EXHIBIT 1.A.(10(a)
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THE PRUDENTIAL [GRAPHIC]
APPLICATION FOR LIFE INSURANCE
OR POLICY CHANGE
| | The Prudential Insurance Company of America
|_| Pruco Life Insurance Company
Policy No. ______________________________________________ A Subsidiary of The Prudential Insurance Company of America
|_| Check here if policy change. Corporate Offices, Newark, New Jersey
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Name of primary proposed Insured (or current Insured, if policy change) (first, initial, last)
PART 1
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A. PERSONAL INFORMATION (Primary Proposed Insured)
1. Social Security No. -- 2. Sex: | | Male |_| Female
3. Marital Status: |_| Single | | Married |_| Widowed |_| Separated |_| Divorced
4. Date of Birth: Mo. 6 Day 15 Yr. 61 5. Age 35 6. State of Birth (Country if not U.S.) (Name of State)
7. Billing Address (City, State and Zip) :
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000 Xxxx Xx., Any City, Any State
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8. Home Address (if different): -------------------------------------------------------------------------------------------------
9. Home telephone number ( ) - 10. Business telephone number --
11. Current Employer ABC Company
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B. ALL OTHER PROPOSED INSUREDS (Include Applicant for Applicant's Waiver of Premium Benefit)
Name Relationship to Sex Date of Age State of Total Life Insurance
primary proposed Birth Birth (country in all companies
Insured (mo., day, yr.) if not U.S.)
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C. COVERAGE INFORMATION
1. Plan of Insurance ________________________________________________________________ 2. Initial Amount $ 25,000
If AL/VAL or applicable to the product, check one: |_| Level Death Benefit |_| Variable Death Benefit
3. SUPPLEMENTARY BENEFITS AND RIDERS (Please indicate amount where applicable)
|_| Waiver of Premium |_| Accidental Death Benefit $
|_| Living Needs Benefit |_| Option to Purchase Additional Insurance $
|_| Applicant's Waiver of Premium |_| Option to Purchase Paid Up Life Insurance Additions
|_| Automatic Premium Loan (include details in special request)
OTHER RIDERS AND BENEFITS: (Please indicate amount where applicabLe) --------------------------------------------
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D. BENEFICIARIES/OWNERSHIP (If Trust, provide name of trust, trustee and date of trust.)
1. Beneficiary: Name Relationship to primary proposed Insured Age
Primary (Class 1) ------------------------------------------------------------------------------------------------------------
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Contingent (Class 2) --------------------------------------------------------------------------------------------------------
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2. Is the owner other than the primary proposed Insured? |_| Yes || No
If yes: Name: ---------------------------------------------------------------------------------------------------------------
Address ---------------------------------------------------------------------------------------------------------------
---------------------------------- Owner's date of birth -------------------------------------------------------------------
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E. PAYMENT DETAILS
1. Within the last 12 months, has any proposed Insured had a heart attack, stroke or cancer other than of the skin? |_| Yes || No
2. Is a medical examination required on: Primary Proposed Insured? |_| Yes || No Second Proposed Insured? |_| Yes || No
3. Premium Payment Mode: (collect full modal premium)
|_| Pru-matic |_| Annual |_| Semi-annual |_| Quarterly ||Monthly |_| Payroll Budget |_| Gov't Allotment
4. Amount paid with this application $ . |_| None (Must be "None" if E1 is answered Yes, except Gibraltar
products.)
5. Date premium collected 2-1-96
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F. REPLACEMENT
For any proposed Insured, would this insurance replace or cause a change in any existing insurance or
annuity in any company? |_| Yes || No
(If yes, give insurance company, plan, amount and policy number(s). Enclose all required state replacement forms.)
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G. SPECIAL REQUESTS
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H. BACKGROUND ON PROPOSED INSUREDS
1. Total Life Insurance on the primary proposed insured in effect Check here if None ||.
2. What are the primary proposed Insured's occupation and duties? ---------------------------------------------------------
Manager & Administrative duties
3. Has any proposed Insured participated in the following activities within the last 2 years (or does anyone plan to do so in the
future):
a. operated or had any duties aboard an aircraft, glider, balloon, or like device? |_| Yes || No
If yes, complete Aviation Questionnaire.
b. hazardous sports, such as auto, motorcycle, snowmobile or powerboat competitions/exhibitions;
scuba diving; mountain climbing; parachuting; sky diving or any other such sport or hobby? |_| Yes || No
If yes, complete Avocation Questionnaire.
For any questions answered yes below, give the details in 8.
4. Is any proposed Insured applying for or requesting reinstatement or policy change (s) of any other life or health
insurance policy ? If yes, give 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 motor vehicle law within the last 5 years? |_| Yes || No
6. a. Primary Proposed Insured driver's license number and state of issue:
-- (Name of State)
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b. Has any proposed Insured in the last 3 years:
1. had a driver's license denied, suspended or revoked? |_| Yes || No
2. been convicted of or cited for:
(a) 3 or more moving violations? |_| Yes || No
(b) driving under the influence of alcohol or drugs? |_| Yes || No
3. been involved as a driver in 2 or more auto accidents? _| Yes || No
If yes, give 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, give countries, purpose and duration of trip.
8. Details of yes answers for questions 4-7. Give question no., proposed Insured's name and full details
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I. CHANGES MADE BY THE COMPANY (Not applicable in New Mexico and West Virginia)
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ORD 96200-96
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ANY PERSON WHO KNOWINGLY GIVES FALSE OR DECEPTIVE INFORMATION, WHEN COMPLETING
THIS APPLICATION, FOR THE PURPOSE OF DEFRAUDING THE COMPANY COULD BE FOUND
GUILTY OF INSURANCE FRAUD.
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On this page the words "I" and "my" refer to the primary proposed Insured and
applicant, if different. The words "the Company" refer to the company checked on
page 1 of this application. If a policy change, "I" and "my" refer to Insured or
Owner, if other than Insured.
TERMS AND CONDITIONS
No new coverage requested in this application starts on any proposed Insured
until all required initial medical examinations agreed to are completed, even if
an amount has been paid to the Company.
When the Company gives a Limited Insurance Agreement form dated on the same date
shown below, coverage will start as written in that Agreement. Otherwise,
coverage will start on the contract date, provided:
. The Company issues a contract and I accept it; and
. the first premium is paid in full while all proposed Insureds' health
remains as stated in the application.
If the Company enters any change in section I, I approve the change by accepting
the contract, unless the law requires written consent to changes. Then, a change
can be made only if I approve it in writing. No agent can make or change a
contract, or waive any of the Company's rights or requirements.
The beneficiary named in the application (or in the contract if requesting a
policy change) is for insurance payable in either of the following cases:
. at the death of the primary Insured; and
. at the death of an Insured child after the death of the primary
Insured if there is no Insured spouse.
If this is a policy change and no beneficiary has been named in the application,
the beneficiary for any insurance payable will be carried over from the contract
that is being changed.
The owner of the contract is the primary proposed Insured or applicant if other
than the primary proposed Insured unless a different owner is named in the
application. If this is a policy change, the ownership arrangement will be
carried over from the contract that is being changed unless a different owner is
named in the application. This is subject to any provisions for the automatic
transfer of ownership stated in the contract. If joint owners are named,
ownership will be with the right of survivorship unless otherwise specified.
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SIGNATURES
By signing below:
. I certify that to the best of my knowledge and belief the statements in
this application are complete, true and correctly recorded.
. I understand that new coverage could be invalidated if any information in
the application is materially misrepresented.
. I confirm that if I have requested the Living Needs Benefit, I have read
the disclosures in the brochure (ORD 87246).
. I agree to the Terms and Conditions shown above and on the Important Notice
About Your Application, which I have received and read.
Signed at: on
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(City/State) Date (month/day/year)
Signature of primary proposed Insured, if age 8 or over X______________________
or current Insured, if policy change
Signature of Applicant, if different than primary proposed Insured X__________
or if a policy change, Signature of Owner, if different than Insured
If applicant is a firm or corporation, give that company's name and have an
officer sign below.
Signature and title of Officer of firm or corporation X_______________________
Signature of Beneficiary, if policy change and rights are limited X___________
Signature of Witness (Licensed Writing Representative must witness)X__________
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Licensed Writing Representative's Certification: Do you have any information,
other than what is stated in this application, that indicates that any proposed
Insured may replace or change any current insurance or annuity in any company?
[ ] YES [ ] NO
Witness (Licensed Writing Representative must witness) X_______________________
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PART 2 - MEDICAL INFORMATION
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SECTION A - TO BE COMPLETED FOR ALL CATEGORY II CHANGES AND PLANS OTHER THAN GIBRALTAR
1. Doctor Information:
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A. Primary Proposed Insured
Physician last consulted:____________________ Primary Physician: ________________________
Date Last seen:_______________________________ Date last seen: ___________________________
Reason:_______________________________________ Reason:____________________________________
Address and Phone no.:________________________ Address and Phone no.:_____________________
B. Second Proposed Insured or AWP Applicant
Physician last consulted:____________________ Primary Physician:_________________________
Date last seen:______________________________ Date last seen:____________________________
Reason:______________________________________ Reason:____________________________________
Address and Phone no.:_______________________ Address and Phone no.:_____________________
_____________________________________________ ___________________________________________
2. Build: Height Weight
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a. Primary Proposed Insured _______ _______
b. Second Proposed Insured or AWP Applicant _______ _______
3. Has either the primary proposed Insured or second proposed Insured, if proposed for coverage, ever used
tobacco or other nicotine products? |_| Yes || No
If yes, give date last used: Cigarettes Any other nicotine product such as cigar, pipe, smokeless
(Mo/Yr) tobacco, nicotine gum or nicotine patch (mo/yr)
Primary Proposed Insured __________________________ _________________________________________________________
Second Proposed Insured __________________________ _________________________________________________________
4. Has anyone proposed for coverage had:
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. sexually transmitted disease, AIDS or AIDS related condition, or a positive HIV related test? |_| Yes || No
g. asthma or an disorder of the lungs? || Yes |_| No
h. any disorder of the brain or the nervous system? |_| Yes || No
i. hepatitis or any disorder of the liver, stomach or intestines? |_| Yes || No
j. any disorder of the kidney or urinary tract? |_| Yes || No
5. Other than above, is anyone proposed for coverage currently taking prescription medication? |_| Yes || No
6. 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 5 years, had or been advised to have surgery, medical tests, or diagnostic procedures
(ECGs, stress tests, -rays, blood tests, urine tests, etc)? |_| Yes || No
7. Has anyone proposed for coverage:
a. used or is now using cocaine, amphetamines, marijuana, heroin, or other drugs except as prescribed
by a health care provider? |_| Yes || No
b. had or been advised to have treatment or counseling for alcohol or drug use? |_| Yes || No
8. Does anyone proposed for coverage have any disease, disorder or condition not indicated above? |_| Yes || No
9. Has anyone proposed for coverage had life or health insurance declined, postponed, or issued with an
increased premium? |_| Yes || No
10. Has anyone proposed for coverage requested or received disability or compensation benefits? |_| Yes || No
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11. Details of yes answers for questions 4 -10.
Question No. Illness, operation or other reason Dates and Name, address and telephone
and proposed for any check-up, health care provider's duration number of health care
Insured's name advice, treatment and medications of illness providers and hospitals
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FOR ADDITIONAL MEDICAL DETAILS USE ANOTHER APPLICATION
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All the answers are, to the best of my knowledge and belief, complete, true and correctly recorded. It is understood that any new
coverage could be invalidated if any information in the application is materially misrepresented.
X__________________ X____________________________ X________________________________________________________
Date Witness Signature of primary proposed Insured (if age 15 or over)
otherwise Applicant (or Owner, if policy change)
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PART 2 - MEDICAL INFORMATION
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SECTION B - TO BE COMPLETED FOR CATEGORY I CHANGES ONLY
1. Has either the primary proposed Insured or second proposed Insured, if proposed for coverage, ever used
tobacco or other nicotine products? |_| Yes |_| No
If yes, give date last used: Cigarettes Any other nicotine product such as cigar, pipe, smokeless
(Mo/Yr) tobacco, nicotine gum or nicotine patch (mo/yr)
Primary Proposed Insured___________________ __________________________________________________________
Second Proposed Insured____________________ __________________________________________________________
2. Has anyone proposed for coverage been declined or charged an increased premium for new life insurance
or reinstatement of life insurance? If yes, give details |_| Yes |_| No
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3. Is anyone proposed for coverage currently unable to perform the normal duties of their occupation and/or
normal daily activities? If yes, give details |_| Yes |_| No
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4. Within the last five (5) years, has anyone proposed for coverage:
a. taken prescription medication, or been treated for or diagnosed as having: high blood pressure, any disease
or disorder of the heart, arteries or veins, diabetes, cancer, respiratory disorder (including asthma, recurrent
bronchitis, emphysema), a mental illness or psychiatric disorder or any disease or disorder of the nervous
system, alcohol or drug use? |_| Yes |_| No
b. been treated for or diagnosed as having AIDS or any AIDS related conditions, other sexually transmitted
diseases or positive test results for HIV? |_| Yes |_| No
5. Details of any "Yes" answer to question 4:
Question No. Illness, operation or other reason Dates and Name, address and telephone
and proposed for any check-up, health care provider's duration number of health care
insured's name advice, treatment and medications of illness providers and hospitals
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All the answers are, to the best of my knowledge and belief, complete, true and correctly recorded. It is understood that any new
coverage could be invalidated if any information in the application is materially misrepresented.
X______________ X_______________ X________________________________________________________
Date Witness Signature of primary proposed Insured (if age 15 or over)
otherwise Owner
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XXX 00000-00
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PART 2 - MEDICAL INFORMATION
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SECTION C - TO BE COMPLETED FOR GIBRALTAR PLANS ONLY
1. Doctor Information:
A. Primary Proposed Insured
Physician last consulted:_______________________________ Primary Physician:______________________
Date Last seen:__________________________________________ Date last seen:_________________________
Reason:__________________________________________________ Reason:_________________________________
Address and Phone no.:___________________________________ Address and Phone no.:__________________
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B. Second Proposed Insured or AWP Applicant
Physician last consulted:_______________________________ Primary Physician:______________________
Date Last seen:__________________________________________ Date last seen:_________________________
Reason:__________________________________________________ Reason:_________________________________
Address and Phone no.:___________________________________ Address and Phone no.:__________________
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2. Build: Height Weight
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a. Primary Proposed Insured ---------------- ----------
b. Second Proposed Insured or AWP Applicant ---------------- ----------
3. Has either the primary proposed Insured or second proposed Insured, if proposed for coverage, ever used
tobacco or other nicotine products? |_| Yes |_| No
If yes, give date last used: Cigarettes Any other nicotine product such as cigar, pipe, smokeless
(Mo/Yr) tobacco, nicotine gum or nicotine patch (mo/yr)
Primary Proposed Insured _____________________________________________
Second Proposed Insured _____________________________________________
4. Within the last five (5) years, has anyone proposed for coverage:
a. taken prescription medication, or been treated for or diagnosed as having: high blood pressure, any disease
or disorder of the heart, arteries or veins, diabetes, cancer, respiratory disorder (including asthma, recurrent
bronchitis, emphysema), a mental illness or psychiatric disorder or any disease or disorder of the nervous
system, alcohol or drug use? |_| Yes |_| No
b. been treated for or diagnosed as having AIDS or any AIDS related conditions, other sexually transmitted
diseases or positive test results for HIV? |_| Yes |_| No
5. Has anyone proposed for coverage been declined or charged an increased premium for new life insurance or
reinstatement of life insurance? |_| Yes |_| No
6. Is anyone proposed for coverage currently unable to perform the normal duties of their occupation and/or
normal daily activities? |_| Yes |_| No
Please include the details of any "Yes" answer to the questions 4-6: -----------------------------------------------------
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All the answers are, to the best of my knowledge and belief, complete, true and
correctly recorded. It is understood that any new coverage could be invalidated
if any information in the application is materially misrepresented.
X____________________ X______________________ X________________________________________________________
Date Witness Signature of primary proposed Insured (if age 15 or over)
otherwise Applicant
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