Document

EX-99.E 42 newjerseyapplicationformfo.htm NEW JERSEY APPLICATION FORM FOR VARIABLE APPRECIABLE LIFE INSURANCE CONTRACT Document

[Prudential Logo]

EXHIBIT 30(e)(iii)

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APPLICATION FOR LIFE INSURANCE

[LOGO]

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Proposed Insured

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Submitted By

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Name & Title Contract No. Agcy. No./Rep. Init. Office Code

Detached Office

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Credit

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[ ] Debit Ord. [ ] New Acct. [ ] Existing Acct. No. of Apps.__________ Fam.

Acct. No.

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[ ] Reg. Ord. Premium Quoted/Scheduled Premium Payment $______________________________________ (According

to mode selected)

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[ ] Pruco FOR FIELD OFFICE STAFF TO COMPLETE: Control No. _________ County Code __________

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ORD 84376 82 NEW JERSEY

II-90

Part 1 Application to [ ] The Prudential Insurance Company of America No.

[ ] Pruco Life Insurance Company*

[ ] Pruco Life Insurance Company of New Jersey*

* A Subsidiary of The Prudential Insurance Company of America

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1a. Proposed Insured's name -- first, initial, last (Print) 1b. Sex 2a. Date of birth 2b. Age

2c. Place of birth

Mo. Day Yr.

[ ]M [ ]F

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3. [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ] Divorced 4. Occupation(s)

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5. Address for mail No. Street City

State Zip

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6a. Kind of policy 6b. Initial amount 7.

Accidental death coverage

$ initial

amount $

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8. Beneficiary: (Include name, age and relationship.) 9. List all life insurance on proposed Insured.

(If NONE, so state.)

a. Primary (Class 1): b. Contingent (Class 2) if any: Initial Yr.

Kind Medical

Company amt. issued (Indiv.,

Group) Yes No

[ ] [ ]

_________________________________________________________

___________________________________________________________________

(For insurance payable upon death of (1) the Insured,

and [ ] [ ]

(2) an insured child after the death of the Insured if

___________________________________________________________________

there is no insured

spouse.) [ ] [ ]

___________________________________________________________________

[ ] [ ]

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10. Other person(s) proposed for coverage including the Applicant for Applicant's Waiver of Premium benefit (AWP)

Relationship to Date of birth

Total life insurance

Name--first, initial, last Sex proposed Insured Mo. Day Yr. Age Place of birth in

all companies

a. Spouse $

___________________________________________________________________________________________________________________________________

b. $

___________________________________________________________________________________________________________________________________

c. $

___________________________________________________________________________________________________________________________________

d. $

___________________________________________________________________________________________________________________________________

e. $

___________________________________________________________________________________________________________________________________

f. $

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11. Supplementary benefits: a. For proposed Insured b. For spouse, children, Applicant for AWP

Type and duration of benefit Amount Type and duration of

benefit Amount

$ $

___________________________________________________________________________________________________________________________________

$ $

___________________________________________________________________________________________________________________________________

$ $

___________________________________________________________________________________________________________________________________

[ ] Option to Purchase Additional Ins. $ [ ] Applicant's Waiver of Premium benefit

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12. State any special request.

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13. Will this insurance replace or change any existing insurance or annuity in any company on any person

named Yes No

in 1a or 10? If "Yes", give their names, name of company, plan, amount and policy

numbers. [ ] [ ]

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14. Is anyone applying for, or trying to reinstate, life or health insurance on any person named in 1a or 10

in Yes No

this or any company? If "Yes", give amount, details and

company. [ ] [ ]

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15. Does any person named in 1a or 10 plan to live or travel outside the United States and Canada within the

next Yes No

12 months? If "Yes", give

details. [ ] [ ]

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16. Has any person named in 1a or 10 operated or had any duties aboard an aircraft, glider, balloon, or

like Yes No

device, within the last 2 years, or does any such person have any plans to do so in the future? If

"Yes", [ ] [ ]

complete Aviation Questionnaire.

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17. Has any person named in 1a or 10, within the last 12

months: Yes No

a. been treated by a doctor for or had a known heart attack, stroke or cancer other than of the skin?

............ [ ] [ ]

b. had an electrocardiogram for any physical complaint, or taken medication for high blood pressure?

............. [ ] [ ]

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18. Premiums payable [ ] Ann. [ ] Semi-Ann. [ ] Quar. [ ] Mon. [ ] Pay. Budg. [ ] Pru-Matic [ ] Gov't.

Allot.

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19. Amount paid $ [ ] None (Must be "None" if either 17a or 17b is answered "Yes".)

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20. Is a medical examination to be made on a. the proposed

Insured?.................................................. Yes [ ] No [ ]

b. spouse (if proposed for coverage)?

.................................... Yes [ ] No [ ]

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21. If 20a or 20b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage

until Yes No

the person(s) indicated in 20 have been examined, even if 19 shows that an amount has been paid?

................. [ ] [ ]

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22. Changes made by the Company

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ORD 84376-82 NEW JERSEY Page 1 (Continued on page 2)

II-91

Continuation of Part 1 of Application

Complete on all persons named in 1a and 10 if any one of them can have insurance on a non-medical basis.

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23. Height and weight of:

a. Proposed Insured Ht._______ Wt._______ b. Spouse Ht.________ Wt.________ c. Applicant for AWP Ht.________

Wt.________

Has the weight changed more than 10 pounds in the past year? Yes [ ] No [ ] If "Yes", give details in 30.

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24. Has the proposed Insured or spouse ever smoked? a. Proposed Insured Yes [ ] No [ ] b. Spouse Yes [ ]

No [ ]

If "Yes", give date(s) last smoked: Cigarettes Cigars Pipe

Proposed Insured Mo.______ Yr. ______ Mo.______ Yr. ______ Mo.______ Yr. ______

Spouse Mo.______ Yr. ______ Mo.______ Yr. ______ Mo.______ Yr. ______

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25. When was a doctor last consulted by: a. Proposed Insured? b. Spouse? c. Applicant

for AWP?

Mo.______ Yr. ______ Mo.______ Yr. ______ Mo.______

Yr. ______

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26. Has any person to be covered now being treated or taking medicine for any condition or disease?

.................Yes [ ] No [ ]

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27. Has any person to be covered

ever: Yes No

a. had any surgery or been advised to have surgery and has not done

so?............................................... [ ] [ ]

b. been in a hospital, sanitarium or other institution for observation, rest, diagnosis or treatment?

................ [ ] [ ]

c. regularly used or is any such person now using, barbiturates or amphetamines, marijuana or other

hallucinatory drugs, or heroin, opiates or other narcotics, except as prescribed by a doctor?

..................... [ ] [ ]

d. been treated or counseled for alcoholism?

......................................................................... [ ] [ ]

e. had life or health insurance declined, postponed, changed, rated-up or withdrawn?

................................. [ ] [ ]

f. had life or health insurance canceled, or its renewal or reinstatement refused?

................................... [ ] [ ]

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28. Other than as shown above, in the past 5 years has any person to be

covered: Yes No

a. consulted or been attended or examined by any doctor or other practitioner?

...................................... [ ] [ ]

b. had electrocardiograms, X-rays for diagnosis or treatment, or blood, urine, or other medical tests?

.............. [ ] [ ]

c. made claim for or received benefits, compensation, or a pension because of sickness or injury?

................... [ ] [ ]

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29. Does any person to be covered now have a known sign of any physical disorder, disease or defect not shown

above? Yes [ ] No [ ]

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30. What are the full details of the answer to 25 and to each part of 23 and 26 thru 29 which is answered "Yes"?

Name & Full names and

addresses of

Question No. Illness or other resason Dates and duration of illness doctors and

hospitals

___________________________________________________________________________________________________________________________________

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Those who sign below declare, to the best of their knowledge and belief, that the statements in this application

are complete and

true.

When the Company gives a Temporary Indurance Agreement form, ORD 84376A-82 New Jersey, of the same date as this

Part 1, coverage

will start as shown in that form. Otherwise, no coverage will start unless: (1) a contract is issued, (2) it is

accepted, and (3)

the full first premium is paid while all persons to be covered are living and their health remains as stated in

Part 1. If all these

take place, coverage will start on the contract date. If the Company makes a change as indicated in 22 it will be

approved by

acceptance of the contract. But where the law requires written consent for any change in the application, such as

change can be made

only if those who sign this form approve the change in writing. No agent can make or change a contract, or waive

any of the

Company's rights or needs.

OWNERSHIP: Unless otherwise asked for above, the owner of the contract will be (1) the applicant if other than

the proposed Insured,

otherwise (2) the proposed Insured. But this is subject to any automatic transfer of owership stated in the

contract.

Signature of Proposed Insured (If Age 8 or over)

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Dated at on , 19 Signature of Applicant (If other than proposed

Insured)

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City/State

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Witness (If applicant is a firm or corporation, show that

company's name)

- --------------------------------------------------- By

(Licensed agent must witness where required by law)

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(Signature and title of officer signing for that

company)

ORD 84376-82 NEW JERSEY Page 2

II-92

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ACKNOWLEDGEMENT

I have received and read a copy of the IMPORTANT NOTICE ABOUT YOUR APPLICATION

FOR INSURANCE.

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Date

, 19

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AUTHORIZATION For the Release of Information to:

[ ] The Prudential Insurance Company of America

[ ] Pruco Life Insurance Company

[ ] Pruco Life Insurance Company of New Jersey

To: Any licensed physician, medical practitioner, hospital, clinic or like

facility, insurance company or the Medical Information Bureau, Inc. or other

organization, institution or person.

To determine eligibility for life insurance coverage, I authorize you to give

the Company checked above and, through it, to its reinsurers and the Medical

Information Bureau, any data or records you may have about me or my mental or

physical health. This also applies to any child proposed for insurance in the

application.

This authorization is valid until two years after the effective date of any

contract issued in connection with this authorization. A photo of this form will

be as valid as the original. (The person who signs this form may have a copy of

it upon request.)

Signature of Proposed Insured (if age 15 or over) otherwise Applicant

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Signature of Spouse (if proposed for coverage)

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ORD 84377 82 NEW JERSEY

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[ ] The Prudential Insurance Company of America

[ ] Pruco Life Insurance Company [ ] Pruco Life Insurance Company of New Jersey

IMPORTANT NOTICE ABOUT YOUR APPLICATION FOR INSURANCE

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Before we can issue a policy we must first underwrite your application. This

means that we evaluate all the information necessary to determine if you qualify

for the insurance.

In addition to the information on the application, a medical examination may be

required. We also ask you to authorize any doctor, hospital or other

organization or person who has any data about you to give us any such

information.

We may ask for a report from a consumer reporting agency. These reports provide

information about a person's character, residence, activities, general

reputation, personal characteristics and mode of living. The agency may get this

information through interviews with friends, neighbors and associates. Any

person on whom we ask for a report has a right to ask to be interviewed. You may

also get a copy of the report from the consumer reporting agency which completed

it. An agency may keep the information it has about you and disclose it to other

persons. If you would like further information as to the nature and scope of

these reports, it will be provided upon request.

Any information which we obtain about you will be treated as confidential.

However, we may give this information, as necessary, to: your doctor, if we find

a serious health problem which you do not know about; persons conducting

mortality or morbidity studies; and affiliate companies for marketing purposes.

If you ask, we will describe any other circumstances when we may disclose

information about you without your prior authorization.

ORD 84378-82 NEW JERSEY (Continued on reverse)

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[ ] The Prudential Insurance Company of America

[ ] Pruco Life Insurance Company*

[ ] Pruco Life Insurance Company of New Jersey*

* A Subsidiary of The Prudential Insurance Company of America

TEMPORARY INSURANCE AGREEMENT

We, the Company, agree to provide temporary insurance as follows:

1. It will start on the latest of these dates: (a) the date of this agreement,

(b) the date of completion of all medical examinations agreed to, and (c)

any date asked for in the application.

2. This insurance is subject to the terms of the contract applied for.

3. The sum of all death benefits for any person who is to be covered by this

insurance will be the amount asked for on that person or $250,000,

whichever is less.

The temporary insurance will end:

1. When we issue a contract as applied for. It will replace the temporary

insurance.

2. When we issue a contract other than as applied for. It will replace the

temporary insurance if: (a) it is accepted on delivery (this includes

paying at the same time any excess of the correct first premium over the

amount shown below); and (b) the persons who are to be covered are living

when the contract is delivered. If the contract is not accepted on delivery

the temporary insurance will end at once.

3. When we tell you that we rejected the application or when we tell you that

we will not consider it on a prepaid basis.

4. At the end of 60 days if the temporary insurance has not been ended as we

state in 1, 2 or 3.

ORD 84376A-82 NEW JERSEY (Continued on reverse) Printed in U.S.A.

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II-93

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Names and addresses of three Friends or Business Associates:

1. Name _______________________________________________________________________

Address ____________________________________________________________________

2. Name _______________________________________________________________________

Address ____________________________________________________________________

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II-94

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We may also make a brief report to the Medical Information Bureau (MIB) which

provides an information exchange for its member insurance companies. When you

apply for life or health insurance or submit a claim for benefits to any member

company, MIB will, on request, give that company the information in its file. If

you wish to know if there is an MIB report about you or if you question its

accuracy, you may contact MIB at Post Office Box 105, Essex Station, Boston, MA

02112, (617) 426-3660.

If you have any questions concerning any of the personal information which we

obtain or report, let us know. You have the right to see this information and to

correct, amend or delete any information which may be wrong. We will tell you

how to do this if you ask us.

If we are unable to issue the policy you requested, we will tell you and explain

the reasons.

Thank you for applying to us for insurance.

Corporate Offices, Newark, N.J.

These Regional Home Offices of The Prudential Insurance Company of America are

also Service Offices of Pruco Life Insurance Company. Asterisk (*) designates

Service Offices of Pruco Life Insurance Company of New Jersey.

Central Atlantic Home Office, Northeastern Home Office,

Fort Washington, Pa. Boston, Mass.*

Eastern Home Office, South-Central Home Office,

South Plainfield, N.J.* Jacksonville, Fla.

Mid-America Home Office, Southwestern Home Office,

Chicago, Ill. Houston, Tex.

North Central Home Office, Western Home Office,

Minneapolis. Minn. Los Angeles, Calif.

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We received $_____________ on_________, 19___ from __________________________.

This amount was paid when a life insurance application was signed, on the same

date, in which ____________________________________________ is named as the

proposed Insured. This agreement is issued on the condition that any check,

draft or other order for the payment of money is good and can be collected.

ALL CHECKS MUST BE DRAWN ONLY TO THE COMPANY AND NOT TO ANY OTHER PARTY.

No change may be made in the terms and conditions of this form. No statement

which claims to make such a change will bind the Company.

Field Office Writing Representative (Agent)

___________________________________ ________________________________________

The Prudential Insurance Company of America

Pruco Life Insurance Company Pruco Life Insurance Company of New Jersey

Corporate Offices, Newark, N.J.

These Regional Home Offices of The Prudential Insurance Company of America are

also Service Offices of Pruco Life Insurance Company. Asterisk (*) designates

Service Offices of Pruco Life Insurance Company of New Jersey.

Central Atlantic Home Office, Northeastern Home Office,

Fort Washington, Pa. Boston, Mass.*

Eastern Home Office, South-Central Home Office,

South Plainfield, N.J.* Jacksonville, Fla.

Mid-America Home Office, Southwestern Home Office,

Chicago, Ill. Houston, Tex.

North Central Home Office, Western Home Office,

Minneapolis, Minn. Los Angeles, Calif.

_____________________________________________________________

Note--Unless you get a contract, or your money back within eight weeks from the

date of this agreement, please notify the Company. Give the amount paid, date of

payment, and name of person to whom paid. (Locations are shown above.)

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3. Name _______________________________________________________________________

Address ____________________________________________________________________

Furnished by ___________________________________________________________

(Name of Proposed Insured/Applicant)

Proposed Insured's Expiration Dates: Auto ___________ Homeowners ______________

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