Document

EX-99.E 10 applicationforlifeinsuranc.htm APPLICATION Document

Exhibit 30(e)(i)

APPLICATION FOR LIFE INSURANCE

OR POLICY CHANGE

[ ] The Prudential Insurance Company

of America

[ ] Pruco Life Insurance Company

A Subsidiary of The Prudential

Insurance Company of America

Policy No. _____________________ Corporate Offices, Newark,

[ ] Check here if policy change. New Jersey

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Name of primary proposed Insured (or current Insured, if policy change) (first,

initial, last)

PART 1

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A. PERSONAL INFORMATION (PRIMARY PROPOSED INSURED)

1. Social Security No. __________________ 2. Sex: [ ]Male [ ] Female

3. Marital Status: [ ]Single [ ]Married [ ]Widowed [ ]Separated [ ] Divorced

4. Date of Birth: Mo._____ Day _____ Yr._____ 5. Age _____ 6. State of Birth

(Country if not

U.S.)_________

7. Billing Address (City, State and Zip):_____________________________________

8. Home Address (if different):_______________________________________________

9. Home Telephone Number( )_________ 10. Business Telephone Number( )_______

11. Current /Employer__________________________________________________________

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B. ALL OTHER PROPOSED INSUREDS (Include Applicant for Applicant's Waiver of

Premium Benefit)

Name Relationship to Sex Date of Age State of Total Life

primary proposed Birth Birth (country Insurance

Insured (mo., day, yr.) if not U.S.) in all

companies

________________________________________________________________________________

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C. COVERAGE INFORMATION

1. Plan of Insurance________________________ 2. Initial Amount $______________

If AL/VAL or applicable to

the product, check one: [ ]Level Death Benefit [ ]Variable Death Benefit

3. SUPPLEMENTARY BENEFITS AND RIDERS (Please indicate amount where applicable)

[ ] Waiver of Premium [ ] Accidental Death Benefit $____________

[ ] Living Needs Benefit [ ] Option to Purchase Additional Insurance

[ ] Applicant's Waiver of Premium $____________

[ ] Automatic Premium Loan [ ] Option to Purchase Paid Up Life

Insurance Additions (include details in

special request)

OTHER RIDERS AND BENEFITS: (Please indicate amount where applicable)

_____________________________________________________________________________

D. BENEFICIARIES/OWNERSHIP (If Trust, provide name of trust, trustee and date

of trust.)

1. Beneficiary: Name Relationship to primary proposed Insured Age

Primary (Class 1)____________________________________________________________

_____________________________________________________________________________

Contingent (Class 2)_________________________________________________________

2. Is the owner other than the primary proposed Insured? [ ] Yes [ ] No

If yes: Name_____________________________________________________________

Address ____________________________________________________________________

___________________________________ Owner's date of birth ___________________

=============================================================================

ORD 96200-96

(BAR/BATCH CODE HERE)

E. PAYMENT DETAILS

1. Within the last 12 months, has any proposed Insured had a heart attack,

stroke or cancer other than of the skin? [ ] Yes [ ] No

2. Is a medical examination required on:

Primary Proposed Insured? [ ] Yes [ ] No

Second Proposed Insured? [ ] Yes [ ] No

3. Premium Payment Mode: (collect full modal premium if prepaid)

[ ] Pru-matic [ ] Annual [ ,] Semi-annual [ ] Quarterly [ ] Monthly

[ ] Payroll Budget [ ] Gov't Allotment

4. Amount paid with this application $_______ [ ] None (Must be "None" if E1 is

answered Yes, except Gibraltar

products.)

5. DATE PREMIUM COLLECTED________________________________________

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F. REPLACEMENT

For any proposed Insured, would this insurance replace or cause a change in

any existing insurance or annuity in any company? [ ] Yes [ ] No

(If yes, give insurance company, plan, amount and policy number(s).

Enclose all required state replacement forms.)

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G. SPECIAL REQUESTS

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H. BACKGROUND ON PROPOSED INSUREDS

1. Total Life Insurance on the primary proposed Insured in effect ______________

Check here if None. [ ]

2. What are the primary proposed Insured's occupation and duties?_______________

3. Has any proposed Insured participated in the following activities within the

last 2 years (or does anyone plan to do so in the future):

a. operated or had any duties aboard an aircraft, glider, balloon,

or like device? [ ] Yes [ ] No

If yes, complete Aviation Questionnaire.

b. hazardous sports, such as auto, motorcycle, snowmobile or powerboat

competitions/exhibitions; scuba diving; mountain climbing; parachuting;

sky diving or any other such sport or hobby? [ ] Yes [ ] No

If yes, complete Avocation Questionnaire.

For any questions answered yes below, give the details in 8.

4. Is any proposed Insured applying for or requesting reinstatement or policy

change(s) of any other life or health insurance policy? If yes, give

insurance company, policy plan and amount. [ ] Yes [ ] No

5. Has any proposed Insured been convicted of, or currently charged with, the

commission of any criminal offense, other than the violation of a motor

vehicle law within the last 5 years? [ ] Yes [ ] No

6. a. Primary Proposed Insured driver's license number and state of issue:

_________________________________________________________________________

b. Has any proposed Insured in the last 3 years:

(1.) had a driver's license denied, suspended or revoked? [ ] Yes [ ] No

(2.) been convicted of or cited for:

(a) 3 or more moving violations? [ ] Yes [ ] No

(b) driving under the influence of alcohol or drugs? [ ] Yes [ ] No

(3.) been involved as a driver in 2 or more auto accidents? [ ] Yes [ ] No

If yes, give details including type of violation, accident or reason for

denial, suspension or revocation.

7. Does any proposed Insured plan to live or travel outside the United States or

Canada within the next 12 months? [ ] Yes [ ] No

If yes, give countries, purpose and duration of each trip.

8. Details of yes answers for questions 4-7. Give question number, proposed

Insured's name and full details

_____________________________________________________________________________

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I. CHANGES MADE BY THE COMPANY (Not applicable in New Mexico and West Virginia)

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ORD 96200-96

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ANY PERSON WHO KNOWINGLY GIVES FALSE OR DECEPTIVE INFORMATION, WHEN COMPLETING

THIS APPLICATION, FOR THE PURPOSE OF DEFRAUDING THE COMPANY COULD BE FOUND

GUILTY OF INSURANCE FRAUD.

=============================================================================

On this page the words "I" and "my" refer to the primary proposed Insured and

applicant, if different. The words "the Company" refer to the company checked at

the beginning of this application. If a policy change, "I" and "my" refer to

Insured or Owner, if other than Insured.

TERMS AND CONDITIONS

No new coverage requested in this application starts on any proposed Insured

until all required initial medical exams and tests agreed to are completed, even

if an amount has been paid to the Company.

When the Company gives a Limited Insurance Agreement form dated on the same date

shown below, coverage will start as written in that Agreement. Otherwise,

coverage will start on the contract date, provided:

o The Company issues a contract and I accept it; and

o the first premium is paid in full while all proposed Insureds' health

remains as stated in the application.

If the Company enters any change in section I, I approve the change by accepting

the contract, unless the law requires written consent to changes. Then, a change

can be made only if I approve it in writing. No agent can make or change a

contract, or waive any of the Company's rights or requirements.

The beneficiary named in the application (or in the contract if requesting a

policy change) is for insurance payable in either of the following cases:

o at the death of the primary Insured; and

o at the death of an Insured child after the death of the primary Insured

if there is no Insured spouse.

If this is a policy change and no beneficiary has been named in the application,

the beneficiary for any insurance payable will be carried over from the contract

that is being changed.

The owner of the contract is the primary proposed Insured or applicant if other

than the primary proposed Insured unless a different owner is named in the

application. If this is a policy change, the ownership arrangement will be

carried over from the contract that is being changed unless a different owner is

named in the application. This is subject to any provisions for the automatic

transfer of ownership stated in the contract. If joint owners are named,

ownership will be with the right of survivorship unless otherwise specified.

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SIGNATURES

By signing below:

o I certify that to the best of my knowledge and belief the statements in

this application are complete, true and correctly recorded.

o I understand that new coverage could be invalidated if any information in

the application is materially misrepresented.

o I confirm that if I have requested the Living Needs Benefit, I have read

the disclosures in the brochure (ORD 87246).

o I agree to the Terms and Conditions shown above and on the Important

Notice About Your Application, which I have received and read.

Signed at:_______________________________ on ___________________________________

(City/State) Date (month/day/year)

Signature of primary proposed Insured, if age 8 or over X_______________________

or current Insured, if policy change

Signature of Applicant, if different than primary

proposed Insured X ____________________________________________________________

or if a policy change, Signature of Owner, if different than Insured

If applicant is a firm or corporation, give that company's name and have an

officer sign below.

Signature and title of Officer of firm or corporation X_________________________

Signature of Beneficiary, if policy change and rights are limited X_____________

Signature of Witness (Licensed Writing Representative must witness) X___________

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LICENSED WRITING REPRESENTATIVE'S CERTIFICATION:

Do you have any information, other than what is stated in this application,

that indicates that any proposed Insured may replace or change any current

insurance or annuity in any company? [ ] Yes [ ] No

Witness (Licensed Writing Representative must witness) X

=============================================================================

ORD 96200-96

=============================================================================

PART 2 -- MEDICAL INFORMATION

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SECTION A--TO BE COMPLETED FOR ALL CATEGORY II CHANGES AND PLANS OTHER THAN

GIBRALTAR

1. Doctor Information:

A. Primary Proposed Insured

Physician last consulted:_______________ Primary Physician:_________________

Date last seen:_________________________ Date last seen:____________________

Reason:_________________________________ Reason:____________________________

Address and Phone no.:__________________ Address and Phone no.:_____________

________________________________________ ___________________________________

B. Second Proposed Insured or AWP Applicant

Physician last consulted:_______________ Primary Physician:_________________

Date last seen:_________________________ Date last seen:____________________

Reason:_________________________________ Reason:____________________________

Address and Phone no.:__________________ Address and Phone no.:_____________

________________________________________ ___________________________________

2. Build: Height Weight

a. Primary Proposed Insured ________ _______

b. Second Proposed Insured or AWP Applicant ________ _______

3. Has either the primary proposed Insured or second

proposed Insured, if proposed for coverage, ever

used tobacco or other nicotine products? [ ] Yes [ ] No

If yes, give date last used: Cigarettes Any other nicotine product such as

(Mo/Yr) a cigar, pipe, smokeless tobacco,

nicotine gum or nicotine patch

(Mo/Yr)

Primary Proposed Insured ________________ _________________________________

Second Proposed Insured ________________ _________________________________

4. Has anyone proposed for coverage had:

a. chest pain, or any disorder of the heart or blood vessels?[ ] Yes [ ] No

b. high blood pressure? [ ] Yes [ ] No

c. cancer, tumor, leukemia, melanoma, or lymphoma? [ ] Yes [ ] No

d. diabetes or high blood sugar? [ ] Yes [ ] No

e. mental or psychiatric illness? [ ] Yes [ ] No

f. AIDS or any AIDS related condition, other sexually

transmitted diseases or positive test results for HIV? [ ] Yes { ] No

g. asthma or any disorder of the lungs? [ ] Yes [ ] No

h. any disorder of the brain or the nervous system? [ ] Yes [ ] No

i. hepatitis or any disorder of the liver, stomach or

intestines? [ ] Yes [ ] No

j. any disorder of the kidney or urinary tract? [ ] Yes [ ] No

5. Other than above, is anyone proposed for coverage currently

taking prescription medication? [ ] Yes [ ] No

6. Other than above, has anyone proposed for coverage:

a. been a patient in a hospital or other medical facility? [ ] Yes [ ] No

b. in the last 5 years, had or been advised to have surgery,

medical tests, or diagnostic procedures (ECGs, stress

test, X-rays, blood tests, urine tests, etc)? [ ] Yes [ ] No

7. Has anyone proposed for coverage:

a. used or is now using cocaine, amphetamines, marijuana,

heroin, or other drugs except as prescribed by a health

care provider? [ ] Yes [ ] No

8. Does anyone proposed for coverage have any disease, disorder

or condition not indicated above? [ ] Yes [ ] No

9. Has anyone proposed for coverage had life or health insurance

declined, postponed, or issued with an increased premium? [ ] Yes [ ] No

10. Has anyone proposed for coverage requested or received

disability or compensation benefits? [ ] Yes [ ] No

=============================================================================

ORD 96200-96

=============================================================================

11. Details of yes answers for questions 4-10.

<TABLE>

Question No. Illness, operation or other reason Dates and Name, address and telephone

and proposed for any check-up, health care provider's duration number of health care

Insured's name advice, treatment and medications or illness providers and hospitals

________________ __________________________________________ _______________ ______________________________

FOR ADDITIONAL MEDICAL DETAILS USE ANOTHER APPLICATION

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</TABLE>

All the answers are, to the best of my knowledge and belief, complete, true and

correctly recorded. It is understood that any new coverage could be invalidated

if any information in the application is materially misrepresented.

________________ X__________________________ X_________________________________

Date Witness Signature of primary proposed

Insured (if age 15 or over)

otherwise Applicant (or Owner, if

policy change)

=============================================================================

ORD 92200-96

=============================================================================

PART 2--MEDICAL INFORMATION

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SECTION B--TO BE COMPLETED FOR CATEGORY I CHANGES ONLY

1. Has either the primary proposed Insured or second

proposed Insured, if proposed for coverage, ever

used tobacco or other nicotine products? [ ] Yes [ ] No

If yes, give date last used: Cigarettes Any other nicotine product such as

(Mo/Yr) a cigar, pipe, smokeless tobacco,

nicotine gum or nicotine patch

(Mo/Yr)

Primary Proposed Insured ________________ __________________________________

Second Proposed Insured ________________ __________________________________

2. Has anyone proposed for coverage been declined or charged an increased

premium for new life insurance or reinstatement of life insurance?

If yes, give details. [ ] Yes [ ] No

_____________________________________________________________________________

3. Is anyone proposed for coverage currently unable to perform the normal duties

of their occupation and/or normal daily activities? If yes, give details.

[ ] Yes [ ] No

_____________________________________________________________________________

4. Within the last five (5) years, has anyone proposed for coverage:

a. taken prescription medication, or been treated for or diagnosed as having:

high blood pressure, any disease or disorder of the heart, arteries or

veins, diabetes, cancer, respiratory disorder (including asthma, recurrent

bronchitis, emphysema), a mental illness or psychiatric disorder or any

disease or disorder of the nervous system, alcohol or drug use?

[ ] Yes [ ] No

b. been treated for or diagnosed has having AIDS or any AIDS related

condition, other sexually transmitted diseases or positive test

results for HIV? [ ] Yes [ ] No

5. Details of any "Yes" answer to question 4:

<TABLE>

Question No. Illness, operation or other reason Dates and Name, address and telephone

and proposed for any check-up, health care provider's duration number of health care

Insured's name advice, treatment and medications or illness providers and hospitals

________________ __________________________________________ _______________ ______________________________

---------------------------------------------------------------------------------------------------------------

</TABLE>

All the answers are, to the best of my knowledge and belief, complete, true and

correctly recorded. It is understood that any new coverage could be invalidated

if any information in the application is materially misrepresented.

________________ X__________________________ X_________________________________

Date Witness Signature of primary proposed

Insured (if age 15 or over)

otherwise Owner

=============================================================================

ORD 96200-96

=============================================================================

PART 2 -- MEDICAL INFORMATION

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SECTION C--TO BE COMPLETED FOR GIBRALTAR PLANS ONLY

1. Doctor Information:

A. Primary Proposed Insured

Physician last consulted:_______________ Primary Physician:__________________

Date last seen:_________________________ Date last seen:_____________________

Reason:_________________________________ Reason:_____________________________

Address and Phone no.:__________________ Address and Phone no.:______________

________________________________________ ____________________________________

B. Second Proposed Insured or AWP Applicant

Physician last consulted:_______________ Primary Physician:__________________

Date last seen:_________________________ Date last seen:_____________________

Reason:_________________________________ Reason:_____________________________

Address and Phone no.:__________________ Address and Phone no.:______________

________________________________________ ____________________________________

2. Build: Height Weight

a. Primary Proposed Insured ________ _______

b. Second Proposed Insured or AWP Applicant ________ _______

3. Has either the primary proposed Insured or second

proposed Insured, if proposed for coverage, ever

used tobacco or other nicotine products? [ ] Yes [ ] No

If yes, give date last used: Cigarettes Any other nicotine product such as

(Mo/Yr) a cigar, pipe, smokeless tobacco,

nicotine gum or nicotine patch

(Mo/Yr)

Primary Proposed Insured ________________ __________________________________

Second Proposed Insured ________________ __________________________________

4. Within the last five (5) years, has anyone proposed for coverage:

a. taken prescription medication, or been treated

or diagnosed as having: high blood pressure, any

disease or disorder of the heart, arteries or

veins, diabetes, cancer, respiratory disorder

(including asthma, recurrent bronchitis,

emphysema), a mental illness or psychiatric

disorder or any disease or disorder of the

nervous system, alcohol or drug use? [ ] Yes [ ] No

b. been treated for or diagnosed as having AIDS or

any AIDS related condition, other sexually

transmitted diseases or positive test results

for HIV? [ ] Yes [ ] No

5. Has anyone proposed for coverage been declined or

charged an increased premium for new life insurance

or reinstatement of life insurance? [ ] Yes [ ] No

6. Is anyone proposed for coverage unable to perform

the normal duties of their occupation and/or normal

daily activities? [ ] Yes [ ] No

Please include the details of any "Yes" answer to questions 4-6: _______________

________________________________________________________________________________

All the answers are, to the best of my knowledge and belief, complete, true and

correctly recorded. It is understood that any new coverage could be invalidated

if any information in the application is materially misrepresented.

____________ X_____________ X_______________________________________________

Date Witness Signature of primary proposed insured (if age 15

or over) otherwise Applicant