Pruco Life Insurance Company

The Prudential Insurance Company of America

Both are Prudential companies.

Policy is issued by the company named at the beginning of this application.

PROPOSED INSURED(S): John Doe     

POLICY NUMBER (IF KNOWN): XX XXX XXX     

1. VARIABLE PRODUCTS OFFERING THE S&P 500®INDEXED ACCOUNT RIDER     

oCheck this box to elect the S&P 500®Indexed Account Rider.

The election of this rider allows you to select the S&P 500®Indexed Account, now or in the future. This rider may not be available on all variable products.

The S&P 500®Indexed Account is an available allocation option only on policies with this rider. Until you provide revised instructions, as index segments mature, proceeds from each maturing index segment will be allocated to a new segment in the S&P 500®Indexed Account. Other options for allocating proceeds from maturing index segments are available. In order to change your maturing index segment allocation instructions, please use the Request for Reallocations, Directed Payments, and Transfers Form (ORD 84689). For further information regarding the S&P 500®Indexed Account, please see the prospectus supplement for the S&P 500®Indexed Account Rider.

A.OPTIONAL: Designated Transfers

The S&P 500®Indexed Account Rider allows you to specify a dollar amount to be transferred monthly on the transfer date, from the Fixed Rate Option to the S&P 500®Indexed Account. Transfers will continue until the sooner of the following events:

•You discontinue Designated Transfers, or

•The number of months you specified has elapsed since the first designated transfer.

Use of this feature requires that at least a portion of your payment allocations in Section 2 be directed to the Fixed Rate Option.

Until you provide revised instructions, as funds become eligible for transfer we will transfer amounts monthly as you indicate below:

Dollar amount of designated transfer: $

Number of months for designated transfer: o Unlimited

If the Fixed Rate Option is only sufficient for us to transfer part of your designated transfer amount, then the entire available amount will be transferred. Months where only a partial or no transfer takes place because the Fixed Rate Option is insufficient will count against the number of months elapsed in your instructions.

2. INVESTMENT OPTIONS AND ALLOCATIONS     

I request that net premium payments be allocated to the investment options selected below. Investment allocations must be made in whole numbers and the total allocation must equal 100%.

Investment Option        CodeAllocationInvestment OptionCodeAllocation

[PSF Equity]    [CSTK]    [50]    %     [Fixed Rate Option]    [FXRT]    [50] %

%     %

%     %

%     %

%     %

%     %

%     %

%     %

%     %

Total 100%

ORD 96200-2019Variable                            A007                [1]

3. ALLOCATED CHARGES     

You may select up to two investment options from which your monthly charges will be deducted.

• Percentages selected must be whole numbers (for example, 33⅓ is invalid). The sum of all percentages must equal 100%.

• Indexed accounts may not be selected.

• If you do not specify an allocation of monthly charges or if there is insufficient money in the selected investment options, charges will be deducted from the remaining investment options using the method described in the prospectus.

Investment Option        CodeAllocationInvestment OptionCodeAllocation

PSF Equity]    [CSTK]    [50]    %     [Fixed Rate Option]    [FXRT]    [50] %

%     %

%     %

%     %

%     %

%     %

%     %

%     %

%     %

Total 100%

4. TELEPHONE REALLOCATIONS/TRANSFER PRIVILEGES     

[If more than one owner, telephone reallocations/transfer privileges are not allowed.

o I do not wish to authorize telephone reallocations/transfers. I understand that by not taking this option, any future request for this option must be submitted in writing.]

5. SIGNATURE     

I believe this contract meets my insurance needs and financial objectives. I acknowledge receipt of a current prospectus for the contract. If I elected the S&P 500®Indexed Account Rider, I acknowledge having received the prospectus supplement.

I understand that the contract’s value and death benefit may vary depending on the contract’s investment experience.

oYes oNo

An illustration of values is available upon request.

è Signature of Policyowner        X John Doe    5/1/2019     

ORD 96200-2019Variable                                            [2]