SPECIAL LIMITATIONS (CONTINUED FROM PAGE 1). This Agreement does not provide coverage for any riders or additional supplemental benefits which you have requested from the Company. • The limited insurance is subject to the terms, limitations and exclusions of the policy you have requested from the Company. We will pay the death benefit under this Agreement to the beneficiary you designated to the Company. • If benefits are payable under this Agreement, then no benefit relating to that death will be payable under any policy that is subsequently issued. • No producer, medical examiner, or any other Company representative is authorized to accept risks or determine insurability, or to alter or waive any of the terms or conditions of this Agreement, or to waive any of the Company's rights or requirements. • The total amount of insurance requested in all applications on the proposed insured (or if survivorship coverage is requested, both proposed insureds combined) cannot exceed $5,000,000. • There is no coverage under this Limited Insurance Agreement if the Health Certification is materially misrepresented or fraudulent. If death is due to suicide or intentionally self-inflicted injury, while sane or insane, payment will be limited to the return of the amount paid. Definitions: The term "Company" refers to the company named at the beginning of the Application for Life Insurance. My original signature has been affixed to this Agreement. The original will be retained by the Company and I will receive a copy identical in form and substance. ORD 96200A-2010 IMPORTANT NOTICE ABOUT YOUR APPLICATION FOR INSURANCE The Prudential Insurance Company of America Pruco Life Insurance Company The words “you” and “your” refer to the primary proposed insured and policyowner or applicant, if other than the primary proposed insured. This notice tells you about the information practices we will employ in evaluating your application for insurance. Information about Prudential’s information policies and practices relating to its customers and former customers is provided in our publication “Your Financial Security, Your Satisfaction and Your Privacy.”
SPECIAL LIMITATIONS (CONTINUED FROM PAGE 1). This Agreement does not provide coverage for any riders or additional supplemental benefits which you have requested from the Company. • The limited insurance is subject to the terms, limitations and exclusions of the policy you have requested from the Company. We will pay the death benefit under this Agreement to the beneficiary you designated to the Company. • If benefits are payable under this Agreement, then no benefit relating to that death will be payable under any policy that is subsequently issued. • No producer, medical examiner, or any other Company representative is authorized to accept risks or determine insurability, or to alter or waive any of the terms or conditions of this Agreement, or to waive any of the Company's rights or requirements. • The total amount of insurance requested in all applications on the proposed insured (or if survivorship coverage is requested, both proposed insureds combined) cannot exceed $5,000,000. • There is no coverage under this Limited Insurance Agreement if the Health Certification is materially misrepresented or fraudulent. If death is due to suicide or intentionally self-inflicted injury, while sane or insane, payment will be limited to the return of the amount paid. Definitions: The term "Company" refers to the company named at the beginning of the Application for Life Insurance. My original signature has been affixed to this Agreement. The original will be retained by the Company and I will receive a copy identical in form and substance. ORD 96200A-2010
