Exhibit (5)(A)
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Application for an Annuity Contract
No.________________________________________
The Prudential Insurance Company of America
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1. Proposed Annuitant (Owner, unless otherwise indicated in #3) Sex Date of birth Age Social Security No.
Name--first, initial, last (Print) M F Mo. Day Yr.
[ ] [ ]
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Address No. Street City State Zip State of Residence
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2. Proposed Co-Annuitant (if any) (Do not complete if applying for a tax-qualified plan)
Name--first, initial, last (Print) Sex Date of birth Age Social Security No. Relationship to person
M F Mo. Day Yr. named in 1
[ ] [ ]
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3. Contract Owner (if other than Proposed Annuitant) (Do not complete if applying for an IRA, SEP or TDA plan)
Name Social Security or Tax ID No.
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Address No. Street City State Zip
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4. Contingent Contract Owner (if any) (Do not complete if applying for a tax-qualified plan)
Name Social Security or Tax ID No.
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Address No. Street City State Zip
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5. Beneficiary: (Give name, age and relationship to person named in 1.)(Do not complete if applying for a Pension/Profit Sharing
plan. The beneficiary for a contract owned by a trustee or an employer is the owner.)
a. Primary (Class 1):
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b. Contingent (Class 2) if any:
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6. Will this annuity replace or change any existing insurance or annuity contract in any company on any person Yes No
named in 1 or 2? (If "Yes", for each such contract give the person's name, name of company, plan, amount and [ ] [ ]
contract numbers.)
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7A. Kind of Annuity 7B. Type of Annuity 9. Complete this Section only if a Qualified Plan or
a. Variable [ ] a. Non-Qualified [ ] Program is the contract being applied for (Check One)
b. Fixed b. Qualified [ ]
3 yr. guaranteed interest [ ] Type:
6 yr. guaranteed interest [ ] [ ] IRA--Individual Retirement Annuity
==================================================================== [ ] SEPP (Plan Name)____________________________________
8. Source of Funds ________________________________________________________
a. Amount paid with application: $____ [ ] None (check 'None' on [ ] Premium/Profit Sharing (Plan Name)__________________
TDA or Section 457 Plan Apps.) ________________________________________________________
b. IRA: Is any part of this purchase payment an IRA rollover? Section 457 (Plan Name)_________________________________
[ ] Yes [ ] No ________________________________________________________
Amount of Rollover: $______________ [ ] Tax Deferred Annuity
Regular Contribution: $______________ Year_______ [ ] Public School Employees
$______________ Year_______ [ ] 501(c)(3)
For TDA Billing:
Employer Name_______________________________________
Employer Address____________________________________
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10. Remarks or Special Requests
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11. Investment Selection (Select one or more): Allocation (%) 12. Telephone Transfer/Reallocation Privileges
Bond __________ %
[] I wish to authorize telephone transfers/
Money Market __________ % reallocations.
Common Stock __________ % I give the company permission to change the
allocation of my net premium payments and/or
Aggressively Managed Flexible __________ % to transfer funds among my investment
choices based on my telephone instructions
Conservatively Managed Flexible __________ % when they agree with the established
conditions and requirements.
High Dividend Stock __________ %
I have read and I understand the conditions and requirements
Stock Index __________ % associated with the transfer of funds from the Fixed Rate
Option and the Real Property Option. I understand that the
High Yield Bond __________ % Company will not be subject to any claims, liability, loss,
expense or cost resulting from following my telephone
Natural Resources __________ % instructions (or anyone successfully representing
him/herself to be me).
Real Property (Not available in qualified __________ %
Contracts) I am aware that my telephone instructions will be recorded
to protect me and the Company and will be put into effect
Fixed Account __________ % only when proper identification is provided.
Other_____________________________________ __________ % [] I do not wish to authorize telephone
Total Investment 100 transfers/reallocations.
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13. Acknowledgement
OWNERSHIP: The owner of the contract will be as required by the applicable retirement plan. If there is no such plan, the
owner will be (1) the applicant if other than the proposed Annuitant, or else (2) the proposed Annuitant. In either case, any
limitations required by the retirement plan or program will be part of the contract.
If this application is for a variable annuity contract, I understand that; (1) payments and values may be based on the
investment experience of a separate account; and (2) if so, they may vary and are not guaranteed as to fixed dollar amount.
I have received the current prospectus for (1) the variable annuity contract; (2) The Prudential Series Fund, Inc.; and, if
applying for a non-qualified annuity, The Prudential Variable Contract Real Property Account. I have read the Section in the
prospectus titled "ERISA Disclosure" and conclude that the representative recommending these contracts and I do not have a
proscribed relationship. Check here if a Statement of Additional Information is desired.[]
If this application is for an IRA, I have received an explanatory booklet, and I understand that I will be given a financial
statement with the contract.
Application made at: Signature of Proposed Annuitant
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STATE______________________________________________________ Signature of Applicant (if other than proposed Annuitant)
DATE_______________________________________________________ _____________________________________________________________
(If owner is a firm or corporation, show that company's name)
WITNESS____________________________________________________
(Writing Agent or Representative) By___________________________________________________________
(Signature and title of officer signing for that Company)
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Supplementary Information
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1. Give proposed Xxxxxxxxx's current Home and Business addresses if not shown on face of application. (Print)
Home: No._______ Street____________________________ City___________________________________________ State_________ Zip_________
Business: Employer No. Street City State Zip
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2. Do you have, from any source, facts that any person named in 1 or 2 of the application may replace or change any Yes No
current insurance or annuity in any company? (Give details of "Yes", answers in "Remarks".) [ ] [ ]
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3. Does the purchase payment come from the proceeds of insurance contracts in this or another company? [ ] Yes [ ] No If "Yes", give
a. Company name_____________________________________________ b. Prudential/Pruco Life contract no.(s)_______ ___________________
c. Amount $_______________ d. Proceeds are from: [ ] Loan [ ] Dividends [ ] Surrender [ ] Other (describe)
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To be Completed by Writing Agent or Registered To be Completed by Registered Representative (Xxx Xxxxx)
Representative (Pruco Securities)
___________________________________________________________ ________________________________________________________________
NAME AND TITLE--Please Print NAME--Please Print
___________________________________________________________ ________________________________________________________________
CONTRACT NO. OFFICE CODE RHO CONTRACT NO. OFFICE CODE
___________________________________________________________ ________________________________________________________________
OFFICE BRANCH OFFICE
( )______________________________________________________ ( )___________________________________________________________
PHONE NO. PHONE NO.
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