as beneficiaries. If the Beneficiary is a Minor at the time of the claim, additional information may be required. Every state has different requirements, which may vary depending upon the amount of the benefits payable. If your state requires a legal guardian for the minor s property and/or estate or custodian to accept payment on the minor s behalf, a certified copy of the court appointment will be required. Please note that the timing of your beneficiary(ies) claim may impede our ability to distribute the death benefit proceeds in accordance with any restrictions elected on this form. Specifically, please note that due to Internal Revenue Service (IRS) regulations, a claim must be made, and the first distribution must occur, within one year of the date the death benefit becomes payable for non-qualified contracts and by 12/31 of the year following the year in which the death benefit becomes payable for qualified contracts. We strongly recommend that you consult with your Financial Professional and tax advisor to determine if a restriction is appropriate and if so, which best meets your and/or your beneficiary(ies) needs. The following is a brief description of each Predetermined Payout Option available: Note: All eligibility requirements, including death benefit payout option minimums, must be met (see contract for more details). Page 3 of 8

4 STOP (continued) Beneficiary Annuity - This option will require the completion of a Beneficiary Annuity Application once the Death Claim process has begun. A Beneficiary Annuity will allow the beneficiary to continue the contract and receive payments over his/her life expectancy while maintaining the ability to allocate the death benefit proceeds among the interest crediting strategies. The beneficiary will receive the minimum amount each year needed to satisfy IRS Requirements. The beneficiary may name successor beneficiaries and if the beneficiary dies prior to receiving all payments, their designated successor beneficiaries may continue receiving the payments or elect a lump-sum distribution. If the Age Restriction to withdraw Death Benefit option is elected, no withdrawals (other than Required Distributions) will be permitted until the beneficiary reaches the attained age that you provide. Please contact your Financial Professional or the Annuities Service Center with any questions. Life Only Income This option will restrict the beneficiary to receive payments over his/her life expectancy via a fixed immediate annuity. No additional withdrawals are permitted. There is no death benefit value payable at the time of this beneficiary s death. Life Income with a Period Certain* This fixed immediate annuity option will restrict the beneficiary to receive payments over his/her remaining life expectancy where you can predetermine a number of years of guaranteed payments. No additional withdrawals are permitted. If the beneficiary dies prior to the end of the certain period the remaining amount will be passed to that beneficiary s successor beneficiary(ies). If the beneficiary dies after the end of the certain period there will be no death benefit payable. Beneficiary s Choice This option will restrict the beneficiary to receive payments over his/her remaining life expectancy, but will allow the beneficiary to choose any of the payout options described above. Lump Sum in Combination with a Restriction You may select a certain percentage of the death benefit to be paid in a lumpsum to their designated beneficiary(ies). The remainder will be applied to the Death Benefit Distribution Option elected by the Contract Owner(s). Age Restriction Death Benefit Distribution Option If the death benefit becomes payable when the beneficiary is below the age indicated, the death benefit will be applied to the Death Benefit Distribution Option elected. If the death benefit becomes payable after the beneficiary reaches the age indicated, these restrictions will no longer apply and the beneficiary can elect any Death Benefit Option available at the time. *Note: If a Period Certain option is chosen and it exceeds the beneficiary s life expectancy at the time that the death benefit becomes payable, the next longest duration not exceeding the beneficiary s current life expectancy will be applied. Page 4 of 8

5 4. BENEFICIARY DESIGNATIONS WITH PREDETERMINED PAYOUT ELECTIONS Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will Beneficiary 1 Beneficiary 1: Predetermined Payout Options (Only one payout option is permitted.) Stretch Annuity Option: Beneficiary Annuity Please also choose one of the following three options if Stretch Annuity Option is elected. Required Distributions only; no additional withdrawals are permitted. The beneficiary may take withdrawals in addition to the Required Distribution. Age Restriction to Withdraw Death Benefit: Required Distributions only. Once the beneficiary attains the age of, he/she may take withdrawals in addition to the Required Distributions. Life Only Annuity (not available for Beneficiary Annuities) Life Annuity with a Period Certain 1 (not available for Beneficiary Annuities) Beneficiary s choice (not available for Beneficiary Annuities) 1 Period Certain Options: 5 years 10 years 15 years 20 years 25 years Additional Options: Lump Sum Distribution of % of the death benefit to be paid to the beneficiary. Any remainder will be applied to the Death Benefit Distribution Option elected above. Age Restriction Death Benefit Distribution Option. Predetermined payout elections are in effect only until the beneficiary attains years of age. Page 5 of 8

6 4. BENEFICIARY DESIGNATIONS WITH PREDETERMINED PAYOUT ELECTIONS (continued) Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will Beneficiary 2 Beneficiary 2: Predetermined Payout Options (Only one payout option is permitted.) Stretch Annuity Option: Beneficiary Annuity Please also choose one of the following three options if Stretch Annuity Option is elected. Required Distributions only; no additional withdrawals are permitted. The beneficiary may take withdrawals in addition to the Required Distribution. Age Restriction to Withdraw Death Benefit: Required Distributions only. Once the beneficiary attains the age of, he/she may take withdrawals in addition to the Required Distributions. Life Only Annuity (not available for Beneficiary Annuities) Life Annuity with a Period Certain 1 (not available for Beneficiary Annuities) Beneficiary s choice (not available for Beneficiary Annuities) 1 Period Certain Options: 5 years 10 years 15 years 20 years 25 years Additional Options: Lump Sum Distribution of % of the death benefit to be paid to the beneficiary. Any remainder will be applied to the Death Benefit Distribution Option elected above. Age Restriction Death Benefit Distribution Option. Predetermined payout elections are in effect only until the beneficiary attains years of age. Page 6 of 8

7 4. BENEFICIARY DESIGNATIONS WITH PREDETERMINED PAYOUT ELECTIONS (continued) Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will Beneficiary 3 Beneficiary 3: Predetermined Payout Options (Only one payout option is permitted.) Stretch Annuity Option: Beneficiary Annuity Please also choose one of the following three options if Stretch Annuity Option is elected. Required Distributions only; no additional withdrawals are permitted. The beneficiary may take withdrawals in addition to the Required Distribution. Age Restriction to Withdraw Death Benefit: Required Distributions only. Once the beneficiary attains the age of, he/she may take withdrawals in addition to the Required Distributions. Life Only Annuity (not available for Beneficiary Annuities) Life Annuity with a Period Certain 1 (not available for Beneficiary Annuities) Beneficiary s choice (not available for Beneficiary Annuities) 1 Period Certain Options: 5 years 10 years 15 years 20 years 25 years Additional Options: Lump Sum Distribution of % of the death benefit to be paid to the beneficiary. Any remainder will be applied to the Death Benefit Distribution Option elected above. Age Restriction Death Benefit Distribution Option. Predetermined payout elections are in effect only until the beneficiary attains years of age. 5. SPECIAL REMARKS / ADDITIONAL BENEFICIARY REQUESTS Use this section to name an additional beneficiary, a class or group. If additional space is needed you can attach additional documentation with all the required information for each beneficiary. Page 7 of 8

8 6. ADDITIONAL INFORMATION If you are naming an Entity, (i.e., corporation, charity, etc.), as a beneficiary, you must include the complete address. If this information is not included, the new beneficiary designation will not be completed as requested. Your resident state may be subject to the Uniform Unclaimed Property Act. This legislation requires that you complete all information pertaining to your beneficiary(ies) i.e., address, Social Security number, date of birth. If you reside in AZ, CA, ID, LA, NV, NM, WA, WI and want to change the beneficiary on this contract your spouse s consent may be required. If the change is a result of marriage, divorce, or death, we will require your marriage certificate, divorce decree, or death certificate. Massachusetts residents state law requires that a disinterested adult who is not a party to the contract witness any request to change the beneficiary arrangement. Note: Your Financial Professional can sign as a witness. 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. 7. SIGNATURES Based on Product, we: Agree to the request(s) made on this form; Certify that no other person has any claim or interest in the contract except for an assignee under any assignment now on record with Prudential; and I hereby authorize Prudential to act on instructions within this restriction form. I understand that it is my responsibility to notify Prudential in writing of a change in or revocation of restriction. Special Note: I understand that Prudential reserves the right, to terminate the restriction and pay a lump sum distribution, if at the time the death benefit becomes payable, the Internal Revenue regulations, federal, or, state laws prohibit the requested restriction. SIGN HERE Contract Owner Signature Date of Signature SIGN HERE Joint Owner Signature (if applicable) Date of Signature SIGN HERE Spouse Signature (if applicable) Date of Signature SIGN HERE Witness Signature (if applicable) Date of Signature Name of Broker Dealer Firm 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 :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 Page 8 of 8 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA 19025