Document

EX-99.E 44 revisednewyorkapplicationf.htm REVISED NY APPLICATION FORM FOR VARIABLE APPRECIABLE LIFE INSURANCE CONTRACT Document

EXHIBIT 30(e)(v)

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

[ ] 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: (name age and relationship) 9. List all life insurance, annuities and vanable

contracts on

a. Primary (Class 1): ________________________________ proposed Insured. (If NONE, so state.)

___________________________________________________ Initial Yr.

Kind Medical

___________________________________________________ Company amt. issued (Indiv.,

Group) Yes No

______________________________________________________

[ ] [ ]

b. Contingent (Class 2) if any:

___________________________________________________________________

___________________________________________________

[ ] [ ]

___________________________________________________

___________________________________________________________________

[ ] [ ]

___________________________________________________________________

[ ] [ ]

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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. Dividend Option election COMPLETE ONLY IF APPLYING TO THE PRUDENTIAL INSURANCE COMPANY OF AMERICA

[ ] Paid-up additions [ ] Accumulate at interest [ ] Cash

[ ] Reduce premiums (Not available for monthly mode) [ ] ______________________________

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ORD 84376-84 NEW YORK Page 1 (Continued on page 2)

II-88

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. The beneficiary named in the application is 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.

When the Company gives a Limited Insurance Agreement form, ORD 84376A-84, NEW YORK, 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. 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 84376-84 NEW YORK Page 2