a) It mainly provides general inpatient medical care and treatment of sick and injured persons by the use of medical, diagnostic and major surgical facilities. All such facilities are in it or under its control. (b) It mainly provides specialized...
The Prudential [LOGO]
Annuitant Contract No.
Xxxx Xxx xx xxx xxx
-------------------------------------------------------------- ---------------
================================================================================
WAIVER OF WITHDRAWAL CHARGES
Subject to all the provisions of this rider and
of the rest of the contract, we will waive part
or all of (1) any withdrawal and maintenance
charges otherwise associated with a full or
partial withdrawal, or (2) any annuitization or
withdrawal charge due on the annuity date, if an
annuitant is (a) terminally ill, or (b) confined
to an eligible nursing home or hospital
continuously for three months while this
contract is in force. This waiver applies only
to any purchase payment(s) made one year or more
prior to your request(s) for withdrawal, or the
annuity date.
Terminal Illness Option You may use this option if you give us evidence
that satisfies us that an Annuitant's life
expectancy is six months or less. Part of that
evidence must be a certification by a licensed
physician.
Nursing You may use this option if an Annuitant is
Home/Hospital Option confined to an eligible nursing home and/or
hospital starting any time after the contract
date, and has been confined there continuously
for at least three months.
Eligible Nursing Home An eligible nursing home is an institution or
special nursing unit of a hospital which meets at
least one of the following requirements:
1. it is Medicare approved as a provider of
skilled nursing care services; or
2. it is licensed as a skilled nursing home or as
an intermediate care facility by the state in
which it is located; or
3. it meets all of the requirements listed below:
(a) it is licensed as a nursing home by the
state in which it is located;
(b) its main function is to provide skilled,
intermediate, or custodial nursing care;
(c) it is engaged in providing continuous room
and board accommodations to 3 or more
persons;
(d) it is under the supervision of a registered
nurse (RN) or licensed practical nurse
(LPN);
(e) it maintains a daily medical record of each
patient; and
(f) it maintains control and records for all
medications dispensed.
Institutions which primarily provide residential
facilities are not eligible nursing homes.
Eligible Hospital An eligible hospital is an institution that meets
either of these requirements:
1. It is accredited as a hospital under the
Hospital Accreditation Program of the Joint
Commission on Accreditation of Healthcare
Organizations.
2. It is legally operated, has 24 hour a day
supervision by a staff of doctors, has 24 hour
a day nursing service by registered graduate
nurses, and complies with (a) or (b):
------------
ORD 88754-92
------------
(a) It mainly provides general inpatient
medical care and treatment of sick and
injured persons by the use of medical,
diagnostic and major surgical facilities.
All such facilities are in it or under its
control.
(b) It mainly provides specialized inpatient
medical care and treatment of sick or
injured persons by the use of medical and
diagnostic facilities (including x-ray and
laboratory). All such facilities are in it,
under its control, or available to it under
a written agreement with a hospital (as
defined above) or with a specialized
provider of these facilities.
An eligible hospital is not an institution, or
part of one, which: (a) furnishes mainly homelike
or custodial care, or training in the routines of
daily living; or (b) is mainly a school.
Conditions Your right to be paid under one of these options
is subject to the following conditions:
1. You must choose the option in writing in a
form that meets our needs.
2. The contract must not be assigned.
3. You must give us any facts we need to satisfy
us that an Annuitant qualifies for one of the
options described above.
Rider attached to and made a part of this contract
The Prudential Insurance Company of America,
By /s/ [ILLEGIBLE]
-------------------------------------------
Secretary
Effective Date Nov. 18, 1992 Attest X. Xxxxx
------------
ORD 88754-92
------------
