STRATEGIC PARTNERS APPLICATION ORD 99730
Published on
EXHIBIT (4)(d)
PRUCO LIFE INSURANCE COMPANY, STRATEGIC PARTNERS(SM)
a Prudential Financial company ANNUITY ONE APPLICATION
Flexible Payment Variable Deferred Annuity
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ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THE CONTRACT ARE
VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
IF MONIES ARE ALLOCATED TO VARIABLE INVESTMENT OPTIONS, THAT PORTION OF THE
POLICY OR CONTRACT IS NOT PROTECTED BY THE MINNESOTA LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION OR THE MINNESOTA INSURANCE GUARANTY
ASSOCIATION. IN THE CASE OF INSOLVENCY, PAYMENT OF CLAIMS IS NOT GUARANTEED.
ONLY THE ASSETS OF THE INSURER WILL BE AVAILABLE TO PAY YOUR CLAIM.
On these pages, I, you, and your refer to the contract owner. We, us, and our
refer to Pruco Life Insurance Company.
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1 CONTRACT OWNER INFORMATION
Contract number (if any)____________________________
[ ] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other
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 RevenueCode 501
[ ] Trust acting as agent for an individual under Internal Revenue Code 72(u)
Name of owner (first, middle initial, last name)
_____________________________________________________________________________
Street Apt.
________________________________________________________ _________________
City State ZIP code
__________________________________________ ________ ________- __________
Social Security number/EIN Date of birth (mo., day, year) Telephone number
__________________________ _________ _________ __________ ____ ____-______
A. [ ] Female
[ ] Male
B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien).
[ ] Resident alien I am a citizen of
__________________________________________________
Attach the applicable IRS Form W-8(BEN, ECI, EXP,
IMY).
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2 JOINT OWNER INFORMATION (if any) Do not complete if you are opening an IRA.
Unmarried persons who wish to own the contract jointly should consult with
their tax adviser.
Name of joint owner, if any (first, middle initial, last name)
_____________________________________________________________________________
Street (Leave address blank if same as owner.) Apt.
________________________________________________________ _________________
City State ZIP code
__________________________________________ ________ ________-___________
Social Security number/EIN Date of birth (mo., day, year) Telephone number
__________________________ _________ _________ __________ ____ ____-______
A. [ ] Female
[ ] Male
B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien).
[ ] Resident alien I am a citizen of
__________________________________________________
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3 ANNUITANT INFORMATION Do not complete if you are opening an IRA.
This section must be completed only if the annuitant is not the owner or if
the owner is a trust or a corporation.
Name of annuitant (first, middle initial, last name)
_____________________________________________________________________________
Street (Leave address blank if same as owner.) Apt.
________________________________________________________ _________________
(continued)
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Pruco Corporate Office: Pruco Life Insurance Company, Ed.5/2003
Phoenix, AZ 85014
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ORD 99730 Page 1 of 7
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3 ANNUITANT INFORMATION (continued)
City State ZIP code
__________________________________________ ________ ________-___________
Social Security number Date of birth (mo., day, year) Telephone number
__________________________ _________ _________ __________ ____ ____-______
A. [ ] Female
[ ] Male
B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien).
[ ] Resident alien I am a citizen of
__________________________________________________
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4 CO-ANNUITANT INFORMATION (if any) Do not complete if you are opening an IRA
or if the contract will be owned by a corporation or trust.
Name of co-annuitant (first, middle initial, last name)
_____________________________________________________________________________
Social Security number Date of birth (mo., day, year) Telephone number
__________________________ _________ _________ __________ ____ ____-______
A. [ ] Female
[ ] Male
B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien).
[ ] Resident alien I am a citizen of
__________________________________________________
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5 BENEFICIARY INFORMATION Please add additional beneficiaries in section 17.
[X] PRIMARY CLASS
Name of beneficiary (first, middle initial, last name) If trust, include name
of trust and trustee's name.
_____________________________________________________________________________
TRUST: [ ] Revocable [ ] Irrevocable Trust date (mo., day, year)__ __ ____
Beneficiary's relationship to owner__________________________________________
Social Security number______________________________________
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.
_____________________________________________________________________________
TRUST: [ ] Revocable [ ] Irrevocable Trust date (mo., day, year)__ __ ____
Beneficiary's relationship to owner__________________________________________
Social Security number______________________________________
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6 ELECTION OF CREDIT (BONUS)
Complete this section if you want to elect Credit (bonus). The election of
Credit to each purchase payment results in a higher insurance and
administrative cost and higher withdrawal charges than if the Credit was not
elected. The Credit that is allocated to the contract vests upon expiration
of the the Right to Cancel period. We reserve the right to recapture any
Credit granted within one year of the date of the owner's death.
[ ] Yes, I want Credit(bonus).
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7 DEATH BENEFIT
THIS SECTION MUST BE COMPLETED. Check one of the following four Death Benefit
options. The cost of each benefit is in parentheses immediately following the
option.
[ ] Base Death Benefit. (1.40% without credit; 1.50% with credit)
[ ] Guaranteed Minimum Death Benefit (GMDB) with a Roll-Up option. (1.65%
without credit; 1.75% with credit)
[ ] GMDB with an annual Step-Up option. (1.65% without credit; 1.75% with
credit)
[ ] GMDB with a Roll-Up and an annual Step-Up option. (1.75% without credit;
1.85% with credit)
Indicate below if you want to elect the Earnings Appreciator supplemental
death benefit. THIS OPTION IS NOT AVAILABLE IN ND.
[ ] Yes, I would like to elect the Earnings Appreciator. (0.30%)
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ORD 99730 Page 2 of 7 Ed. 5/2003
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8 INCOME BENEFITS
Check all that apply. The cost of each benefit is in parentheses immediately
following the option. ONCE ELECTED, THE GUARANTEED MINIMUM INCOME BENEFIT
(GMIB) CANNOT BE REVOKED.
[ ] Yes, I would like to elect the GMIB. THIS OPTION IS NOT AVAILABLE IN ND
AND OR. (0.45%)
[ ] Yes, I would like to elect the Income Appreciator Benefit (IAB). (0.25%)
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9 TYPE OF PLAN AND SOURCE OF FUNDS (minimum of $10,000)
PLAN TYPE.
Check only one: [ ] Non-qualified [ ] Traditional IRA
[ ] Roth IRA/Custodial [ ] Custodial account (PSI only)
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SOURCE OF FUNDS. Check all that apply:
[ ] Total amount of the check(s)
included with this application.
(Make checks payable to Prudential.) $______,_________,___________._____
[ ] IRA Rollover $______,_________,___________._____
If Traditional IRA or Roth IRA new contribution(s) for the current and/or
previous year, complete the following:
$____,___________._______ Year___________ $______,________.______ Year_______
[ ] 1035 Exchange (non-qualified only),
estimated amount: $ _______,_________,___________._______
[ ] IRA Transfer (qualified),
estimated amount: $ _______,_________,___________._______
[ ] Direct Rollover (qualified),
estimated amount: $ _______,_________,___________._______
[ ] Roth Conversion IRA, establishment
date:* _______ ________ __________
month day year
*This is the date you originally converted from a traditional IRA to a
Roth Conversion IRA. (If omitted, the current tax year will be used.)
This is required for the IRA five-tax year, holding period requirement.
A CONVERSION FROM A TRADITIONAL IRA TO A ROTH CONVERSION IRA WILL RESULT IN A
TAXABLE EVENT WHICH WILL BE REPORTED TO THE INTERNAL REVENUE SERVICE.
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10 PURCHASE PAYMENT ALLOCATION(S)
Please write in the percentage of your payment that you want to allocate to
the following options. The total must equal 100 percent. IF CHANGES ARE MADE
TO THE ALLOCATIONS LISTED BELOW, THE APPLICANT MUST INITIAL THE CHANGES.
* THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $2,000.
** THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $1,000.
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ORD 99730 Page 3 of 7 Ed.5/2003
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11 DOLLAR COST AVERAGING PROGRAM
If you elect to use more than one Dollar Cost Averaging option, you must also
complete a Request for Dollar Cost Averaging Enrollment or Change form (ORD
78275).
[ ] DOLLAR COST AVERAGING: I authorize Prudential to automatically transfer
funds as indicated below.
TRANSFER FROM: (You cannot transfer from the 1 Year Fixed-Rate Option.)
*If you selected the DCA6 or DCA12 option in section 10, only complete
the TRANSFER TO information.
Option code:__________ $_______,_________,________.________ or ________%
TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually
[ ] Quarterly [ ] Monthly
TRANSFER TO: (You cannot transfer to the DCAInterest Rate options or any
of the Market Value Adjustment options.)
The total of the two columns must equal 100 percent.
OPTION CODE PERCENT OPTION CODE PERCENT
_______________ ________% ______________ _________%
_______________ ________% ______________ _________%
_______________ ________% ______________ _________%
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12 AUTO-REBALANCING
[ ] AUTO-REBALANCING: I want to maintain my allocation percentages. Please
have my portfolio mix automatically adjusted as allocated in section
10 under my variable investment options.
Adjust my portfolio: [ ] Annually [ ] Semiannually
[ ] Quarterly [ ] Monthly
Please specify the start date if different than the contract date:
_________ ________ __________
month day year
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13 TELEPHONE TRANSFERS
We will accept your transfers and reallocations over the telephone. Please
indicate below if you wish to extend authority as follows.
[ ] I authorize Prudential to accept telephone transfers and reallocation
instructions from my Registered Investment Adviser.
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14 REPLACEMENT QUESTIONS AND DISCLOSURE STATEMENT
THIS DISCLOSURE STATEMENT SECTION MUST BE COMPLETED IF STATE REPLACEMENT
REGULATIONS REQUIRE. (Check one):
[ ] I do have existing life insurance policies or annuity contracts. (You
must complete the Important Notice Regarding Replacementform
(COMB 89216), 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
_____________________________________________________________________________
Policy or contract number Year of issue (mo., day, year)
__________________________ ________ _________ ___________
Name of plan(if applicable)
___________________________
FOR VIRGINIA ONLY:
X_________________________________________ _________ _______ ___________
Contract owner's signature and date month day year
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REPRESENTATIVE'S QUESTION
THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE.
Do you have, from any source, facts that any person named as the owner or
joint owner above is replacing or changing any current insurance or annuity
in any company?
[ ] Yes [ ] No
FOR VIRGINIA ONLY:
X_________________________________________ _________ _______ ___________
Representative's signature and date month day year
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ORD 99730 Page 4 of 7 Ed.5/2003
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15 SIGNATURE(S)
If applying for an IRA or Roth 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, the ability to transfer among investment options
without sales or withdrawal charges, 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.
Furthermore, I (1) understand that any amount of purchase payments allocated
to a variable investment option will reflect the investment experience of
that option and, therefore, annuity payments and surrender values may vary
and are not guaranteed as to a fixed dollar amount, and (2) acknowledge
receipt of the current prospectus for this contract and the variable
investment options.
[ ] If this contract has a joint owner, please check this box to authorize
Prudential to act on the instruction(s) of either the owner or joint
owner with regard to transactions under the contract.
[ ] 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, including the right to make purchase
payments to the contract.
We must have both the owner's and annuitant's signatures even if this
contract is owned by a trust, corporation, or other entity. If the annuitant
is a minor, please provide the signature of a legal guardian or custodian.
THOSE AMOUNTS ALLOCATED TO ANY MVA OPTION WILL BE SUBJECT TO A MARKET VALUE
ADJUSTMENT IF WITHDRAWN OR TRANSFERRED AT ANY TIME OTHER THAN DURING THE
30-DAY PERIOD FOLLOWING THE INTEREST CELL'S MATURITY. A MARKET VALUE
ADJUSTMENT CAN BE A POSITIVE OR NEGATIVE ADJUSTMENT. THERE IS NO MARKET VALUE
ADJUSTMENT AT DEATH.
I hereby represent that my answers to the questions on this application are
correct and true to the best of my knowledge and belief. ALL PAYMENTS AND
VALUES PROVIDED BY THE CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF
THE VARIABLE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. I
have read the applicable fraud warning for my state listed in section 18. I
acknowledge receipt of current product and fund prospectuses.
______________________________________
SIGNED AT (CITY, STATE)
X__________________________________________________ _______ _____ ______
Contract owner's signature and date month day year
X__________________________________________________ _______ _____ ______
Joint owner's signature (if applicable) and date month day year
X__________________________________________________ _______ _____ ______
Annuitant's signature (if applicable) and date month day year
X__________________________________________________ _______ _____ ______
Co-annuitant's signature (if applicable) and date month day year
OWNER'S TAX CERTIFICATION
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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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X__________________________________________________ _______ _____ ______
Contract owner's signature and date month day year
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ORD 99730 Page 5 of 7 Ed.5/2003
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16 REPRESENTATIVE'S SIGNATURE(S)
Commission Option (For Retail Distribution only. Choose one.):
1. [ ] No Trail 2. [ ] Mid Trail 3. [ ] High Trail
Note: If an option is not selected, the default option will be Option 1.
This application is submitted in the belief that the purchase of this
contract is appropriate for the applicant based on the 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 is true to the best of his or her knowledge.
___________________________________________ ___________________________
Representative's name (Please print) Rep's contract/FA number
X___________________________________________ ________ _________ _________
Representative's signature and date month day year
___________________________________________ ___________________________
Second representative's name (Please print) Rep's contract/FA number
X___________________________________________ ________ _________ _________
Second representative's signature and date month day year
___________________________________________ ________ _________-__________
Branch/field office name and code Representative's telephone
number
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17 ADDITIONAL REMARKS
ANY REMARKS ENTERED INTO THIS SECTION MUST BE INITIALED AND DATED BY ALL
PERSONS WHO HAVE SIGNED THIS APPLICATION IN SECTIONS 15 AND 16.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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ORD 99730 Page 6 of 7 Ed.5/2003
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18 FRAUD WARNINGS
COLORADO: It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. 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 policy holder or claimant
for the purpose of defrauding or attempting to defraud the policy holder 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.
CONNECTICUT: Any person who knowingly gives false or deceptive information
when completing this form for the purpose of defrauding the company may be
guilty of insurance fraud. This is to be determined by a court of competent
jurisdiction.
NEW JERSEY: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil
penalties.
NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to civil
fines and criminal penalties.
OKLAHOMA: WARNING -- Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information
is guilty of a felony.
PENNSYLVANIA: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
VIRGINIA: Any person who, with the intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement may have violated state law.
ALL OTHER STATES: Any person who knowingly gives false or deceptive
information when completing this form for the purpose of defrauding the
company may be guilty of insurance fraud.
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STANDARD PRUDENTIAL ANNUITY SERVICE OVERNIGHT PRUDENTIAL ANNUITY SERVICE
MAIL TO: CENTER MAIL TO: CENTER
PO BOX 7590 2101 WELSH ROAD
PHILADELPHIA, PA 19101 DRESHER, PA 19025
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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ORD 99730 Page 7 of 7 Ed.5/2003
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