EXHIBIT A(10)(e)
Prudential
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APPLICATION FOR LIFE INSURANCE
LOGO
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Proposed Insured
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Submitted By
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Name & Title Contract No. Agcy. No./Rep. Init. Office Code Detached Office
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Credit
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[ ] Debit Ord. [ ] New Acct. [ ] Existing Acct. No. of Apps.__________ Fam. Acct. No.
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[ ] Reg. Ord. Premium Quoted/Scheduled Premium Payment $______________________________________ (According to mode selected)
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[ ] Pruco FOR FIELD OFFICE STAFF TO COMPLETE: Control No. _________ County Code __________
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ORD 84376 82 MISSOURI
II-135
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We may also make a brief report to the Medical Information Bureau (MIB) which
provides an information exchange for its member insurance companies. When you
apply for life or health insurance or submit a claim for benefits to any member
company, MIB will, on request, give that company the information in its file. If
you have any questions about any report which MIB may have on you, you may
contact MIB at Post Office Box 105, Essex Station, Boston, MA 02112, (617)
426-3660.
If you have any questions concerning any of the personal information which we
obtain or report, let us know. You have the right to see this information and to
correct, amend or delete any information which may be wrong. We will tell you
how to do this if you ask us. If we are unable to issue the policy you
requested, we will tell you and explain the reasons. Thank you for applying to
us for insurance.
Corporate Offices, Newark, N.J.
These Regional Home Offices of The Prudential Insurance Company of America are
also Service Offices of Pruco Life Insurance Company.
Central Atlantic Home Office, Fort Washington, Pa.
Eastern Home Office, South Plainfield, N.J.
Mid-America Home Office, Chicago, Ill.
North Central Home Office, Minneapolis, Minn.
Northeastern Home Office, Boston, Mass.
South-Central Home Office, Jacksonville, Fla.
Southwestern Home Office, Houston, Tex.
Western Home Office, Los Angeles, Calif.
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We received $_____________ on _____________, 19___ from _______________________
This amount was paid when a life insurance application was signed, on the same
date, in which ____________________________________________ is named as the
proposed Insured. This agreement is issued on the condition that any check,
draft or other order for the payment of money is good and can be collected. All
checks must be drawn only to the Company and not to any other party.
No change may be made in the terms and conditions of this form. No statement
which claims to make such a change will bind the Company.
Field Office Writing Representative (Agent)
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The Prudential Insurance Company of America Pruco Life Insurance Company
Corporate Offices, Newark. N.J.
These Regional Home Offices of The Prudential Insurance Company of America are
also Service Offices of Pruco Life Insurance Company.
Central Atlantic Home Office, Fort Washington, Pa.
Eastern Home Office, South Plainfield, N.J.
Mid-America Home Office, Chicago, Ill.
North Central Home Office, Minneapolis, Minn.
Northeastern Home Office, Boston, Mass.
South-Central Home Office, Jacksonville, Fla.
Southwestern Home Office, Houston, Tex.
Western Home Office, Los Angeles, Calif.
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Note--Unless you get a contract, or your money back within eight weeks from the
date of this agreement, please notify the Company. Give the amount paid, date of
payment, and name of person to whom paid. (Locations are shown above.)
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3. Name _______________________________________________________________________
Address ____________________________________________________________________
Furnished by ___________________________________________________________
(Name of Proposed Insured/Applicant)
Proposed Insured's Expiration Dates: Auto ___________ Homeowners ______________
II-136
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Continuation of Part 1 of Application
Complete on all persons named in 1a and 10 if any one of them can have insurance on a non-medical basis.
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23. Height and weight of:
a. Proposed Insured Ht._______ Wt._______ b. Spouse Ht.________ Wt.________ c. Applicant for AWP Ht.________ Wt.________
Has the weight changed more than 10 pounds in the past year? Yes [ ] No [ ] If "Yes", give details in 30.
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24. Has the proposed Insured or spouse ever smoked? a. Proposed Insured Yes [ ] No [ ] b. Spouse Yes [ ] No [ ]
If "Yes", give date(s) last smoked: Cigarettes Cigars Pipe
Proposed Insured Mo.______ Yr. ______ Mo.______ Yr. ______ Mo.______ Yr. ______
Spouse Mo.______ Yr. ______ Mo.______ Yr. ______ Mo.______ Yr. ______
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25. When was a doctor last consulted by: a. Proposed Insured? b. Spouse? c. Applicant for AWP?
Mo.______ Yr. ______ Mo.______ Yr. ______ Mo.______ Yr. ______
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26. Is any person to be covered now being treated or taking medicine for any condition or disease? ................. Yes [ ] No [ ]
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27. Has any person to be covered ever:
Yes No
a. had any surgery or been advised to have surgery and has not done so?............................................... [ ] [ ]
b. been in a hospital, sanitarium or other institution for observation, rest, diagnosis or treatment? ................ [ ] [ ]
c. regularly used or is any such person now using, barbiturates or amphetamines, marijuana or other hallucinatory
drugs, or heroin, opiates or other narcotics, except as prescribed by a doctor? ................................... [ ] [ ]
d. been treated or counseled for alcoholism? ......................................................................... [ ] [ ]
e. had life or health insurance declined, postponed, changed, rated-up or withdrawn? ................................. [ ] [ ]
f. had life or health insurance canceled, or its renewal or reinstatement refused? ................................... [ ] [ ]
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28. Other than as shown above, in the past 5 years has any person to be covered: Yes No
a. consulted or been attended or examined by any doctor or other practitioner? ...................................... [ ] [ ]
b. had electrocardiograms, X-rays for diagnosis or treatment, or blood, urine, or other medical tests? .............. [ ] [ ]
c. made claim for or received benefits, compensation, or a pension because of sickness or injury? ................... [ ] [ ]
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29. Does any person to be covered now have a known sign of any physical disorder, disease or defect not shown above? Yes [ ] No [ ]
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30. What are the full details of the answer to 25 and to each part of 23 and 26 thru 29 which is answered "Yes"?
Name & Full names and addresses of
Question No. Illness or other resason Dates and duration of illness doctors and hospitals
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
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Those who sign below declare, to the best of their knowledge and belief, that the statements in this application are complete and
true.
When the Company gives a Temporary Indurance Agreement form, ORD 84376A-82, of the same date as this Part 1, coverage will start as
shown in that form. Otherwise, no coverage will start unless: (1) a contract is issued, (2) it is accepted, and (3) the full first
premium is paid while all persons to be covered are living and their health remains as stated in Part 1. If all these take place,
coverage will start on the contract date. If the Company makes a change as indicated in 22 it will be approved by acceptance of the
contract. But where the law requires written consent for any change in the application, such as change can be made only if those
who sign this form approve the change in writing. No agent can make or change a contract, or waive any of the Company's rights or
needs.
OWNERSHIP: Unless otherwise asked for above, the owner of the contract will be (1) the applicant if other than the proposed Insured,
otherwise (2) the proposed Insured. But this is subject to any automatic transfer of ownership stated in the contract.
Signature of Proposed Insured (If Age 8 or over)
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Dated at on , 19 Signature of Applicant (If other than proposed Insured)
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(City/State) ----------------------------------------------------------------------
Witness (If applicant is a firm or corporation, show that company's name)
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(Licensed agent must witness where required by law) ----------------------------------------------------------------------
(Signature and title of officer signing for that company)
ORD 84376-82 MISSOURI Page 2
II-137
No.
Part 1 Application to _________________
[ ] The Prudential Insurance Company of America
[ ] Pruco Life Insurance Company--A Subsidiary of The Prudential Insurance Company of America
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1a. Proposed Insured's name--first, initial, last (Print) 1b. Sex 2a. Date of birth 2b. Age 2c. Place of birth
M F Mo. Day Yr.
[ ] [ ]
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3. [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ] Divorced 4. Occupation(s)
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5. Address for mail No. Street City State Zip
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6a. Kind of policy 6b. Initial amount 7. Accidental death coverage
$ initial amount $
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8. Beneficiary: (Include name, age and relationship.) 9. List all life insurance on proposed Insured. (If NONE, so state.)
a. Primary (Class 1): b. Contingent (Class 2) if any: Initial Yr. Kind Medical
Company amt. issued (Indiv., Group) Yes No
[ ] [ ]
_________________________________________________________ ___________________________________________________________________
(For insurance payable upon death of (1) the Insured, and [ ] [ ]
(2) an insured child after the death of the Insured if ___________________________________________________________________
there is no insured spouse.) [ ] [ ]
___________________________________________________________________
[ ] [ ]
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10. Other person(s) proposed for coverage including the Applicant for Applicant's Waiver of Premium benefit (AWP)
Relationship to Date of birth Total life insurance
Name--first, initial, last Sex proposed Insured Mo. Day Yr. Age Place of birth in all companies
a. Spouse $
___________________________________________________________________________________________________________________________________
b. $
___________________________________________________________________________________________________________________________________
c. $
___________________________________________________________________________________________________________________________________
d. $
___________________________________________________________________________________________________________________________________
e. $
___________________________________________________________________________________________________________________________________
f. $
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11. Supplementary benefits: a. For proposed Insured b. For spouse, children, Applicant for AWP
Type and duration of benefit Amount Type and duration of benefit Amount
$ $
___________________________________________________________________________________________________________________________________
$ $
___________________________________________________________________________________________________________________________________
$ $
___________________________________________________________________________________________________________________________________
[ ] Option to Purchase Additional Ins. $ [ ] Applicant's Waiver of Premium benefit
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12. State any special request.
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13. Will this insurance replace or change any existing insurance or annuity in any company on any person named Yes No
in 1a or 10? If "Yes", give their names, name of company, plan, amount and policy numbers. [ ] [ ]
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14. Is anyone applying for, or trying to reinstate, life or health insurance on any person named in 1a or 10 in Yes No
this or any company? If "Yes", give amount, details and company. [ ] [ ]
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15. Does any person named in 1a or 10 plan to live or travel outside the United States and Canada within the next Yes No
12 months? If "Yes", give details. [ ] [ ]
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16. Has any person named in 1a or 10 operated or had any duties aboard an aircraft, glider, balloon, or like Yes No
device, within the last 2 years, or does any such person have any plans to do so in the future? If "Yes", [ ] [ ]
complete Aviation Questionnaire.
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17. Has any person named in 1a or 10, within the last 12 months: Yes No
a. been treated by a doctor for or had a known heart attack, stroke or cancer other than of the skin? ............ [ ] [ ]
b. had an electrocardiogram for any physical complaint, or taken medication for high blood pressure? ............. [ ] [ ]
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18. Premiums payable [ ] Xxx. [ ] Semi-Xxx. [ ] Quar. [ ] Mon. [ ] Pay. Budg. [ ] Pru-Matic [ ] Gov't. Allot.
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19. Amount paid $ [ ] None (Must be "None" if either 17a or 17b is answered "Yes".)
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20. Is a medical examination to be made on Yes No
a. the proposed Insured? ......................................................................................... [ ] [ ]
b. spouse (if proposed for coverage)? ............................................................................ [ ] [ ]
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21. If 20a or 20b is "Yes", is it agreed that no insurance will take effect on anyone proposed for coverage until Yes No
the person(s) indicated in 20 have been examined, even if 19 shows that an amount has been paid? ................. [ ] [ ]
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22. Changes made by the Company
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ORD 84376-82 MISSOURI Page 1 (Continued on page 2)
II-138
ACKNOWLEDGEMENT
I have received and read a copy of the IMPORTANT NOTICE ABOUT YOUR APPLICATION
FOR INSURANCE.
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Date
, 19
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AUTHORIZATION For the Release of Information to:
[ ] The Prudential Insurance Company of America
[ ] Pruco Life Insurance Company
To: Any licensed physician, medical practitioner, hospital, clinic or like
facility, insurance company or the Medical Information Bureau, Inc. or other
organization, institution or person.
To determine eligibility for life insurance coverage, I authorize you to give
the Company checked above and, through it, to its reinsurers and the Medical
Information Bureau, any data or records you may have about me or my mental or
physical health. This also applies to any child proposed for insurance in the
application.
This authorization is valid until two years after the effective date of any
contract issued in connection with this authorization. A photo of this form will
be as valid as the original. (The person who signs this form may have a copy of
it upon request.)
Signature of Proposed Insured (if age 15 or over) otherwise Applicant
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Signature of Spouse (if proposed for coverage)
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ORD 84377 82
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[ ] The Prudential Insurance Company of America [ ] Pruco Life Insurance Company
IMPORTANT NOTICE ABOUT YOUR APPLICATION FOR INSURANCE
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Before we can issue a policy we must first underwrite your application. This
means that we evaluate all the information necessary to determine if you qualify
for the insurance.
In addition to the information on the application, a medical examination may be
required. We also ask you to authorize any doctor, hospital or other
organization or person to give us any information which they may have about you
or your mental or physical health.
We may ask for a report from a consumer reporting agency. These reports provide
information about a person's character, residence, activities, general
reputation, personal characteristics and mode of living. The agency may get this
information through interviews with friends, neighbors and associates. Any
person on whom we ask for a report has a right to ask to be interviewed. You may
also get a copy of the report from the consumer reporting agency which completed
it. An agency may keep the information it has about you and disclose it to other
persons. If you would like further information as to the nature and scope of
these reports, it will be provided upon request.
Any information which we obtain about you will be treated as confidential.
However, we may give this information, as necessary, to: your doctor, if we find
a serious health problem which you do not know about; persons conducting
mortality or morbidity studies; and affiliate companies for marketing purposes.
If you ask, we will describe any other circumstances when we may disclose
information about you without your prior authorization.
ORD 84378-82
(Continued on reverse)
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[ ] The Prudential Insurance Company of America
[ ] Pruco Life Insurance Company
A Subsidiary of The Prudential Insurance Company of America
TEMPORARY INSURANCE AGREEMENT
We, the Company, agree to provide temporary insurance as follows:
1. It will start on the latest of these dates: (a) the date of this agreement,
(b) the date of completion of all medical examinations agreed to, and (c)
any date asked for in the application.
2. This insurance is subject to the terms of the contract applied for.
3. The sum of all death benefits for any person who is to be covered by this
insurance will be the amount asked for on that person or $250,000,
whichever is less.
The temporary insurance will end:
1. When we issue a contract as applied for. It will replace the temporary
insurance.
2. When we issue a contract other than as applied for. It will replace the
temporary insurance if: (a) it is accepted on delivery (this includes
paying at the same time any excess of the correct first premium over the
amount shown below); and (b) the persons who are to be covered are living
when the contract is delivered. If the contract is not accepted on delivery
the temporary insurance will end at once.
3. When we tell you that we rejected the application or when we tell you that
we will not consider it on a prepaid basis.
4. At the end of 60 days if the temporary insurance has not been ended as we
state in 1, 2 or 3.
ORD 84376A-82 (Continued on reverse) Printed in U.S.A.
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Names and addresses of three Friends or Business Associates:
1. Name _______________________________________________________________________
Address ____________________________________________________________________
2. Name _______________________________________________________________________
Address ____________________________________________________________________
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II-139
AGENT'S SUPPLEMENTAL INFORMATION
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1. Give current and last previous HOME and BUSINESS addresses.
From To Employer No. Street City or Town State
Home
Mo. Yr. Mo. Yr.
Present
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Bus.
Mo. Yr. Mo. Yr.
Present
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2. If an Investigative Consumer Report is necessary, is a direct interview desired? .............................. Yes [ ] No [ ]
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3. What is the total yearly income of: a. Proposed Insured? $ b. Spouse? $
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4. Does more than 50% of the Insured's support come from someone else? Yes [ ] No [ ] If "Yes", give that person's:
Full name Relationship Amt. of Life ins. force $
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5. Who is to pay the premium? (Check one) [ ] Insured [ ] Employer [ ] Spouse [ ] Parent [ ] Other _______________________________
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6 a. Did someone other than you suggest this insurance? Yes [ ] No [ ] If "Yes", state who and what prompted the request?
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b. What was the primary source of the Sales Lead? (Check one) (1) [ ] Policyholder Service (2) [ ] Referred Lead
(3) [ ] Cold Call
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7. What Sales Services did you use? (Check appropriate boxes)
a. [ ] FACTOR 1 b. [ ] FACTOR 2 c. [ ] Other CPI d. [ ] CNA e. [ ] FNA f. [ ] Business Security Analysis
g. [ ] Employer's Advisory Service h. [ ] Estate Conservation Service i. [ ] Other __________________________________
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8. Complete if this application is for business insurance: c. Amount of business insurance in force and applied for in all
a. Is firm a: (1) [ ] Sole Proprietorship companies on each officer or member of the firm.
(2) [ ] Partnership (3) [ ] Corporation Name Age Position Inforce Applied for
b. Is proposed Insured: $ $
[ ] Owner of firm (state _______%) [ ] Employee --------------------------------------------------------------
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9. Do you have, from any source, facts which you have not stated any place else in the application which indicate that
any person named in 1a or 10 of the application may: (Give details of "Yes" answers in "REMARKS".) Yes No
a. replace or change any current insurance or annuity in any company? ............................................ [ ] [ ]
b. have in the last 3 years participated in hazardous sports (such as auto racing or parachuting), or been
arrested for driving recklessly or while intoxicated? ......................................................... [ ] [ ]
c. have frequently drunk to excess, illegally used habit forming drugs or have a record of indictment or
conviction of any crime? ...................................................................................... [ ] [ ]
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10. Has the last name of any person named in 1a or 10 of the application been changed in the last 5 years (marriage, Yes No
court order, etc.)? If "Yes", who, and what was the previous last name? [ ] [ ]
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11. Are the proposed Insured and agent related? Yes [ ] No [ ] If "Yes", state relationship: [ ] Self [ ] Other ______________
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12. a. Proposed Insured's telephone no. b. Social Security no.
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Complete 13 if proposed Insured is age 0-14
13. Family Name Date of Present Pending Family Name Date of Present Pending
details birth insurance Pru app.? details birth insurance Pru app.?
Father Brothers
---------------------------------------------------------- & Sisters
Mother
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Complete 14 and 15 if dependent children are proposed for coverage (Give details of "Yes" answers in "REMARKS".)
14. Are any children named in 10 of the application: Yes No
x. xxxxxx children or children whole legal adoption has not yet been made final? ................................. [ ] [ ]
b. living in a household other than the proposed Insured's or dependent on someone other than the
proposed Insured? ............................................................................................. [ ] [ ]
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15. Are there any other children less than 18 years of age who have not been named in 10 of the application? ..... Yes [ ] No [ ]
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CERTIFICATION
I certify that (a) on this date I saw the proposed Insured and (b), except as stated in "REMARKS", I am not aware of any information
not shown in the answers to the questions in any Part of this application, that would adversely affect the eligibility,
acceptability or insurability of any person proposed for coverage, I recommend that the Company accept the risks proposed for
coverage.
Date Signature of Writing Representative (Agent) Mgr., Asst. Mgr. or Sales Mgr. must sign if present
when application signed
, 19
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REMARKS:
ORD 84376 82
II-140
