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[PRUDENTIAL LOGO] STRATEGIC PARTNERS SELECT(SM) APPLICATION
Pruco Life Insurance Company, Flexible Payment Variable Deferred Annuity
a Prudential Company
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On these pages, I, you,and your refer to the contract owner. We, us, and our refer to Pruco Life Insurance
Company, a Prudential company.
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1 CONTRACT Contract number (if any)| | | | | | | | | |
OWNER
INFORMATION [ ] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other
TRUST: [ ] Grantor [ ] Revocable [ ] Irrevocable TRUST DATE (mo., day, year)| | | | | | | | | | |
Name of owner (first, middle initial, last name)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Street Apt.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
City State ZIP code
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - | | | |
Social Security number/TIN Date of birth(mo., day, year) Telephone number
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - | | | | |
[ ] Female [ ] U.S. citizen [ ] I am not a U.S. citizen or resident alien. I am a citizen of
[ ] Male [ ] Resident alien | | | | | | | | | | | | | | | | | | | | | | | | |
If a corporation or trust is indicated above, please check the following as it applies.
[ ] Tax-exempt entity under IRS Code 501 [ ]Trust acting as agent for an individual under IRS Code 72(u)
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2 JOINT The joint owner can only be the owner's spouse and must be listed as the primary beneficiary.
OWNER
INFORMATION Name of joint owner (first, middle initial, last name)
(if any)
Do not | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
complete if Street (Leave address blank if same as owner.) Apt.
you are
opening | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
an IRA. City State ZIP code
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |-| | | |
Social Security number/TIN Date of birth(mo., day, year) Telephone number
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - | | | |
[ ] Female [ ] U.S. citizen [ ] I am not a U.S. citizen or resident alien. I am a citizen of
[ ] Male [ ] Resident alien | | | | | | | | | | | | | | | | | | | | | | | | |
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3 ANNUITANT This section must be completed only if the annuitant is not the owner or if the owner is a trust or
INFORMATION a corporation.
(if different Name of annuitant (first, middle initial, last name)
than the
owner) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Street (Leave address blank if same as owner.) Apt.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
City State ZIP code
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - | | | | |
Social Security number/TIN Date of birth(mo., day, year) Telephone number
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - | | | |
[ ] Female [ ] U.S. citizen [ ] I am not a U.S. citizen or resident alien. I am a citizen of
[ ] Male [ ] Resident alien | | | | | | | | | | | | | | | | | | | | | | | | |
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Pruco Corporate Office: Pruco Life Insurance Company, Phoenix, AZ 85014
ORD 99669 Page 1 of 6 Ed. 3/2001
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4 CO-ANNUITANT Name of co-annuitant (first, middle initial, last name)
INFORMATION | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
(if any)
Do not Social Security number/TIN Date of birth(mo., day, year) Telephone number
complete if | | | | | | | | | | | | | | | | | | | | | | | | |-| | | |
you are
opening an [ ] Female [ ] U.S. citizen [ ] I am not a U.S. citizen or resident alien. I am a citizen of
IRA.
[ ] Male [ ] Resident alien | | | | | | | | | | | | | | | | | | | | |
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5 BENEFICIARY [ X ]PRIMARY CLASS
INFORMATION Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee's name.
(Please add
additional | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
beneficiaries
in section TRUST: [ ] Revocable [ ] Irrevocable Trust date (mo., day, year)| | | | | | | | | |
15.)
Beneficiary's relationship to owner | | | | | | | | | | | | | | | | | | | | | | | |
CHECK ONLY ONE: [ ] Primary class [ ] Secondary class
Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee's name.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
TRUST: [ ] Revocable [ ] Irrevocable Trust date (mo., day, year)
Beneficiary's relationship to owner | | | | | | | | | | | | | | | | | | | | | | | |
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6 TYPE OF PLAN TYPE. Check only one:
PLAN AND
SOURCE OF [ ] Non-qualified [ ] Traditional IRA [ ] Roth IRA/Custodial [ ] Custodial Account (PSI only)
FUNDS ----------------------------------------------------------------------------------------------------------
(minimum of
$10,000) SOURCE OF FUNDS. Check all that apply:
[ ] Total amount of the check(s) included with this
application. (Make checks payable to Prudential.) $| | |,| | | |,| | | |.| | |
[ ] IRA Rollover $| | |,| | | |,| | | |.| | |
If Traditional IRA or Roth IRA new contribution(s) for the current and/or previous year, complete the
following:
$| |,| | | |.| | | Year $| |,| | |.| | |Year| | | | |
[ ] 1035 Exchange (non-qualified only), estimated amount: $| | |,| | | |,| | | |.| | |
[ ] IRA Transfer (qualified), estimated amount: $| | |,| | | |,| | | |.| | |
[ ] Direct Rollover (qualified), estimated amount: $| | |,| | | |,| | | |.| | |
[ ] Roth Conversion IRA, establishment date:(*) | | | | | | | | | | | |
month day year
(*)This is the date you originally converted from a traditional IRA to a Roth Conversion IRA. (If omitted,
the current tax year will be used). This is required for the IRA five-tax year, holding period
requirement.
A CONVERSION FROM A TRADITIONAL IRA TO A ROTH CONVERSION IRA WILL RESULT IN A TAXABLE EVENT WHICH WILL BE
REPORTED TO THE INTERNAL REVENUE SERVICE.
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ORD 99669 Page 2 of 6 Ed. 3/2001
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PURCHASE Please write in the percentage of your payment that you want to allocate to the following options. The
PAYMENT total must equal 100 percent. IF CHANGES ARE MADE TO THE ALLOCATIONS LISTED BELOW, THE APPLICANT MUST
ALLOCATION(S) INITIAL THE CHANGES.
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OPTION OPTION
INTEREST RATE OPTIONS CODES % VARIABLE INVESTMENT OPTIONS CODES %
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1 Year Fixed-Rate Option 1YRFXD SP Davis Value Portfolio VALUE
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7 Year Market Value Adjustment 7YRM VA SP Deutsche International Equity DEUEQ
Option* Portfolio
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VARIABLE INVESTMENT OPTIONS SP Growth Asset Allocation Portfolio GRW AL
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Prudential Global Portfolio GLEQ SP INVESCO Small Company Growth Portfolio VIFSG
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Prudential Jennison Portfolio GROWTH SP Jennison International Growth Portfolio JENIN
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Prudential Money Market Portfolio MMKT SP Large Cap Value Portfolio LRCAP
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Predential Stock Index Portfolio STIX SPM FS Capital Opportunities Portfolio MFSCO
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SP Aggressive Growth Asset AGGGW SP MFS Cap Growth Portfolio MFSCO
Allocation Portfolio
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SP AIM Aggressive Growth Portfolio AIMAG SP PIMCO High Yield Portfolio MFSMC
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SP AIM Growth and Income Portfolio AIMGI SP PIMCO Total Return Portfolio RETURN
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SP Alliance Large Cap Growth Portfolio LARCP SP Prudential U.S. Emerging Growth Portfolio EMRGW
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SP Alliance Technology Portfolio ALLTC SP Small/Mid Cap Value Portfolio SMDVL
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SP Balanced Asset Allocation Portfolio BALAN SP Strategic Partners Focus Growth Portfolio STRPR
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SP Conservative Asset Allocation CONSB Janus Aspen Series Growth Portfolio- JANSR
Portfolio Service Shares
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TOTAL 100%
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* The 7-Year Market Value Adjustment option is not available in OR or WA.
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8 DOLLAR COST [ ] DOLLAR COST AVERAGING: I authorize Prudential to automatically transfer funds as indicated below.
AVERAGING
PROGRAM TRANSFER FROM:(7 year market value adjustment option not available.)
Option code:| | | | | | | $| | |,| | | |,| | |.| | | or | | |
TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly
TRANSFER TO: (You cannot transfer to the Interest Rate Options.)
The total of the two columns must equal 100 percent.
OPTION CODE PERCENT OPTION CODE PERCENT
| | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | |
| | | | | | | | | | | | | | | | | | | | | | | |
I understand that the transfer will continue until: (1) I terminate the program; (2) the funds in the account
from which money is being transferred are exhausted; or (3) the funds in the account fall below the required
minimum. I also understand that the Dollar Cost Averaging (DCA) programs are described in and subject to
the rules and restrictions contained in the prospectus.
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ORD 99669 Page 3 of 6 Ed. 3/2001
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9 AUTO- [ ] AUTO-REBALANCING: I want to maintain my allocation percentages. Please have my portfolio mix
REBALANCING automatically adjusted as allocated in section 10 under my variable
investment options.
Adjust my portfolio: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly
Please specify the start date if different than the contract date: | | | | | | | | | | |
month day year
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10 TELEPHONE We will accept your transfers and reallocations over the telephone. Please indicate below if you wish to
TRANSFERS extend authority as follows.
[ ] I authorize Prudential to accept telephone transfers and reallocation instructions from my Registered
Investment Adviser.
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11 AGGREGATION [ ] I have purchased another non-qualified annuity from Prudential or an affiliated company this
(non-qualified calendar year.
annuities only) | | | | | | | | | | | | | | | |
Contract number
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12 REPLACEMENT THIS SECTION MUST BE COMPLETED.
(Please enter
additional Will the proposed annuity contract replace any existing insurance policy(ies) or annuity contract(s)?
comments in
section 15.) [ ] Yes [ ] No
If "Yes," provide the following information for each policy or contract and attach all applicable
Prudential disclosure and state replacement forms.
Company name
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Policy or contract number Year of issue (mo., day, year) Name of plan (if applicable)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE.
Do you have, from any source, facts that any person named as the owner or joint owner above is replacing
or changing any current insurance or annuity in any company?
[ ] Yes [ ] No
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13 SIGNATURE(S) If applying for an IRA or Roth IRA, I acknowledge receiving an IRA disclosure statement and understand that
I will be given a financial disclosure statement with the contract. I understand that tax deferral is
provided by the IRA, and acknowledge that I am purchasing this contract for its features other than tax
deferral, including the lifetime income payout option, the Death Benefit protection, the ability to transfer
among investment options without sales or withdrawal charges, and other features as described in the
prospectus.
No representative can make or change a contract or waive any of the rights.
I believe that this contract meets my needs and financial objectives. Furthermore, I (1) understand that any
amount of purchase payments allocated to a variable investment option will reflect the investment
experience of that option and, therefore, annuity payments and surrender values may vary and are not
guaranteed as to a fixed dollar amount, and (2) acknowledge receipt of the current prospectus for this
contract and the variable investment options.
[ ] If this contract has a joint owner, please check this box to authorize Prudential to act on the
instruction(s) of either the owner or joint owner with regard to transactions under the contract.
[ ] If this application is being signed at the time the contract is delivered, I acknowledge receipt
of the contract.
[ ] Check here to request a Statement of Additional Information.
Any person who knowingly gives false or deceptive information when completing this form for the purpose
of defrauding the company may be guilty of insurance fraud.
CONNECTICUT: Any person who knowingly gives false or deceptive information when completing this form
for the purpose of defrauding the company may be guilty of insurance fraud.
(continued)
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ORD 99669 Page 4 of 6 Ed. 3/2001
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13 SIGNATURE(S) COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
(continued) insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado Division of Insurance within the Department of Regulatory Agencies.
MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR
IN WHICH THE FUNDS ARE PAID TO PRUDENTIAL:
I understand it is my responsibility to remove the minimum distribution from the purchase payment PRIOR TO
sending money to Prudential with this application. Unless we are notified otherwise, Prudential will assume
that the owner is satisfied with the required minimum distributions from other IRA funds.
By signing this form, the trustee(s)/officer(s) hereby represents that the trustee(s)/officer(s) possess(es)
the authority, on behalf of the non-natural person, to purchase the annuity contract and to exercise all rights
of ownership and control over the contract, including the right to make purchase payments to the contract.
OWNER'S TAX CERTIFICATION
Under penalty of perjury, I certify that the taxpayer identification number (TIN) I have listed on this form
is my correct taxpayer identification number. I HAVE/HAVE NOT (circle one) been notified by the Internal
Revenue Service that I am subject to backup withholding due to underreporting of interest or dividends.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS
DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED TO AVOID BACKUP WITHHOLDING.
We must have both the owner's and annuitant's signatures even if this contract is owned by a trust,
corporation, or other entity. If the annuitant is a minor, please provide the signature of a legal guardian or
custodian.
X
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Contract owner's signature and date month day year
X
------------------------------------------------------- | | | | | | | | | | | |
Joint owner's signature (if applicable) and date month day year
X
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Annuitant's signature (if applicable) and date month day year
X
-------------------------------------------------------- | | | | | | | | | | | |
Co-annuitant's signature (if applicable) and date month day year
--------------------------------------------------------
Signed at (city, state)
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ORD 99669 Page 3 of 6 Ed. 3/2001
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14 Represen- Commission Option (For Retail Distribution only. Choose only one.):
tative's
1. [ ] No Trail 2. [ ] Mid Trail 3. [ ] High Trail
Signature(s)
Note: If an option is not selected, the default option will be Option 3.
This application is submitted in the belief that the purchase of this contract is appropriate for the applicant
based on the information provided and as reviewed with the applicant. Reasonable inquiry has been made of
the owner concerning the owner's overall financial situation, needs, and investment objectives.
The representative hereby certifies that all information contained in this application is true to the best of
his or her knowledge.
| | | | | | | | | | | | | | | | | |
Representative's name (Please print) Rep's contract/FA number
X | | | | | | | | | | | | | | |
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Representative's signature and date month day year
| | | | | | | | | | | | | | | | | |
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Second representative's name (Please print) Rep's contract/FA number
X | | | | | | | | | | | | | | |
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Second representative's signature and date month day year
| | | | | | | | | - | | | | | | | | |
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Branch/field office name and code Representative's telephone number
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Additional
Remarks
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Standard Prudential Annuity Service Center Overnight Prudential Annuity Service Center
mail to: PO Box 7590 mail to: 2101 Welsh Road
Philadelphia, PA 19101 Dresher, PA 19025
If you have any questions, please call the Prudential Annuity Service Center at (888) 778-2888, Monday
through Friday between 8:00 a.m. and 9:00 p.m. Eastern time.
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ORD 99669 Page 6 of 6 Ed. 3/2001
