EX-99.E 3 genericapplicationvul3.htm GENERIC VUL3 APPLICATION

_ The Prudential Insurance Company of America
_ Pruco Life Insurance Company, a subsidiary of
The Prudential Insurance Company of America
Corporate Office, Newark, New Jersey

Application for Life Insurance or Policy Change

Policy Number___________ __ check here if policy change

A. About the Primary Proposed Insured

1. Name of primary proposed insured (or current insured person, if policy change.) (First name, middle initial, last
name)

2. Social Security number _____________________________

3. Sex _ female _ male

4. Marital status _ single _ married _ widowed _ separated _ divorced

5. Date of birth __/__/____

6. Age __________

7. State of birth (country if not U.S.) ______________________

8. Billing address
____________________________________
(street, city, state, ZIP)

9. Home address____________________________________

(if different) (street, city, state, ZIP)

10. Home telephone number (_____)___________________

11. Business telephone number (_____)___________________

12. Current employer ____________________________________

13. List all existing life insurance coverage. _ Check here if none.

Company Amount Year issued Type of insurance To be replaced?
$ _Individual _ Group _ yes _ no
$ _Individual _ Group _ yes _ no
$ _Individual _ Group _ yes _ no
$ _Individual _ Group _ yes _ no
$ _Individual _ Group _ yes _ no

B. All Other Proposed Insureds. (Include applicant if requesting Applicant's Waiver of Premium [AWP] Benefit.)

Name (first, initial, last); relationship to primary proposed insured; Sex (F/M); date of birth (M/D/Y); age; state of birth
(country if not U.S.); total life insurance in all companies.

C. Coverage Information.

1. Plan of insurance __________________________________________
If applicable to the plan, check one. _ Level Death Benefit _ Variable Death Benefit

2. Initial amount of insurance $__________________

3. Supplementary benefits and riders _ Waiver of Premium _ Accidental Death Benefit $
_ Applicant's Waiver of Premium _ Option to Purchase Additional Insurance (OPAI) $___
_ Automatic Premium Loan _ Option to Purchase Paid-up Life Insurance Additions (include details in section G,
Special Requests)
_ Acceleration of Death benefits (Living Needs Benefit) _ Other riders and benefits (indicate amount where applicable.)

D. Beneficiaries and Ownership. (If trust, provide name of trust, trustee and date of trust.)
1. Beneficiary information
Name; Relationship to primary proposed insured; Age
Primary (Class 1)
Contingent (Class 2)
2. Is the policyowner someone other than the primary proposed insured? _ Yes _ No
(If Yes, provide information requested below.)
Name _______________________________ Date of birth (month; day; year)
(First name, middle initial, last name);
Address _________________________________________________________
(street, city, state, ZIP)
________________________________________________________________

E. Payment Information.

1a.Within the past 90 days, has any proposed insured been hospitalized or been advised by a member of the medical
profession that he or she needs hospitalization for any reason other than for normal pregnancy or well-baby care? _
Yes _ No
b. Within the past 12 months, has any proposed insured received treatment or advice from a member of the medical
profession for heart disease, chest pain, stroke or cancer (except skin)? _ Yes _ No

2. Is a medical examination required on the primary proposed insured? _ Yes _ No;
second proposed insured? _ Yes _ No

3. Premium payment mode (collect full modal premium if prepaid)
_ Annual; _ Semiannual; _ Quarterly; _ Monthly
_ Electronic Funds Transfer (EFT); _ Payroll Budget; _ Government Allotment

4. Amount of prepayment submitted with this application $ ________________ (include any unscheduled premium payments)
_ None (must be None if 1a or 1b is Yes, except for Gibraltar [GIB] products.)

5. Date prepayment collected (month; day; year)

F. Replacement. For any proposed insured, would this insurance replace or cause a change in any existing insurance or
annuity in any company? (If Yes, enclose all required replacement forms.) _ Yes _ No

G. Special Request

H. Background on Proposed Insureds

1. Has either the primary proposed insured or second proposed insured (if any) ever used tobacco or other nicotine
products such as cigarettes, cigars, pipe, chewing tobacco, snuff, nicotine gum; or nicotine patch? (If Yes, provide
date when last used and indicate all types of products.) _ Yes _ No

Date (mo., yr.); Product(s);
Primary proposed insured;
Second proposed insured;

2. What are the occupation and duties of the primary proposed insured?
_______________________________________________________________________

3. Within the last two years, has any proposed insured done or does he or she plan to do the following:
a. operate or have any duties aboard an aircraft, glider, balloon or similar device? _ Yes _ No (If Yes,
complete Aviation Questionnaire.)
b. participate in hazardous sports, such as: auto; motorcycle; snowmobile; or powerboat competitions/exhibitions;
scuba diving; mountain climbing; parachuting; skydiving; or any other such sport or hobby? (If Yes, complete
Avocation Questionnaire.) _ Yes _ No

4. Is any proposed insured applying for or requesting reinstatement or policy change(s) of any other life or health
insurance policy? (If Yes, provide 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 10 years? _ Yes _ No (If Yes, provide details.)

6. a. Driver's license number and state of issue of primary proposed insured
b. In the last three years, has any proposed insured
(1) had a driver's license denied, suspended or revoked? _ Yes _ No
(2) been convicted of or cited for
a. three or more moving violations? _ Yes _ No
b. driving under the influence of alcohol or drugs? _ Yes _ No
(3) been involved as a driver in two or more auto accidents? _ Yes _ No
(If Yes to any of the above, provide 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, list countries and purpose and duration of each trip.)

I. Additional Coverage
Complete only if this is an application for additional coverage on a person already covered by a Prudential or Pruco
policy with an application date within three months of the date of this application.
To the best of your knowledge, has the health or the mental or physical condition of any person proposed for
insurance changed since the answers and statements were given in the application included in policy number
__________________? _ Yes _ No
(If Yes, complete the appropriate Part 2 Medical Information section.)

J. Changes
Changes made by the Company (Not applicable in New Mexico or West Virginia)
Part 2 Medical Information

K. Physician Information

Primary proposed insured
Physician last consulted:
Name
_________________________________________________________

Address _______________________________________________________
(street, city, state, ZIP)

Telephone number (__)__________ Date last seen ____/____/________
(month, day, year)
Reason last seen
_______________________________________________

Primary
physician
Name
_________________________________________________________

Address _______________________________________________________
(street, city, state, ZIP)

Telephone number (__)__________ Date last seen ____/____/________
(month, day, year)
Reason last seen
_______________________________________________

Second proposed insured or applicant for Applicant's Waiver of Premium (AWP)
Physician last consulted
Name
_________________________________________________________

Address _______________________________________________________
(street, city, state, ZIP)

Telephone number (__)__________ Date last seen ____/____/________
(month, day, year)
Reason last seen
_______________________________________________

Primary physician
Name
_________________________________________________________

Address _______________________________________________________
(street, city, state, ZIP)

Telephone number (__)__________ Date last seen ____/____/________
(month, day, year)
Reason last seen
_______________________________________________

L. Physical Measurements
Height Weight

Primary proposed insured
Second proposed insured
AWP applicant
M.

Category I Changes and Gibraltar (GIB) Plans

1. Within the last five years, has anyone proposed for coverage been diagnosed with or treated by a member of the
medical profession for
a. high blood pressure, diabetes, cancer, respiratory disorder (including asthma, recurrent bronchitis, emphysema), any
disease or disorder of the heart, arteries, blood or veins, a mental illness or psychiatric disorder, any
disease or disorder of the neuromuscular system, or alcohol or drug use? _ Yes _ No
b. Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? _ Yes _ No
c. infection caused by the Human Immunodeficiency Virus (HIV) (Not applicable in California and Maine. Wisconsin: AIDS
virus HIV antibody testing is limited to FDA-licensed enzyme immunoassay and confirmatory HIV antibody
tests. Any test performed at an anonymous counseling and testing site or home testing is confidential and
need no be revealed on this application.) _ Yes _ No
d. any sexually transmitted diseases? _ Yes _ No
(If Yes to any of the above, provide letter of question, name of person to be insured and full medical
details.)

2. Is anyone proposed for coverage currently under treatment for any medical condition or taking prescription medication?
_ Yes _ No
(If Yes, provide name of person to be insured and full medical details.)

3. Within the last 12 months, has anyone proposed for coverage been hospitalized or been advised to have surgery or
medical tests (other than HIV)? _ Yes _ No
(If Yes, provide name of person to be insured and full medical details.)

4. Has anyone proposed for coverage been declined or charged an increased premium for new life insurance or
reinstatement of life insurance? (Missouri: this question may be answered No if an individual has been declined
for coverage.) _ Yes _ No
(If Yes, provide name of person to be insured and full details.)

5. Is anyone proposed for coverage currently unable to perform his or her normal daily activities or all normal
occupational duties on a full-time basis at the customary place of employment? _ Yes _ No
(If Yes, provide name of person to be insured and full details.)

Part 2 Medical Information

M. Category II Changes and Plans other than Gibraltar (GIB)
1) Family record:
Current age or age at death Year and cause of death
Father
Brother
Brother
Brother

Current age or age at death Year and cause of death
Mother
Sister
Sister
Sister

2) Has anyone proposed for coverage been diagnosed with or treated by a member of the medical profession for:
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) Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC)? (Maine: this question may be answered No if
an individual has tested HIV positive and does not have symptoms of the disease AIDS such as dry coughs, skin
lesions, weakness, fatigue, weight loss or loss of appetite) _ Yes _ No
g) infection caused by the Human Immunodeficiency Virus (HIV) (Not applicable in California and Maine. Wisconsin: AIDS
virus HIV antibody testing is limited to FDA-licensed enzyme immunoassay and confirmatory HIV antibody tests. Any
test performed at an anonymous counseling and testing site or home testing is confidential and need no be revealed on
this application.) _ Yes _ No
h) any sexually transmitted diseases? _ Yes _ No
i) asthma or any disorder of the lungs? _ Yes _ No
j) any disorder of the brain or nervous system? _ Yes _ No
k) hepatitis or any disorder of the liver, stomach or intestines? _ Yes _ No
l) any disorder of the kidney or urinary tract? _ Yes _ No

3) Is anyone proposed for coverage currently taking prescription medication? _ Yes _ No

4) 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 five years, had or been advised to have surgery, medical tests (other than HIV) or diagnostic procedures
such as ECGs, stress tests, X-rays, blood tests, urine tests, etc.? _ Yes _ No

5) Has anyone proposed for coverage:
a) used, or is he or she now using, cocaine, amphetamines, marijuana, heroin or other drugs, except as prescribed by a
member of the medical profession? _ Yes _ No
b) had or been advised to have treatment or counseling for alcohol or drug use? _ Yes _ No

6) Does anyone proposed for coverage have any disease, disorder or condition not previously mentioned? _ Yes _ No

7) Has anyone proposed for coverage had life or health insurance declined, postponed or issued with an increased
premium? (Missouri: this question may be answered No if an individual has been declined for coverage.) _ Yes _ No

8) Is anyone proposed for coverage currently unable to perform his or her normal daily activities or all normal
occupational duties on a full-time basis at the customary place of employment?
_ Yes _ No

9) Has anyone proposed for coverage requested or received disability or compensation benefits? _ Yes _ No

10) Details of Yes answers for questions 2-9:
Question number and name of proposed insured; Indicate illness, hospitalization, reason for checkup, medication;
and any advice or treatment given by a medical professional; Dates and duration of illness; Name, address and
telephone number of medical professionals and hospitals.

For additional medical details, use another application.

The words "I" and "my" refer to the primary proposed insured and policyowner or applicant if other than the primary proposed
insured. The word "Company" refers to the company checked at the beginning of this application.

Unless I have specified a policy date or special payment plan (e.g., government allotment, payroll budget) in this
application, I understand that if the initial premium is not paid with this request for coverage, the policy will become
effective when all of the following conditions are met:
o the policy is issued, delivered and I accept it,
o the health of all persons proposed for insurance remains as stated in the application and
o the first premium is paid in full and the check or other form of payment is good and can be collected.

If the Company enters any change in section J, I approve the change by accepting the policy unless the law requires written
consent to changes. No Company agent or broker authorized to sell our products can make or change a policy, or waive any of
the Company's rights or requirements.

The Company will pay the beneficiary named in the application (or in the policy if requesting a policy change and no
beneficiary has been named in the application) any applicable insurance benefit either at the death of the primary insured or
at the death of an insured child after the death of the primary insured if there is no insured spouse.

For policy changes, the existing policyowner and beneficiary designation will be used unless a new policyowner or beneficiary
designation is provided in this application.

The policyowner is either the primary proposed insured or the applicant unless a different policyowner is named in the
application. This is subject to any provisions for the automatic transfer of ownership stated in the policy.
If joint policyowner are named, in the event of the death of one policyowner, the survivor shall be the policyowner, unless
otherwise specified.

Signatures
I certify, affirm and understand the following:

To the best of my knowledge and belief, the statements in this application, as well as any forms that the Company
designates to be part of the application and that are attached to the policy, are complete, true and correctly recorded.

Except for failure to pay premium or fraud, the Company will not contest the validity of this policy or change request
after it has been in force during the insured's lifetime for two years from the date it takes effect.

I will inform the Company of any changes in my or any proposed insured's health, mental or physical condition, or of any
changes to any answers on this application, prior to or upon delivery of this policy.

If I have requested the Acceleration of Death Benefit (Living Needs Benefit), I have read the disclosures in the brochure
(ORD 87246).

I have received and read the Terms and Conditions shown above and the Important Notice About Your Application for
Insurance.

I believe this policy meets my insurance needs and financial objectives. For a variable product: I acknowledge receipt of
a current prospectus for the policy. I understand that the policy's value and death benefit may vary depending on the
policy's investment experience.
My original signature has been affixed to this application, the original application will be retained by the Company and I
will receive a copy identical in form and substance to the original, attached to my policy.

Not Applicable in Arizona:

Any person who knowingly and intentionally gives false or deceptive information when completing an application for
insurance or filing a claim, for the purpose of defrauding an insurance company:

may have committed fraud, or may have violated state law.

Arkansas, District of Columbia, Hawaii, Louisiana, Maine, New Mexico, Tennessee and Virginia: may be subject to
fines, denial of insurance benefits, or confinement in prison.

Colorado: penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.

Signed at _________________________ on ___/___/_____
(city, state) month day year

Signature of primary proposed insured, if age 8 or over, or of currently insured person, if policy change
X____________________________________

Signature of spouse (applicable in South Carolina, if proposed for coverage.) X____________________

Signature of policyowner (if different from the primary proposed insured) or of existing policyowner if a policy change. If
owner is a firm or corporation, give that company's name and have an officer sign below.
X______________________________________

Signature and title of officer of firm or corporation X_________________________________

Signature of applicant, if different from primary proposed insured or policy owner X____________________________

Signature of beneficiary, if policy change and rights are limited X________________________

Signature of witness (Licensed Writing Representative must witness.) X__________________________

Licensed Writing Representative's Certification
Do you have any information, other than that stated in this application, which indicates that any proposed insured may replace
or change any current insurance or annuity in any company?
_ Yes _ No

Signature of Writing Representative ______________________________________

Aviation Questionnaire
Supplementary declarations forming a part of the application for insurance

Name____________________________________________
(First name, middle initial, last name)

Flight Hours
How many hours have you flown and do you plan to fly in each category below? (Include flight for flight pay.)

Hours flown in last 12 mos.; Hours flown in last 24 mos.; Total hours flown to date.; Estimate of hours for next 12 mos.

1) Pilot and Co-pilot: Private and Student (not flying for hire) Commercial (flying for hire, including pilot
instruction) Military (including student, Reserve and National Guard)
2) Crew member (with duties aboard aircraft, including photographer, observer, flight attendant, etc.) Commercial
(flying for hire) Military (including Reserve and National Guard)
3) Passenger, except scheduled airlines (with no duties aboard aircraft).

Type of Flights
What were the nature of the flights in section 2 and the type of aircraft flown in the last two years? (If more than one,
check each appropriate box.)
1) Civil Aviation:
_ U.S. Certificated (comparable Canadian) passenger/cargo airline;
_ U.S. Certificate All-Cargo airline; _ U.S. Certificated Charter airline;
_ Other U.S. and Canadian airline; _ Foreign airline flying to U.S.; and Canada
_ Company or private business; _ Other flying service.
_ Giving flight instruction number of hours per year ________________; _ Dusting or spraying;
_ Test - production line (describe in Remarks.);
_ Experimental,; aerobatic; or stunt flying (describe in Remarks.); _ Pleasure;
_ Hang gliding; ultralight, etc. _ Student pilot ; _ Other (describe in Remarks.)

2) Military Aviation:
_ Carrier-based aircraft: _ Land-based aircraft; _ Fighter's Supersonic bombers;
_ Interceptors; _ Fighter or attack bombers;
_ Other land-based aircraft, used for: _ Observation; _ Reconnaissance; _ Spotting;
_ Tactical support of combat personnel;
_ Non-supersonic bombers of the Air Combat Command;
_ Tankers and tactical airlift of the Air Mobility Commando;
_ Other Air Mobility Command aircraft; _ Patrol and reconnaissance planes of the Navy;
_ Search and rescue planes of the Air Force and Navy;
_ Test or experimental (describe in Remarks.);
_ Other (state branch of service including National Guard or Reserve); _ Student pilot.

3) Type of Aircraft: _ Single engine; _ Multi-engine; _ Jet; _ Propeller; _ Helicopter; _ If military, identify
in Remarks (e.g., C-5, B2, etc.)

4) Do you plan that your future flying will be of a different nature? _ Yes _ No (If yes, describe in Remarks.)

5) Do you plan to fly in a different type of aircraft in the future? _ Yes _ No (If yes, describe in Remarks.)

Flight Details

1. Who owns the aircraft?
2. What is your job aboard the aircraft?
3. Month and year of last flight in section 2 for all that apply: Student ____/____;
Pilot or co-pilot ____/____; Crew member ____/____; Passenger ____/____;

Pilots and former pilots only:
4. Do you hold a valid pilot's license or certificate? _ Yes _ No (If yes, state type.)
5. Do you hold an instrument rating or airline transport certificate? _ Yes _ No (If yes, state type.)
6. Have you ever been in any flying accidents or been grounded for violations? _ Yes _ No
(If yes, give details in Remarks).

Remarks/Additional Information
Please indicate the question number associated with your remark.

Avocation Questionnaire
Supplementary declarations forming a part of the application for insurance

Policy number _________________________________

Name _________________________________
(First name, middle initial, last name)

Avocation Information

1. Provide details of each avocation and describe safety equipment used (include exact location where each activity
takes place - including starting point, if applicable).

2. How long have you participated in each activity? ____________________________

3. Date you last participated. ____/_______
month year

4. Number of times you participate per year: Last 12 months_____ Next 12 months ____

Training and Certifications

1. List formal training and qualifying certificates, licenses, etc., held.

2. Are you a member of an organization with national affiliation and established safety rules? _ Yes _ No
If Yes, give name of organization.

Exhibitions and/or Competition Information

1. Have you engaged in, or do you intend to engage in, any exhibitions; stunting; exploration; rescue; dare-devil or
record-setting activities? _ Yes _ No (If Yes, describe fully, including frequency.)

2. Describe type of competition in which you participate. (If motor racing, include exact type of race; e.g., drag;
enduro; against time or competition; and type of track; e.g. oval.)

(a) Is it _ amateur or; _ professional?
(b) If events are supervised, name supervising organization_____________________
(c) Any competition outside of U.S. or Canada? _ Yes _ No (If Yes, where.) __________

Participation in Motor Sports

If you participate in motor sports, describe vehicle.
a. Generic type (e.g., drag racer;, stock;,
hydrofoil;.)____________________________ b. Make
________________________________ c. Model ________________________ d. Horsepower______ e. Engine displacement (cc)
_______ f. Avg. speed (mph)_______ g. Max. speed (mph) __________

Participation in Diving or Aerial Sports

If you participate; in diving or aerial sports
1. Estimate number of dives, jumps, flights Last 12 months ___ Next 12 months ___
2. Average depth/height ____ft. Maximum depth/height ___ ft.
Maximum duration _____ min/hrs.

3. Indicate type of equipment _ purchased completely assembled _ homemade
_ assembled from a factory kit _ for experimental use