Custodial Election of Optional Living Benefits Form

Transcription

1 Custodial Election of Optional Living Benefits Form For Use With Advanced Series Variable Annuities. Not for use in New York. This form is intended to facilitate post issue election of any GRO Plus II or Highest Daily GRO II (HD GRO II) benefit. The following entity types are not permitted to elect or re-elect any optional benefits even if the entity previously owned an optional benefit with Prudential Annuities: Corporation Non-profit Corporation Limited Liability Company (LLC) Partnership Endowment Omnibus Qualified Plan (pooled account) Annuities are issued by Prudential Annuities Life Assurance Corporation, 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. PLEASE NOTE! For use with XTra Credit SM Six XTra Credit SM Eight ASAP III APEX SM II ASL II CHOICE 2000 AS Cornerstone; also for use with Optimum, Optimum 4, Optimum Plus, Optimum XTra (only if LPL Financial Corporation is no longer Broker Dealer firm). Refer to prospectus for information on any specific Owner/Annuitant or beneficiary requirements for electing these benefits. We may apply certain limitations, restrictions, and/or underwriting standards as a condition of our issuance of an optional benefit and/ or acceptance of Purchase Payments. Instructions: All information must be typed or printed using blue or black ink. SECTION 1 CUSTODIAN INFORMATION Annuity Number Custodian Name Telephone Number Annuitant Name (First, Middle, Last Name) Telephone Number Date of Birth (Month/Day/Year) If we require additional information to complete this request, please indicate who Prudential should contact: Owner Financial Professional ORD Ed. 5/18 p1 of 6

2 SECTION 2 ELECTING A NEW BENEFIT Select one of the following options below only if you do not have any existing optional living benefits on your Annuity: GRO Plus II GRO Plus II with Auto Step up Highest Daily GRO II If your Annuity Date is prior to your GRO benefit maturity date, you may change your Annuity Date to the latest available Annuity Date permitted by your Annuity. Changing the Annuity Date will allow you to fully realize your GRO benefit guarantees. Please check the schedule pages of your Annuity and GRO benefit to determine if your Annuity Date is prior to your GRO benefit maturity date. 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. If you add a benefit and wish to continue your current systematic withdrawal program, your withdrawals must be taken in accordance with your benefit and your guarantees will be impacted. Please see your prospectus and contract for further details about how withdrawals impact your benefit. Highest Daily Guaranteed Return Option II (HD GRO II) and Guaranteed Return Option Plus II (GRO Plus II) use a predetermined mathematical formula to help us manage your guarantee(s) through all market cycles. Every business day, the formula determines if any portion of the account value needs to be transferred into or out of certain AST bond portfolio subaccounts (the Bond Portfolios ). HD GRO II and GRO Plus II use separate and different predetermined mathematical formulas. Amounts transferred by each formula depend on a number of factors unique to your individual annuity and include: (i) The difference between the account value and the Guarantee Amount(s); (ii) The amount of time until the maturity of the Guarantee(s); (iii) The amount invested in, and the performance of, the permitted subaccounts; (iv) The amount invested in, and the performance of, the Bond Portfolios; (v) The discount rate used to determine the present value of the Guarantee(s); and (vi) The impact of additional purchase payments made to and withdrawals taken from the annuity. Please note that for GRO Plus II, upon creation of a new enhanced guarantee, an immediate transfer to the AST Bond Portfolio Subaccount associated with the current liability may occur, depending on the discount rate used to determine the present value of each of your guarantees. As such, a low discount rate could cause a transfer of Account Value into an AST Bond Portfolio Sub-account, despite the fact that your Account Value had increased. At any given time, some, none, or most of the account value may be allocated to the Bond Portfolios. Transfers to and from the Bond Portfolios do not impact any guarantees that have already been locked in for HD GRO II and/or GRO Plus II. Any amounts invested in the Bond Portfolios will affect your ability to participate in a subsequent market recovery within the permitted subaccounts. Conversely, the account value may be higher at the beginning of the market recovery; e.g., more of the account value may have been protected from decline and volatility than it otherwise would have been had the benefit not been elected. Please note: We are not providing investment advice through the formula. Your clients may not allocate purchase payments or transfer account value into or out of the Bond Portfolios. See the prospectus for complete details. ORD Ed. 5/18 p2 of 6

3 IMPORTANT INSTRUCTIONS Please ONLY complete EITHER Section 3 or 4 below on the following pages. Total allocations for Sub-account(s) must total 100%. These Allocations will be used for Future Purchase Allocations and Auto Rebalancing for additional subsequent payments, unless additional instructions are received. Special Programs may have specific Sub-account restrictions. SECTION 3 ALLOCATION INSTRUCTIONS (FOR GRO PLUS II AND HD GRO II) Use Current Allocations: Investment allocation restrictions apply. If your existing variable investment allocations are permitted under the GRO Plus II or HD GRO II, those allocations will remain intact at the outset of the program. However, if you are currently invested in variable investment options not allowed under the GRO Plus II or HD GRO II, you will need to reallocate your variable investment options (please complete variable investment allocations below) before beginning the GRO Plus II or HD GRO II. Please Note: Your GRO Plus II or HD GRO II cannot begin unless your variable investment options are allocated to those allowed under the benefit. If you select this box and your current fund allocation includes any restricted funds, a delay in processing the addition of the GRO Plus II or HD GRO II will occur for at least one Business Day following the Business Day when we receive a request in Good Order. Please confirm with your financial professional that your current fund allocation does not include any restricted funds and that your current allocation is in compliance with the Investment allocation restrictions that are applicable with this benefit. If your current investment allocation is not consistent with those Investment allocation requirements, you must complete the allocation form below to effect that reallocation. The transfers to the permitted investment allocation are effective as of the end of the Business Day when we receive a request in Good Order and your GRO Plus II or HD GRO II will commence on the next Business Day. For details, call ASSET ALLOCATION PORTFOLIOS Traditional AST Balanced Asset Allocation 1 AST Capital Growth Asset Allocation 1 AST New Discovery Asset Allocation 1 AST Preservation Asset Allocation 1 AST T. Rowe Price Asset Allocation Tactical AST Goldman Sachs Multi-Asset AST J.P. Morgan Global Thematic AST RCM World Trends Quantitative AST Fidelity Institutional AMSM Quantitative Portfolio 2 AST Prudential Growth Allocation Alternative AST Academic Strategies Asset Allocation 1 AST Advanced Strategies AST BlackRock Global Strategies AST J.P. Morgan Strategic Opportunities AST Wellington Management Hedged Equity Total Investment 100 % Investments must total 100%. If you completed Section 3, please proceed to Signature Page. 1 For the Optimum, Optimum 4, Optimum XTra or Optimum Plus products, if you elect the GRO Plus II or HD GRO II Optional Living Benefits, you may allocate to only one of these Sub-accounts. 2 Fidelity Institutional AM is a service mark of FMR LLC. Used with permission. ORD Ed. 5/18 p3 of 6

4 SECTION 4 CUSTOM PORTFOLIOS PROGRAM INSTRUCTIONS (FOR GRO PLUS II AND HD GRO II) Use Current Allocations: Investment allocation restrictions apply. If your existing variable investment allocations are permitted under the GRO Plus II or HD GRO II, those allocations will remain intact at the outset of the program. However, if you are currently invested in variable investment options not allowed under the GRO Plus II or HD GRO II, you will need to reallocate your variable investment options (please complete variable investment allocations below) before beginning the GRO Plus II or HD GRO II. Please Note: Your GRO Plus II or HD GRO II cannot begin unless your variable investment options are allocated to those allowed under the benefit. If you select this box and your current fund allocation includes any restricted funds, a delay in processing the addition of the GRO Plus II or HD GRO II will occur for at least one Business Day following the Business Day when we receive a request in Good Order. Please confirm with your financial professional that your current fund allocation does not include any restricted funds and that your current allocation is in compliance with the Investment allocation restrictions that are applicable with this benefit. If your current investment allocation is not consistent with those Investment allocation requirements, you must complete the allocation form below to effect that reallocation. The transfers to the permitted investment allocation are effective as of the end of the Business Day when we receive a request in Good Order and your GRO Plus II or HD GRO II will commence on the next Business Day. For details, call 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 A S T W e s t e r n A s s e t C o r e P l u s B o n d 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 3 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 Emerging Markets AST Parametric Emerging Markets Equity FIXED INCOME Domestic AST BlackRock Low Duration Bond AST Government Money Market High Yield AST High Yield International AST Templeton Global Bond (Continued) ORD Ed. 5/18 p4 of 6

5 SECTION 4 CUSTOM PORTFOLIOS PROGRAM INSTRUCTIONS (FOR HD GRO II AND GRO PLUS II) (continued) ALTERNATIVES (continued from ADDITIONAL PORTFOLIOS) AST Cohen & Steers Realty AST Global Real Estate AST T. Rowe Price Natural Resources 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 Fidelity Institutional AM SM Quantitative Portfolio 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 Wellington Management Hedged Equity 2 Fidelity Institutional AM is a service mark of FMR LLC. Used with permission. 3 Not availabe with XTra Credit Eight. ADDITIONAL PORTFOLIOS AVAILABLE WITH APEX II AND CHOICE 2000 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 Total Investment 100 % Investments must total 100%. If you completed Section 4, please proceed to Signature Page. ORD Ed. 5/18 p5 of 6

6 SECTION 5 SIGNATURES 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. By signing below, I: represent and warrant that this Annuity was not purchased to use it, or any of its riders, for speculation, arbitrage, viatication or any other type of collective investment scheme now or at any time prior to termination of the Annuity; acknowledge that I have received the appropriate product prospectus and applicable supplements; acknowledge that the initial guarantees under any newly elected benefit will be based on my Account Value at the time this form is received in Good Order; or the following Business Day if a transfer from restricted investments to allowable investments has to occur; acknowledge that I have read and understand the benefits disclosure explained in the prospectus and any supplement; authorize PALAC to transfer my existing Account Value to the Permitted Sub-account(s) I have chosen above (as applicable); acknowledge that this Annuity may not be traded on any stock exchange or secondary market. Custodian s signature Name of Signatory Title Annuitant s signature (if any) Financial Professional Name Agent Contract Number (if applicable) Party-In-Interest s signature (if any) Financial Professional Statement: I believe that this optional living benefits election is suitable given the Owner s investment time horizon, goals and objectives. Financial Professional s signature (if applicable) 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 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA ORD Ed. 5/18 p6 of 6