FORM OF APPLICATION
Published on
Exhibit 4(a)
PRUCO LIFE INSURANCE COMPANY OF NEW JERSEY, STRATEGIC PARTNERS(SM)
a Prudential Financial company HORIZON APPLICATION
Modified Guaranteed Annuity
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On these pages, I, you, and your refer to the contract owner. We, us, and
our refer to Pruco Life Insurance Company of New Jersey.
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1 CONTRACT Contract number (if any)
OWNER / / Individual / / Corporation / / UGMA/UTMA / / Other
INFORMATION
TRUST: / / Grantor / / Revocable / / Irrevocable
TRUST DATE (mo., day, yr.)
If a corporation or trust is indicated above, please check the
following as it applies. If neither box is checked, we will
provide annual tax reporting for the increasing value of the
contract.
/ / Tax-exempt entity under Internal Revenue Code 501
/ / Trust acting as agent for an individual under Internal
Revenue Code 72(u)
Name of owner (first, middle initial, last name)
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Street Apt.
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City State ZIP code
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Social Security number/EIN Date of birth (mo., day, year)
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Telephone number
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2 ANNUITANT This section must be completed only if the annuitant is not the
INFORMATION owner or if the owner is a trust or a corporation.
Do not Name of annuitant (first, middle initial, last name)
complete if
you are ---------------------------------------------------------------
opening
an IRA. Street (Leave address blank if same as owner.) Apt.
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City State ZIP code
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Social Security number Date of birth (mo., day, year)
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Telephone number
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Pruco Corporate Office: Pruco Life Insurance Company of New Jersey, Newark, NJ
07102 Ed. 1/2003
ORD 99720 New York Page 1 of 4
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3 CO-ANNUITANT Name of co-annuitant (first, middle initial, last name)
INFORMATION
(if any) ---------------------------------------------------------------
Do not complete Social Security number Date of birth (mo., day, year)
if you are
opening an IRA ---------------------------------------------------------------
or if the Telephone number
contract
will be owned ---------------------------------------------------------------
by a
corporation
or trust.
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4 BENEFICIARY /X/ PRIMARY CLASS
INFORMATION Name of beneficiary (first, middle initial, last name)
If trust, include name of trust and trustee's name.
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TRUST: / / Revocable / / Irrevocable
Trust date (mo., day, year)
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Beneficiary's relationship to owner
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Social Security number
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CHECK ONLY ONE: / / Primary class / / Secondary class
Name of beneficiary (first, middle initial, last name)
If trust, include name of trust and trustee's name.
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TRUST: / / Revocable / / Irrevocable
Trust date (mo., day, year)
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Beneficiary's relationship to owner
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Social Security number
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PLEASE ADD ADDITIONAL BENEFICIARIES IN SECTION 10.
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5 TYPE OF PLAN TYPE.
PLAN AND
SOURCE OF Check only one: / / Non-qualified / / Traditional IRA
FUNDS ---------------------------------------------------------------
(minimum of SOURCE OF FUNDS. Check all that apply:
$5,000)
If Traditional IRA new contribution(s) for the current and/or
previous year, complete the following:
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6 GUARANTEE Please choose only one:
PERIOD / / 3 years / / 7 years
/ / 5 years / / 10 years
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Ed. 1/2003
ORD 99720 New York Page 2 of 4
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7 REPLACEMENT THIS DISCLOSURE STATEMENT SECTION MUST BE COMPLETED IF STATE
QUESTIONS REPLACEMENT REGULATIONS REQUIRE. (Check one):
AND
DISCLOSURE / / I do have existing life insurance policies or annuity
STATEMENT contracts. (You must complete the Important Notice Regarding
Replacement form (COMB 89216 NY), whether or not this
transaction is considered a replacement.)
/ / I do not have existing life insurance policies or annuity
contracts.
Will the proposed annuity contract replace any existing
insurance policy(ies) or annuity contract(s)?
/ / Yes / / No
If "Yes," provide the following information for each policy or
contract and attach all applicable Prudential disclosure and
state replacement forms.
Company name
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Policy or contract number Year of issue (mo., day, year)
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Name of plan (if applicable)
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REPRESEN- THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE.
TATIVE'S
QUESTION Do you have, from any source, facts that any person named as
the owner above is replacing or changing any current insurance
or annuity in any company?
/ / Yes / / No
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8 SIGNATURE(S) If applying for an IRA, I acknowledge receiving an IRA
disclosure statement and understand that I will be given a
financial disclosure statement with the contract. I understand
that tax deferral is provided by the IRA, and acknowledge that
I am purchasing this contract for its features other than tax
deferral, including the lifetime income payout option, the
Death Benefit protection, and other features as described in
the prospectus.
No representative has the authority to make or change a
contract or waive any of the contract rights.
I understand that if I have purchased another non-qualified
annuity from Prudential or an affiliated company this calendar
year that they will be considered as one contract for tax
purposes.
I believe that this contract meets my needs and financial
objectives.
/ / If this application is being signed at the time the
contract is delivered, I acknowledge receipt of the contract.
/ / Check here to request a Statement of Additional
Information.
MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE
REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS
ARE PAID TO PRUDENTIAL:
I understand it is my responsibility to remove the minimum
distribution from the purchase payment PRIOR TO sending money
to Prudential with this application. Unless we are notified
otherwise, Prudential will assume that the owner has satisfied
their required minimum distributions from other IRA funds.
By signing this form, the trustee(s)/officer(s) hereby
represents that the trustee(s)/officer(s) possess(es) the
authority, on behalf of the non-natural person, to purchase the
annuity contract and to exercise all rights of ownership and
control over the contract.
I UNDERSTAND THAT THE PURCHASE PAYMENT WILL BE SUBJECT TO A
MARKET VALUE ADJUSTMENT IF THERE IS A WITHDRAWAL,
ANNUITIZATION, OR SETTLEMENT ON ANY DATE OTHER THAN WITHIN THE
30 DAY PERIOD IMMEDIATELY PRECEDING THE END OF THE GUARANTEE
PERIOD. A MARKET VALUE ADJUSTMENT CAN BE A POSITIVE OR NEGATIVE
ADJUSTMENT. THERE IS NO MARKET VALUE ADJUSTMENT AT DEATH.
(continued)
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Ed. 1/2003
ORD 99720 New York Page 3 of 4
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8 SIGNATURE(S) I hereby represent that my answers to the questions on this
(continued) application are correct and true to the best of my knowledge
and belief. I acknowledge receipt of current product and fund
prospectuses.
OWNER'S TAX CERTIFICATION
Under penalty of perjury, I certify that the taxpayer
identification number (TIN) I have listed on this form is my
correct TIN. I further certify that the citizenship/residency
status I have listed on this form is my correct
citizenship/residency status. I HAVE / / HAVE NOT / / (check
one) been notified by the Internal Revenue Service that I am
subject to backup withholding due to underreporting of interest
or dividends.
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9 REPRESEN- This application is submitted in the belief that the purchase
TATIVE'S of this contract is appropriate for the applicant based on the
SIGNATURE(S) information provided and as reviewed with the applicant.
Reasonable inquiry has been made of the owner concerning the
owner's overall financial situation, needs, and investment
objectives.
The representative hereby certifies that all information
contained in this application (including the representative's
replacement question in section 7) is true to the best of his
or her knowledge.
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10 ADDITIONAL ANY REMARKS ENTERED INTO THIS SECTION MUST BE INITIALED AND
REMARKS DATED BY ALL PERSONS WHO HAVE SIGNED THIS APPLICATION IN
SECTIONS 8 AND 9.
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If you have any questions, please call the Prudential Annuity
Service Center at (888) 778-2888, Monday through Friday between
8:00 a.m. and 8:00 p.m. Eastern time.
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Ed. 1/2003
ORD 99720 New York Page 4 of 4