EXHIBIT 26(e)(ii)
Pruco Life Insurance Company No. XX XXX XXX
----------------
A Subsidiary of The Prudential Insurance Company of America
A Supplement to the Application for Life Insurance in which Xxxx Xxx is named as
the proposed Insured. The contract applied for is:
|X| Variable Life Insurance |_| Variable Appreciable Life Insurance
|_| with Variable Insurance Amount
|_| with Fixed Insurance Amount
The person who signs below:
1. UNDERSTANDS THAT UNLESS THE CONTRACT APPLIED FOR IS VARIABLE APPRECIABLE
LIFE INSURANCE WITH FIXED INSURANCE AMOUNT AND IS NOT FULLY PAID UP, THE
DEATH BENEFIT (EXCEPT ANY SUPPLEMENTARY BENEFITS) MAY GO UP OR GO DOWN
DEPENDING ON THE CONTRACT'S INVESTMENT EXPERIENCE BUT WILL NEVER BE LESS
THAN THE GUARANTEED MINIMUM, IF PREMIUMS ARE DULY PAID AND THERE IS NO
CONTRACT DEBT;
2. UNDERSTANDS THAT THE CASH VALUES MAY GO UP OR GO DOWN DEPENDING ON THE
CONTRACT'S INVESTMENT EXPERIENCE AND THAT THERE IS NO GUARANTEED MINIMUM
CASH VALUE;
Yes No
Did the applicant receive the current prospectus for
the contract checked above? ............................ |X| |_|
Does the applicant believe that this contract will meet
insurance needs and financial objectives? .............. |X| |_|
The net premium payments (as described in the prospectus) are to be allocated to
the appropriate Pruco Life variable contract account for the contract checked
above as follows:
Subaccount Allocation+
---------- -----------
Bond 20% (BOND)
Money Market 20% (MMKT)
Common Stock 20% (CSTK)
Aggressively Managed Flexible 20% (AFLX)
Conservatively Managed Flexible 20% (CFLX)
_______________________________ ___% ( )
_______________________________ ___% ( )
100
+ If any portion of a net premium is allocated to a particular subaccount,
that portion must be at least 10% on the date the allocation takes effect.
All percentage allocations must be in whole numbers (e.g. 33% can be
selected, but 33 1/3% cannot).
Date: June 1, 1984 Signature of Applicant
/s/ Xxxx Xxx
-----------------------------
