Instruction Page: Annuity and Variable Life Insurance Death Benefits Claim Form

Transcription

1 Instruction Page: Annuity and Variable Life Insurance Death Benefits Claim Form Annuities are issued by Prudential Annuities Life Assurance Corporation ( PALAC ), a Prudential Financial, Inc. company, which is solely responsible for its own financial condition and contractual obligations. The Rock Prudential Logo is a registered service mark of The Prudential Insurance Company of America and its affiliates. All information must be typed or printed using blue or black ink. Be sure to select a Continuation Option or a Distribution Option, so we know how to pay your claim Read and complete Section 3 Select your tax election preferences Read and complete Section 5 If you elect the Spousal Continuance Option and do not have a contract with us already, include a USA Patriot Act ID Verification form. If you are the Guardian or POA for the beneficiary and are claiming on their behalf, please include the court documents establishing you as such. If your state of residence requires consent from the Department of Taxation/Revenue to pay the claim, please obtain that prior to submitting your claim. If you are claiming on behalf of a trust, please complete the Certificate of Entity form - Read and complete the Entity Beneficiary Authorization Form on page 11. If you are seeking to transfer the funds to another firm, please include a signed letter of acceptance from the receiving firm with your claim. Sign and date the Claim Form. Read and complete Section 6 Mail (do not fax) us an original Death Certificate to: Annuities Service Center P.O. Box 7960 Philadelphia, PA ORD Ed. 11/15

2 Annuity and Variable Life Insurance Death Benefits Claim Form Annuities are issued by Prudential Annuities Life Assurance Corporation ( PALAC ), a Prudential Financial, Inc. company, which is solely responsible for its own financial condition and contractual obligations. The Rock Prudential Logo is a registered service mark of The Prudential Insurance Company of America and its affiliates. For use with Advanced Series Variable Annuities. Instructions: For assistance in completing this form, see page 12. All information must be typed or printed using blue or black ink. SECTION 1 POLICY/CONTRACT INFORMATION Please list each annuity contract and/or variable life policy number for which you are making a claim. The number may be eight or nine characters long; include any letter prefixes. Name of Deceased (First, Middle, Last Name) Date of Birth / / Date of Death / / Month Day Year Month Day Year SECTION 2 CLAIMANT INFORMATION This section is to be completed by the individual claiming death benefits. Name of Claimant (If applicable) If Beneficiary is a trust or other entity, please complete the Entity Beneficiary Authorization form on page 11. Street City State ZIP Code Social Security/Tax I.D. Number MUST BE COMPLETED BY BENEFICIARY Date of Birth / / Month Day Year Daytime Telephone Number Evening Telephone Number This form is being completed by: (Must check one.) Beneficiary (If you have assigned any portion of the claim to a funeral home, please include a copy of the assignment form.) Power of attorney for the beneficiary (Attach a copy of power of attorney authorization only if completing the form on behalf of the beneficiary.) Representative of the insured s/annuitant s estate (Attach a copy of proof of appointment. If there is a will that will not be probated, we may be able to pay the insured s heirs directly if permitted by law.) ORD Ed. 11/15 p1 of 13

3 SECTION 2 CLAIMANT INFORMATION (continued) Trustee (Please complete the Entity Beneficiary Authorization Form.) Legal guardian for the beneficiary (Attach a copy of the letter of guardianship or the court order authorizing you to accept the funds on behalf of the minor. If the beneficiary is a minor, please provide the minor s name and date of birth below.) Name of Minor (First, Middle, Last Name) Date of Birth / / (Month / Day / Year) Assignee (Specify amount you are claiming.) $ Other (Please specify.) If we require additional information to complete this request, please indicate who Prudential should contact: Claimant Financial Professional and phone Other If no selection is made, we will contact the Claimant. SECTION 3 AVAILABLE PAYMENT OPTIONS If you are the beneficiary on an account that begins with the letters VIA and the deceased died prior to receiving their first annuity payment, you must contact us for further information. This form should not be used. For Federal tax purposes, the term spouse also includes any individuals who are lawfully married in a jurisdiction (including a State, District of Columbia, US territory or foreign country) that recognizes same sex marriage. That marriage will be recognized for all federal tax purposes regardless of the law in the jurisdiction where they reside. Federal law does not recognize domestic partnerships or civil unions that are not designated as married under state law. Therefore, we cannot permit a civil union partner or domestic partner to continue the annuity within the meaning of the tax law upon the death of the first partner under the annuity s spousal continuance provision. An alternative distribution option, referred to as a taxable contract continuation, is available to same sex civil union partners and domestic partners. You may wish to consult your tax advisor. SELECTING YOUR PAYMENT OPTION: Although the account may offer several payment options, you can only select one payment option per account. Important: If there is a Plus 40 Rider on the Variable Annuity contract, you will need to select a payment option for that rider separate from the payment option for the annuity. Different payment options may have different tax consequences. You should consult your tax advisor prior to selecting your payment option to ensure it is appropriate for your particular circumstance. If the decedent s account number begins with: VL VIA IA ASGW BA BCO All Others with Plus 40 Rider All Others without Plus 40 Rider A: Spousal Assumption A B: Continuation B B You may choose one of the following options: C: New Annuity D: Continuation Contract Payouts C C C E: Lump Sum E E E F: Beneficiary Income Option G: Transfer** C D E G C D E G C C VL = Variable Life VIA = Variable Immediate Annuity IA = Principle & Income Plan or Continuation Option ASGW = Goodwill BA = Beneficiary Annuity (no unique account number applicable) BCO = Beneficiary Continuation Option All Others = All other annuity contracts * Please note that the Beneficiary Continuation Option for non-qualified business is only available on ASXT 8, ASAP II, ASAP III, Advisors Choice 2000, APEX II, ASL, ASL II, ASXT, ASXT 6, Advisors Select 2000, OAP, OAP 4, OAP Plus and OAP XTra. A non-qualified Beneficiary Annuity contract is available only for those products not mentioned in the prior sentence. A qualified Beneficiary Annuity contract is not available on any product that offers a qualified Beneficiary Continuation Option. **For purposes of establishing a Beneficiary Annuity at another carrier. Trustee to trustee transfer, direct rollover or 1035 Exchange. D* D* E E F F ORD Ed. 11/15 p2 of 13 G G

4 SECTION 3 AVAILABLE PAYMENT OPTIONS (continued) Option A: Spousal and Taxable Contract Continuance Available on any account except those that begin with VL, VIA, IA, BCO, and the Plus 40 Rider benefit. I am Selecting Spousal or Taxable Contract Continuance for the following contracts: Qualification: This is available only to the current spouse of the deceased owner and only if the spouse was designated as the sole primary beneficiary and is entitled to the death benefit under the contract. Spousal Continuance: (Not available for same sex civil unions, domestic partnerships or same-sex spouses not recognized by federal tax law.) This option allows a spouse to assume all rights, privileges and obligations of the existing contract owner. This is a nontaxable event under the Internal Revenue Code as long as the necessary requirements are met. If elected, the spouse will assume all rights, privileges and obligations of the existing contract as Owner. I am selecting Spousal Continuance: As a Spousal Continuance for non-qualified contracts; or As an IRA ownership change for qualified IRA or SEP contracts. Please keep in mind that if a trust is named as a beneficiary, an ownership change will not be permitted even if the spouse is the sole beneficiary of the trust. (If the contract was an IRA there will be an endorsement within the contract.) IRS Minimum Distribution for IRA Contracts (If applicable) Complete (a) below. If the second box in (a) is applicable, (b) must also be completed. a. Check the applicable box: I will be under age 70½ in the year in which I am requesting this ownership change; or I have already or will attain age 70½ in the year in which I am requesting this ownership change. (Complete (b).) b. Please send me a package that describes the minimum distribution requirements for IRAs so that I may request the minimum required distribution from this contract; or I received independent tax advice regarding the distribution requirements for IRAs and the risk associated with deferring settlement of my contract. I agree I shall not bring claim against Prudential in the event I fail to satisfy the minimum distribution required for my contract and sustain any adverse tax consequences as a result of the failure. Taxable Contract Continuation: Process this request as a taxable contract continuation. This option is available to same-sex civil union partners, domestic partners or same-sex spouses not recognized by federal tax law. By electing this option you will be able to continue the contract in your name and retain any applicable benefits, however, you must meet the qualification requirement noted above. By choosing this option you understand that any applicable gain in the contract at the time of continuation will be considered as taxable income to you and will be reported as such to you and the IRS on a Form 1099-R. In addition, if the contract is tax qualified (IRA/SEP/Roth/403(b)), the contract will be continued as a non-qualified annuity going forward. If electing Spousal Continuation or Taxable Contract Continuation, please complete the following: NEW ANNUITY DATE: / / (Month / Day / Year) Annuity date must be the 1st or the 15th day of the Month. If a new annuity date is not provided, the current annuity date will default to the maximum annuity date allowed under the terms of the contract. Complete Beneficiary Information (Section 4) for beneficiary designation. ORD Ed. 11/15 p3 of 13

5 SECTION 3 AVAILABLE PAYMENT OPTIONS (continued) Option B: Continuation for Remaining Period Available on VIA and IA. This option will continue payments to the beneficiary for the remaining time outlined in the contract. Please be aware that if the contract does not have a remaining inheritance period or certain period, the contract has ended and no death benefit is payable. I am Selecting Option B for Contract(s)/Policy(ies): Option C: New Annuity Contract There may be tax consequences associated with selecting Option C. Available on every account except those beginning with the prefix IA. This option allows beneficiaries to apply the death benefit proceeds into a different PALAC deferred annuity product. I am Selecting Option C for Contract(s)/Policy(ies): I am Selecting Option C for the Plus 40 Rider on Contract(s)/Policy(ies): If electing this option you must also complete and return an application for the new product. If you do not have that application, contact your Financial Professional. Option D: Continuation Payouts There may be tax consequences associated with selecting Option D. May not be available on every account. This option allows beneficiaries to apply the death benefit proceeds into a PALAC payout option. Fixed immediate annuity payout options may be available under the existing PALAC product, please check the contract/policy and/or contact your Financial Professional. I am Selecting Option D for Contract(s)/Policy(ies): I am Selecting Option D for the Plus 40 Rider on Contract(s)/Policy(ies): Choose only one: Beneficiary Continuation Option 1 Beneficiary Annuity 1 Life Annuity 1 Payments for life with no certain period. All payments stop with the key life/annuitant s death, whenever that occurs. Life Annuity with a Certain Period 1 Payments for life with a period certain of (check one): Note: Do not use this check box to select payments for a specified period only (Certain Period only). Please use the Fixed Period Annuity (Certain Period Only) check box below. 5 years 10 years 15 years 20 years If the key life/annuitant were to die before the end of this specified period, we will pay the present value of the remaining payments to the named beneficiary in section 4. Joint and Survivor Life Annuity 1 Payments for life until the death of the last surviving key life/annuitant. Joint Key Life/Annuitant Name (First, Middle, Last Name) Telephone Number Date of Birth / / (Month / Day / Year) Social Security/Tax I.D. Number Street City State ZIP Code ORD Ed. 11/15 p4 of 13

6 SECTION 3 AVAILABLE PAYMENT OPTIONS (continued) Fixed Period Annuity (Certain Period Only) Payments for a fixed period as specified below. If the annuitant were to die before the end of the specified period, the remaining payments will be paid to the named beneficiary in section 4. 5 years 10 years 15 years 20 years Interest Payment Option (Not available for 403(b) or 401(a).) Proceeds held at interest, with the right to withdraw any unpaid balance. The Interest Payment Option may not be available on all products. If this option is chosen, earnings are fully reportable at the time of the claim settlement. Check one box: Hold interest to accumulate Interest will be paid to you annually unless a different frequency is checked: Payout Frequency: Monthly Quarterly Semi-annually Annually PLEASE NOTE: If you are electing the Beneficiary Continuation Option or a Beneficiary Variable Annuity you must complete and return the required paperwork. If you do not have the required documentation, please contact your Financial Professional. 1 If you are choosing the Beneficiary Continuation Option, Beneficiary Annuity Option or a Life Settlement Option, please note that for transferring: qualified death benefit proceeds, distributions required under section 401(a)(9)(B) of the Internal Revenue must begin by 12/31 of the year following the deceased s date of death. In order to proceed with your request, we must receive all the requirements 45 days prior to 12/31 cutoff. non-qualified death benefit proceeds, the distributions required under section 72(s) of the Internal Revenue Code must begin within one year of the deceased s date of death. In order to proceed with your request, we must receive all the requirements 45 days prior to the one year anniversary of the date of death. Option E: Lump Sum There may be tax consequences associated with selecting Option E. Certain products may assess a contingent deferred sales charge on the distribution of the death benefit proceeds. Available on every account except those beginning with the prefix IA. This option allows beneficiaries to receive a lump sum check after PALAC receives all necessary paperwork required to complete the processing of this claim. I am Selecting Option E for Contract(s)/Policy(ies): I am Selecting Option E for the Plus 40 Rider on Contract(s)/Policy(ies): Option F: Beneficiary Income Option There may be tax consequences associated with selecting Option F. This option allows beneficiaries to receive the deceased contract owner s Annual Income Amount over a specified period of time. I am Selecting Option F for Contract(s)/Policy(ies): Please select mode you desire: Monthly Quarterly Semi-annually Annually ORD Ed. 11/15 p5 of 13

7 SECTION 3 AVAILABLE PAYMENT OPTIONS (continued) Option G: Transfer/Exchange/Direct Rollover for the purposes of establishing an inherited annuity or account. Please Choose One. Please send my death claim proceeds as a 1035 exchange to the following 2 Please send my death claim proceeds as a trustee-to-trustee transfer to the following 2 Please send my death claim proceeds as a direct rollover to the following 2 Please send my death claim proceeds as a spousal rollover to my Existing Contract number Name of Institution or Company Company s Address (a PO Box cannot be used for overnight delivery) City State ZIP Code A Letter of Acceptance and transfer paperwork from the receiving company may be required. 2 If you are choosing a Transfer/Exchange or a Direct Rollover for the purposes of establishing an inherited annuity or account, please note the following: qualified death benefit proceeds, distributions required under section 401(a)(9)(B) of the Internal Revenue must begin by 12/31 of the year following the deceased s date of death. In order to proceed with your request, we must receive all the requirements 45 days prior to 12/31 cutoff. non-qualified death benefit proceeds, the distributions required under section 72(s) of the Internal Revenue Code must begin within one year of the deceased s date of death. In order to proceed with your request, we must receive all the requirements 45 days prior to the one year anniversary of the date of death. SECTION 4 BENEFICIARY INFORMATION Beneficiary Designation: If you would like to designate more than two primary beneficiary or contingent beneficiary, please include a signed and dated letter and include the same information listed on this page. Beneficiary Name (First, Middle, Last Name) percentage % Primary Telephone Number Date of Birth / / Month Day Year Relationship to Owner/Trustee name(s) if Trust Social Security/Tax I.D. Number Street City State ZIP Code Beneficiary Name (First, Middle, Last Name) percentage % Primary Contingent Telephone Number Date of Birth / / Month Day Year Relationship to Owner/Trustee name(s) if Trust Social Security/Tax I.D. Number Street City State ZIP Code ORD Ed. 11/15 p6 of 13

8 SECTION 5 INCOME TAX WITHHOLDING NOTICE AND ELECTION If this section is left blank, or if this page is not returned, or you do not make a valid election to not have federal and/or state tax withheld, Prudential is required to withhold Federal and/or State taxes. Please refer to Note 2 for mandatory withholding requirements. Federal and State income taxes may be withheld if you do not provide a U.S. residential address. You will not be able to elect out of withholding if we are notified that your taxpayer identification number (TIN) is incorrect. I elect: Not to have Federal or State income taxes withheld. To have 10% Federal income taxes withheld on the taxable portion of my distribution. To have more than 10% Federal income taxes withheld on the taxable portion of my distribution, as indicated below: % (minimum 10%), or $ To have State income taxes withheld on the taxable portion of my distribution, as indicated below: % or $ Note 1: The percent or dollar amount cannot be less than the minimum required by your state of residence. If the amount you selected is less, we will withhold the required default amount. If you elect to have no income tax withheld from your withdrawal, or if you do not have enough income tax withheld from your withdrawal, you may be responsible for payment of estimated tax. You may incur penalties if your withholding and estimated tax payments are not sufficient. For 401(a) and 403(b) tax deferred annuities the eligible rollover portion of your distribution is subject to a mandatory 20 percent federal income tax withholding unless directly rolled to a traditional IRA, a 457 (governmental) or another plan qualified under Internal Revenue Code section 401(a). Note 2: If your payment is from a section 403(b) or a section 401(a) qualified plan, and is an eligible rollover distribution, you will not be able to elect out of federal income tax withholding. Federal taxes will be withheld at a flat 20% rate, unless you elect to have your eligible rollover distribution directly rolled over to an IRA or to another qualified plan. Note 3: If your contract begins with VIA and you selected payment option Continuation for Remaining Period and Yes to withholding options, PALAC will withhold as if you are married claiming three (3) withholding allowances. If you would like a different amount withheld, please submit a completed IRS Form W-4P. In addition, Michigan residents must complete the following. Please choose one: Michigan law now requires 4.25% income tax withholding from pension and retirement benefits, unless your payments are not taxable, or you opt out. Please check the appropriate box below if you are a Michigan resident. Your pension or annuity payments are not taxable or you wish to opt out. Note: Opting out may result in a balance due on your MI-1040 as well as penalties and interest. % Total percentage you want withheld from your annuity payment(s) (must be at least 4.25%). If no selection is made, we will withhold 4.25%. ORD Ed. 11/15 p7 of 13

9 SECTION 6 SIGNATURES AND FRAUD NOTIFICATION If an individual, your full legal name should be used. For example: Elizabeth Cullen, not Beth Cullen or Mrs. Joe Cullen. If you are signing on behalf of an individual or entity, include your title (Trustee, Administrator, Executor, Personal Representative, Attorney-in-Fact, Guardian, and Conservator). For example: John Doe by Jane Doe his Attorney-in-Fact. I have read and agree to sections 1 through 6. By signing this form, I certify that the information I have provided is true and complete. I understand that there may be tax implications as a result of this request. It is fraudulent to fill out this form with information I know to be false or to omit important facts. Criminal and/or civil penalties can result from such acts. Note that if you are a U.S. person (including resident alien), and your address of record is a non-u.s. address, we are required to withhold income tax unless you provide us with a U.S. residential address. If applicable, please include your U.S. residential address with this form. If you purchased Non-Qualified Annuity Contracts from PALAC or an affiliated company in the same calendar year, they will be considered as one Annuity for tax purposes. If you take a distribution from any of these contracts, the taxable amount of the distribution will be reported to you and the IRS based on the earnings of all such contracts purchased during the same calendar year. The Fraud Warning Notification is required if you are a resident of, or if the contract was issued in, one of the following states: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas, Louisiana, Texas and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurancen 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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. Delaware, Idaho, Indiana and Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or any application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine, Tennessee and Washington: WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits. ORD Ed. 11/15 p8 of 13

10 SECTION 6 SIGNATURES AND FRAUD NOTIFICATION (continued) Maryland and Rhode Island: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey and New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oregon: It is fraudulent to fill out this form with information I know to be false or omit important facts with the intention to defraud. Criminal and/or civil penalties may result from such acts. An insurer may deny a claim on the basis of misstatements, misrepresentations, omissions or concealments if such misinformation is material to the contract, the insurer relies on the misinformation, and the information is either material to the risk assumed by the insurer or the misinformation was provided fraudulently. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. VIRGINIA: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law. All Other States: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit may be guilty of a crime and subject to fines and confinement in prison. For the purpose of processing and payment of claims in an efficient and prompt manner, I authorize Prudential to consolidate and disclose completed claims forms and documents to appropriate associates for each and every one of Prudential Financial, Inc. s affiliates or business units for which a claim for payment or distribution is made. ORD Ed. 11/15 p9 of 13

11 µ SECTION 6 SIGNATURES AND FRAUD NOTIFICATION (continued) There may be tax implications as a result of this request(s) and the request(s), including requests to pay advisory fees, (including tax reporting and withholding) cannot be reversed once processed. Please consult tax and/or legal counsel before proceeding. Please refer to your annuity contract and prospectus for provisions and tax considerations regarding withdrawals prior to submitting this form. If not a U.S. person (including resident alien) or U.S. Entity, submit the applicable Form W-8 (BEN, BEN-E, ECI, EXP or IMY). In most instances, Form W-8BEN will be the appropriate form. CLAIMANT S TAX CERTIFICATION (SUBSTITUTE W-9) Under penalties of perjury, I certify that the taxpayer identification number (SSN/TIN) I have listed on this form is my correct SSN/TIN. Failure to provide an SSN/TIN may result in mandatory tax withholding. I further certify that: I am a U.S. citizen or other U.S. person (including resident alien). I am not a U.S. citizen or other U.S. person (including resident alien). I am a citizen of. I have been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest and dividends. (Prudential is required to withhold income tax on any payments which include interest and dividends when the claimant is subject to backup withholding.) I am subject to the reporting requirements of the Foreign Account Tax Compliance Act (FATCA). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. SIGN HERE Claimant s signature / / Date of signature (Month / Day / Year) Title (if applicable) Relationship to the Deceased Note: In order for PALAC to process this claim for payment, documentation of your authority to sign on behalf of an individual or legal entity must either be on file with PALAC or submitted with the claim to support the validity of the representation. Annuities Service Center :00AM 7:00PM ET, Monday Thursday 8:00AM 6:00PM ET, Friday Fax: (800) Regular Mail Delivery Annuities Service Center P.O. Box 7960 Philadelphia, PA Overnight Service, Certified or Registered Mail Delivery Prudential Annuities Service Center 2101 Welsh Road Dresher, PA ORD Ed. 11/15 p10 of 13

12 µ µ ENTITY BENEFICIARY AUTHORIZATION FORM Eligible entities for issuing a BCO or Beneficiary Annuity may only include Grantor Trusts or Qualified Trusts. Note: Required Only if Beneficiary is a Trust or Other Entity. Please check the following box if one or more of the beneficiaries of the trust is considered to be a skip person as defined by the Internal Revenue Code. (A skip person is a person who is two or more generations below the grantor of the trust or an unrelated person who is at least years younger than the grantor). This is not a U.S. Entity If this box is checked, the W8-BEN-E is also required in order to process your request. Name of Entity City State ZIP Code Contract/Policy Number(s) Tax ID Number The document and/or agreement creating and/or organizing the above entity, if applicable, is referred to herein as the Entity Agreement. Does the Entity Agreement authorize more than one individual to act on behalf of the entity? YES - If Yes, list below. NO Authorized Individual s Name(s) Authorized Individual s Name(s) If there is more than one Authorized Individual named in the Entity Agreement, does the Entity Agreement expressly provide that each of the Authorized Individuals can act individually, independently, and without the consent of the other individuals authorized to act on behalf of the Entity? (This question does not apply to corporations.) An option must be selected in order for the claim to be processed. YES NO If Yes, by signing this Form the Authorized Individuals hereby certify that PALAC may follow the instructions of any one Authorized Individual. If no, PALAC will require the signatures of all Authorized individuals to claim a Death Benefit under the annuity. Certification, Indemnity, and Agreement: The Authorized Individuals represent, warrant, and certify that, the representations made in this certificate are true, complete, and accurate, that the Entity is active and in compliance with state and federal laws, and that the Entity Agreement (as defined above) has not been revoked, modified or amended in any manner which would cause the representations contained in this certification to be inaccurate or incorrect. PALAC will rely on this certification and will not be held liable for any act taken by it pursuant to and in reliance upon this certificate and upon the representations made herein unless and until it receives a written amendment regarding the Entity Agreement, written notice of a change in Authorized Individual(s) or written notice of any events affecting the powers of the Authorized Individual described above. The Authorized Individuals agree to send written notice promptly to PALAC of any changes in Authorized Individuals, of any amendment or modification to the Entity Agreement which would cause the representations contained in this certification to be or become inaccurate or incorrect, or of the occurrence of any event which would affect the Entity Agreement s revocability, the powers of the Authorized Individuals to act on behalf of the Entity, or any representations made in this certification. The Authorized Individuals hereby agree, on behalf of themselves and the entity which they represent, to jointly and severally indemnify PALAC and each of its officers, directors, employees, and agents, from, and hold such persons harmless against, any claims, losses, judgments, surcharges, settlement amounts, or other liabilities or costs of defense or settlement (including attorney s fees) arising out of or related to any actual or alleged negligent, improper or unsuitable acts or omissions taken by PALAC upon the instruction of such Authorized Individuals in connection with the contract referenced above. This indemnification is made by the Authorized Individuals both in their capacities as Authorized Individuals for the Entity and in their individual capacities, and shall not be limited by any Authorized Individual s provision to PALAC of independent documentation concerning the representations made herein. SIGNATURES This section must be signed in order for the claim to be processed. SIGN HERE SIGN HERE Print Name Authorized Individual s Authorized Individual s / / Date of signature (Month / Day / Year) / / Date of signature (Month / Day / Year) ORD Ed. 11/15 p11 of 13

13 Annuity and Variable Life Insurance Death Benefits Claim Form Annuities are issued by Prudential Annuities Life Assurance Corporation ( PALAC ), a Prudential Financial, Inc. company, which is solely responsible for its own financial condition and contractual obligations. The Rock Prudential Logo is a registered service mark of The Prudential Insurance Company of America and its affiliates. Use this form to apply for annuity and/or variable life insurance death benefits. Complete each section based upon the type of claim. If there is more than one claimant, each claimant must complete a separate form. Be sure to attach a certified death certificate with the state seal, and send us the policy(ies) and/or contract(s), if available. A certified death certificate is either the original death certificate issued by the state where the insured passed away or a copy of the original death certificate that has a raised seal of the state. Note: For custodial business, where the custodian wishes to continue the Annuity and the Annuity contract permits such continuance, the Custodial Account Continuation Election Form is required in lieu of this form. If you have any questions, please call our customer service office at (800) IMPORTANT INFORMATION ABOUT YOUR PROCEEDS For all contracts except those beginning with VIA, IA, GMA, SGA or CATS: Upon receipt of a certified copy of the death certificate, PALAC will calculate the death benefit and automatically transfer the Account Value into the Money Market Portfolio. The account value will be subject to money market rates of return until the death proceeds are disbursed. During the period from the notification of death until the Death Benefit is paid out in full, the amount of the Death Benefit is impacted by certain charges under your contract and may be subject to market fluctuations. Upon verbal or written notification of death, PALAC will terminate any optional programs currently in force. These programs include, but may not be limited to: Systematic Withdrawals, 72(t)s, Minimum Distributions, Bank Drafting and Third Party Investment Advisors. If an IRS required minimum distribution needs to be taken on behalf of the decedent, the distribution will be processed prior to completing the death benefit. For all contracts beginning with VIA: Upon verbal or written notification of death, PALAC will suspend the services of Third Party Investment Advisors. Annuity payments will be accumulated and will earn at least 3% annual interest, however all other funds will remain in the account and will be subject to normal market fluctuations. For all contracts beginning with IA: Upon verbal or written notification of death, PALAC will suspend all payments. In order to help us identify additional policies insuring the decedent, please provide any other names (such as nicknames, maiden name, etc.) by which the insured may have been known. SPECIAL CIRCUMSTANCES Tax Waiver/Consent Forms vary from state to state. Please call your State Department of Revenue (may also be referred to as the State Tax Department). 1. If the deceased was a resident of one of the following states, an additional approved Tax Waiver/Consent Form may be required: Alabama (only for Estates) Indiana Louisiana New Hampshire Ohio (for claims in excess of $25,000) 2. If the death occurred in a country other than the United States: We require an original Report of Death of a U.S. Citizen Abroad from a U.S. Embassy of the country where the death occurred. 3. If a Beneficiary wants his or her Attorney-in-Fact (Power of Attorney) to complete The Beneficiary Claim Form on his or her behalf, PALAC requires that: The Power of Attorney document must be submitted with the Beneficiary Claim Form. When the Beneficiary Claim Form is completed by an Attorney-in-Fact, the form of signature must properly reflect the fiduciary relationship. Instructions on how to sign this form are provided in the signature section. ORD Ed. 11/15 p12 of 13

14 SPECIAL CIRCUMSTANCES (continued) 4. When the Beneficiary is an Estate: The Beneficiary Claim Form must be completed by the estate s executor or administrator. A certified copy of the court appointment must be included. If the estate is eligible, you may submit a small estate affidavit in lieu of a certified copy of the court appointment. 5. When the Beneficiary is a Minor (under the age of 18): Every state has different requirements, which may vary depending on the amount of the benefits payable. If your state requires a legal guardian or custodian to accept payment on the minor s behalf: A Beneficiary Claim Form must be completed by the legal guardian or custodian of the minor s estate. A certified copy of the court appointment must also be submitted. 6. When the Beneficiary is a Trust: The Trustee(s) must complete and sign the Beneficiary Claim Form and the Entity Beneficiary Authorization Form. 7. When the Beneficiary s name is different than the one listed in the annuity contract: If the Beneficiary s name has changed due to marriage, divorce, etc., include a copy of the legal document (Marriage Certificate, Divorce Decree, etc.) that documents the name change. 8. When the beneficiary designation is children or a similar designation, each beneficiary must provide a notarized affidavit which includes: Name Address Date of Birth Relationship to Deceased (son, daughter) Names of all other siblings 9. If the Beneficiary is deceased prior to submitting the claim: Include a Certified Copy of the Death Certificate for the Beneficiary 10. When a Beneficiary is legally incompetent: Send a letter stating the Beneficiary is legally incompetent. In addition, indicate the name and address of the Beneficiary s Attorney-in-Fact under a Durable Power of Attorney. Follow all instructions for Power of Attorney. (Special Circumstances: No.3) on this form. If a Legal Guardian/Conservator of the beneficiary is responsible for handling the Beneficiary s legal affairs: A certified copy of the court-approved appointment must be submitted. Follow all instructions as if the Beneficiary is a minor. (Special Circumstances, No. 5) on this form. 11. When the Beneficiary is a corporation or charitable organization: A certified copy of a corporate resolution (or its equivalent) indicating the representative is authorized to sign on behalf of the corporation or charitable organization. The corporate secretary must certify (with a raised seal) that the authority granted to the representative has not been revoked, modified or amended as of the date of the filing of the claim. Option A: Spousal Assumption (NEW PRIMARY BENEFICIARY) on the Beneficiary Claim Form must be completed by the named representative in the corporate resolution. The named representative must also complete and sign the Entity Beneficiary Authorization Form. ORD Ed. 11/15 p13 of 13