Pruco Life Insurance Company of New Jersey Election of Optional Benefits Form For Prudential Premier Retirement Variable Annuity Series and Prudential Premier Advisor Variable Annuity Only for use in New York. Variable annuities are issued by Pruco Life Insurance Company of New Jersey and are distributed by Prudential Annuities Distributors, Inc. Both are Prudential Financial companies and each is solely responsible for its own financial condition and contractual obligations. Prudential Annuities is a business of Prudential Financial, Inc. Use this form with the Prudential Premier Retirement Variable Annuity Series and Premier Advisor to (for contracts with contract application signed prior to February 10, 2014): Elect of any one of the following optional benefits after contract issuance: Highest Daily Lifetime Income v2.1 Suite of Benefits (HDI v2.1 Suite of Benefits): Highest Daily Lifetime Income v2.1 (HDI v2.1) Spousal Highest Daily Lifetime Income v2.1 (Spousal HDI v2.1) Highest Daily Lifetime Income v2.1 with Highest Annual Death Benefit (HDI v2.1 with HA DB) Spousal Highest Daily Lifetime Income v2.1 with Highest Annual Death Benefit (Spousal HDI v2.1 with HA DB) Guaranteed Return Option Plus II (GRO Plus II) Highest Daily Guaranteed Return Option II (HD GRO II) Update your investment allocation instructions Please note: We may apply certain limitations, restrictions, and/or standards as a condition of our issuance of an optional benefit and/or acceptance of Purchase Payments. For any election of the HDI v2.1 Suite of Benefits the owner(s) or annuitant must be at least 50 years of age. Instructions: All information must be typed or printed using blue or black ink. SECTION 1 OWNER INFORMATION 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). Annuity Number Date of Birth (Month/Day/Year) Owner/Participant Name For HDI v2.1 or HDI v2.1 with HA DB: Complete only if the Owner is a trust or a qualified plan. Annuitant Name (First, Middle, Last Name) Date of Birth (Month/Day/Year) ORD 202882 NY Rev (9/18) p1 of 6
SECTION 1 OWNER INFORMATION For Spousal HDI v2.1 or Spousal HDI v2.1 with HA DB: Complete only if there is a Co-Owner. Co-Owner/Co-Participant Name (First, Middle, Last Name) Date of Birth (Month/Day/Year) Social Security/Tax I.D. Number For Spousal HDI v2.1 or Spousal HDI v2.1 with HA DB: Complete only if there is no Co-Owner. If there are Co-Owners, then each is the other s primary beneficiary. Primary Beneficiary Name (First, Middle, Last Name) Date of Birth (Month/Day/Year) Social Security/Tax I.D. Number Primary Beneficiary Relationship If we require additional information to complete this request, please indicate who Prudential should contact: Owner SECTION 2 Financial Professional ELECTING A NEW BENEFIT The Highest Daily Lifetime Income v2.1 Suite of Benefits, Highest Daily Guaranteed Return Option II (HD GRO II) and Guaranteed Return Option Plus II (GRO Plus II) each use a separate predetermined mathematical formula to help us manage your guarantee(s) through all market cycles. Every business day, each formula determines if any portion of the account value needs to be transferred into or out of the AST Investment Grade Bond Portfolio for the Highest Daily Lifetime Income v2.1 Suite of Benefits and into or out of certain AST bond portfolio subaccounts (the Bond Portfolios ) for HD GRO II and GRO Plus II. The Highest Daily Lifetime Income v2.1 Suite of Benefits use one predetermined mathematical formula, while HD GRO II and GRO Plus II each use separate and different predetermined mathematical formulas. For the Highest Daily Lifetime Income v2.1 Suite of Benefits, amounts transferred by the formula depend on a number of factors unique to your individual annuity and include: (i) The difference between the account value and the Protected Withdrawal Value; (ii) How long you have owned the benefit; (iii) The amount invested in, and the performance of, the permitted subaccounts; (iv) The amount invested in, and the performance of, the AST Investment Grade Bond Portfolio; and (v) The impact of additional purchase payments made to and withdrawals taken from the annuity. For HD GRO II and GRO Plus II amounts transferred by the 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, in effect, cause a transfer of account value into an AST Bond Portfolio Subaccount, despite the fact that your account value had increased. ORD 202882 NY Rev (9/18) p2 of 6
SECTION 2 ELECTING A NEW BENEFIT (continued) For the Highest Daily Lifetime Income v2.1 Suite of Benefits, HD GRO II and GRO Plus II at any given time, some, none, or most of the account value may be allocated to the AST Investment Grade Bond Portfolio or the Bond Portfolios, as applicable. Transfers to and from the AST Investment Grade Bond Portfolio or the Bond Portfolios (as applicable) do not impact any income guarantees that have already been locked in with the Highest Daily Lifetime Income v2.1 Suite of Benefits or any guarantees that have already been locked in for HD GRO II and/or GRO Plus II. The Protected Withdrawal Value (PWV) only applies to the Highest Daily Lifetime Income v2.1 Suite of Benefits and is the basis for guaranteed lifetime income. The PWV is only used to calculate the guaranteed lifetime income and the benefit fee. It is separate from the account value and is not available as a lump sum withdrawal. The account value is not guaranteed, can fluctuate, and may lose value. Any amounts invested in the AST Investment Grade Bond Portfolio or 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. You may not allocate purchase payments or transfer account value into or out of the AST Investment Grade Bond Portfolio or the Bond Portfolios. See the prospectus for complete details. Select one of the options below to enroll in the HDI v2.1 Suite of Benefits, GRO Plus II or HD GRO II. For any election of HDI v2.1 or HDI v2.1 with HA DB, the annuitant must be at least 50 years of age. For any election of Spousal HDI v2.1 or Spousal HDI v2.1 with HA DB, both spouses must be at least 50 years of age. Highest Daily Lifetime Income v2.1 (HDI v2.1) Spousal Highest Daily Lifetime Income v2.1 (Spousal HDI v2.1) Highest Daily Lifetime Income v2.1 with Highest Annual Death Benefit (HDI v2.1 with HA DB) 2 Spousal Highest Daily Lifetime Income v2.1 with Highest Annual Death Benefit (Spousal HDI v2.1 with HA DB) 2 Guaranteed Return Option Plus II 1 Guaranteed Return Option Plus II with Automatic Step Up 1 Highest Daily GRO II 1 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. 1 GRO Plus II, GRO Plus II with Automatic Step Up and HD GRO II Available only to contracts with an application signed date prior to January 24, 2011(for Regulation 60 contracts only, Authorization to Disclose signed date prior to January 24, 2011). 2 Not available for election on existing contracts with an optional death benefit. 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. SECTION 3 INVESTMENT ALLOCATIONS FOR THE HDI v2.1 SUITE OF BENEFITS, GRO PLUS II AND HD GRO II BENEFITS For the HDI v2.1 Suite of Benefits: Asset Allocation Portfolios: Indicate the percent of your investment for each Asset Allocation Portfolio. Allocations made among these portfolios must total 100%. (BOX 1) OR Use Current Allocations: Investment allocation restrictions apply. If your existing variable investment allocations are permitted under the HDI v2.1 Suite of Benefits, 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 HDI v2.1 Suite of Benefits, you will need to reallocate your variable investment options among the Asset Allocation Portfolios listed in BOX 1 before the HDI v2.1 benefit will be added to your annuity. For GRO PLUS II and HD GRO II: Asset Allocation Portfolios: Indicate the percent of your investment for each Asset Allocation Portfolio. Allocations made among these portfolios must total 100%. (BOX 1) OR Custom Portfolios Program: You must allocate at least 20% among the individual portfolios listed in BOX 2 and the remaining percentage among the individual portfolios listed in BOX 1 and BOX 3 (and BOX 4 for use with the Premier Advisor Variable Annuity only) in any percent combinations. Custom Portfolios will automatically be rebalanced quarterly to the allocations selected. OR ORD 202882 NY Rev (9/18) p3 of 6
SECTION 3 INVESTMENT ALLOCATIONS FOR THE HDI v2.1 SUITE OF BENEFITS, GRO PLUS II AND HD GRO II BENEFITS (continued) Use Current Allocations: Investment allocation restrictions apply. If your existing variable investment allocations are permitted under the GRO Plus II or HD GRO II benefit, 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 benefit, you will need to reallocate your variable investment options (please complete variable investment allocations below) before the GRO Plus II or HD GRO II benefit will be added to your annuity. Please Note: Your HDI v2.1, Spousal HDI v2.1, HDI v2.1 with HA DB, Spousal HDI v2.1 with HA DB, GRO Plus II or HD GRO II benefit cannot begin unless your variable investment options are allocated to those allowed under the benefit. If you select this box and your current investment allocation includes any restricted funds, a delay in processing the addition of the HDI v2.1, Spousal HDI v2.1, HDI v2.1 with HA DB, Spousal HDI v2.1 with HA DB, GRO Plus II or HD GRO II benefit will occur for at least one Valuation Day following the Valuation Day when we receive a request in Good Order. Please confirm with your financial professional that your current investment 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 Valuation Day when we receive a request in Good Order and your HDI v2.1, Spousal HDI v2.1, HDI v2.1 with HA DB, Spousal HDI v2.1 with HA DB, GRO Plus II or HD GRO II benefit will commence on the next Valuation Day. For details, call 1-888-778-2888. BOX 1 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 3 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 Box 1 Total Investment % 3 Fidelity Institutional AM is a service mark of FMR LLC. Used with permission. BOX 2 FIXED INCOME PORTFOLIOS Domestic AST BlackRock/Loomis Sayles Bond 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 Box 2 Total Investment % ORD 202882 NY Rev (9/18) p4 of 6
SECTION 3 INVESTMENT ALLOCATIONS FOR THE HDI v2.1 SUITE OF BENEFITS, GRO PLUS II AND HD GRO II BENEFITS (continued) BOX 3 ADDITIONAL PORTFOLIOS 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 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 ALTERNATIVES AST Cohen & Steers Realty AST Global Real Estate AST T. Rowe Price Natural Resources Box 3 Total Investment % BOX 4 I ADDITIONAL PORTFOLIOS FOR USE WITH THE PRUDENTIAL PREMIER RETIREMENT ADVISOR VARIABLE ANNUITY ONLY 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 Box 4 Total Investment % CUMULATIVE (TOTAL 100%) % ORD 202882 NY Rev (9/18) p5 of 6
SECTION 4 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 and acknowledge that I have read and understand the benefits disclosure explained in the prospectus and any supplement; 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 Valuation Day if a transfer from restricted investments to allowable investments has to occur; authorize Prudential 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. Owner s/participant s signature Co-owner s/co-participant s signature Annuitant s signature Financial Professional Name Agent Contract Number (if applicable) 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 Investor 1-888-778-2888 Financial Professionals 1-800-513-0805 8:00AM 7:00PM ET, Monday Thursday 8:00AM 6:00PM ET, Friday Fax: 1-800-576-1217 www.prudentialannuities.com Regular Mail Delivery Annuities Service Center P.O. Box 7960 Philadelphia, PA 19176 Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA 19025 ORD 202882 NY Rev (9/18) p6 of 6