The Prudential [LOGO]
Annuitant Contract No.
Xxxx Xxx XX XXX XXX
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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 Home/Hospital Option
You may use this option if an Annuitant is 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):
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(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.
Xxxxx attached to and made a part of this contract
The Prudential Insurance Company of America,
By /s/ [SPECIMEN]
Secretary
Effective Date Nov. 18, 1992 Attest X. Xxxxx
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