CREATED EXCLUSIVELY FOR FINANCIAL PROFESSIONALS SERVICE Guide to Completing Life Insuance Applications PURPOSE OF THIS GUIDE This guide povides infomation that will help the use accuately complete the geneic, individual long-fom application packet. Unique applications exist fo Juveniles age 0 to 17 as well as specific suvivoship applications fo use with SUL Potecto. This guide helps ensue once-and-done tansaction pocessing. Easy-to-follow instuctions and emindes ae included about the pimay potions of the foms listed below. The infomation in this guide is not state specific, so be sue to familiaize youself with any state vaiations which can be found on www.puxpess.com. Replacements Infomation on completing eplacements is not included in this guide. If you have questions egading eplacements, please efe to the Replacement Highlightes located on Puxpess. To access the Replacement Highlightes on Puxpess: 4 Click on the New Business tab. 4 Click on Replacement Highlightes (located in the dop-down box). TABLE OF CONTENTS Impotant Notes About This Guide... 2 Application Packet Checklist... 3 Requiements fo Non-Face-to-Face Sales... 3 Application fo Life Insuance (ORD 96200)... 4-7 Authoization to Release Infomation (ORD 96200C)... 8 Limited Insuance Ageement (ORD 96200A)...8 Agent s Repot...9 Application Signatue Requiements...10 Obtaining and Submitting Additional Foms...11-12 NOT FOR CONSUMER USE. 2015 The Pudential Insuance Company of Ameica, Newak, NJ. NR-15A66401 Ed. 06/2015 Exp. 06/30/2017
IMPORTANT NOTES ABOUT THIS GUIDE Obtaining foms Foms ae accessible on-line via www.puxpess.com. To access foms on the website, click on the Foms tab and then Launch Foms. Be sue to select the appopiate state-specific vesion(s). When completing foms 4Black ink is pefeed as it photocopies the best. 4 White-out is not allowed. To make coections, daw a line though the mistake, wite in the coect infomation, and have the appopiate paty initial by the coect data. Selecting the appopiate issuing company At the top of many foms, you ae asked to check the box fo the appopiate company. Check: 4 Puco Life Insuance Company fo all plans. Definition of tems 4Poduce: Sales epesentative, agent, boke, witing epesentative, etc. 4Poposed Insued: Peson who is being consideed fo insuance on thei life. 4Policyowne: Puchase of the policy(s); account owne (often the same peson{s} as the poposed insued). Send completed foms to Pudential Financial, Attn: Life New Business 2101 Welsh Road/Suite DTY Deshe, PA 19025 2
APPLICATION PACKET CHECKLIST Befoe submitting this application: Complete/include a cove lette summaizing the application and poviding details that may help in the appoval pocess, including: 4 Amount (include infomation egading pending applications with othe companies and the ultimate total coveage with all companies, in foce and pending). 4 Pupose (financial justification) and coveage details (e.g., type of coveage, eason, etc.). 4 Clealy labeled application(s) if submitting moe than one application (e.g., is this an altenate, duplicate, etc.?). 4Clea definition(s) indicating if this is new o eplacement* coveage. 4 Specific details about policy change equest(s) (e.g., is it clea what needs to be alteed and/o is the incease amount clealy stated {if applicable}?). 4List all names on the application and povide complete addesses. 4 Povide SSN o TIN A Tax Identification Numbe (TIN) may be eithe a Social Secuity Numbe (SSN) o an Employe Identification Numbe (EIN). 4 Complete/include othe applicable foms See list of possible additional foms on pages 11 and 12. 4Ensue signatues wee obtained. 4Include Special Instuctions with clea explanations. 4 Leave the Impotant Notice About You Application fo Insuance with the pimay poposed insued. 4 Attach the check fo pepayment Povided the poposed insued can cetify the health attestations, and is less than o equal to 75 yeas old, a pepayment may be accepted on face amounts applied fo up to and including $5,000,000, eithe as a single $5,000,000 application o as multiple applications totaling no moe than $5,000,000 fo both individuals on suvivoship plans. NOTE: The total death benefit payable unde all Limited Insuance Ageements (LIAs) combined is the amount applied fo, up to a maximum of $1,000,000 (pe insued). 4Include undewiting equiements APS ECG Exam Financial Infomation Lab Wok Othe REQUIREMENTS FOR NON-FACE-TO-FACE SALES 4 The collection of the application infomation must be conducted by the poduce with both the poposed insued and the owne, if the owne is othe than the poposed insued. 4 The poduce secuely sends the application package to the insued/owne to be signed, along with any equied foms and illustation equiements whee applicable. NOTE: The Agent s Repot and Xpess Woksheet (as applicable) is NOT to be included in the application package. These items ae to be completed by the poduce. 4 The insued/owne eviews and signs the application package, and sends it back to the poduce. 4 The poduce eviews the application package to ensue it s in good ode, signs the application package, and then submits it to the Bokeage Geneal Agency fo submission to Pudential. * Replacement coveage involves a tansaction in which a new life insuance policy o a new annuity contact is to be puchased, and it is known o should be known to the poposing poduce that by eason of the tansaction, an existing life insuance policy o annuity contact has been o is to be lapsed, fofeited, suendeed o patially suendeed, assigned to the eplacing insue, o othewise teminated. See the Replacement Highlightes available on Puxpess.com fo additional infomation on undestanding eplacements. 3
APPLICATION FOR LIFE INSURANCE (ORD 96200) PART ONE: SECTIONS A F Section of Fom Did You Know? Instuctions Heading: Pudential Application fo Life Insuance 4 Check applicable box fo the coect issuing company (Puco). 4Ente policy numbe (if available). A: Poposed Insued B: Plan of Insuance C: Pemium D: Owne E: Beneficiay Details F: Insuance Histoy 4 Vague comments such as consultant as the occupation may pompt additional questions. Without complete and accuate infomation, application appoval may be delayed o denied. 4 The plan name is available on the illustation (e.g., Tem Essential 20, etc.). 4 Only complete this section if the policyowne is othe than the poposed insued. 4 If a tust is the owne, povide the name of the tust, the tustee(s) and the date. Also include whethe the tust is evocable o ievocable. 4 Complete ALL infomation that is asked fo. 4Check YES box if equesting to save age; othewise, check NO. 4Residence addess MUST be a steet addess; P.O. boxes ae not pemitted. 4 If poposed insued is not a pemanent, legal U.S. esident, ALL details egading status must be povided. 4Occupation Povide natue of the business and specific duties. 4 Check the plan name. If the specific plan equested is not listed, check the OTHER box and wite the full plan name on the line. 4 Check the applicable optional benefits and ides. If the specific benefit/ ide equested is not listed, check the OTHER box and wite name on the line. 4 Whee applicable, check the death benefit option type and the definition of life insuance used. If the specific plan is not listed, wite equested selections in SPECIAL REQUESTS (Section H). 4 Fo non-tem plans, ente the billed pemium amount. 4 Send Notices: Check if the notices ae to be sent to the policyowne o someone else s attention. If othe than the policyowne, identify the individual. 4 Check if notices ae to be sent to the policyowne s esidence o anothe location. If a location othe than the policyowne s esidence is equested, identify the location. 4 If the policyowne is an individual, be sue to include the full name, SSN o TIN, date of bith, and addess of the policyowne. 4 If moe than one owne, include the additional owne s infomation in SPECIAL REQUESTS (Section H). 4 Ente complete infomation on all beneficiaies, including checking whethe the beneficiay is a pimay o seconday beneficiay. 4 Check YES o NO egading whethe the client has existing coveage. 4 Check YES o NO if a eplacement. 4 When YES is selected fo a eplacement, also check YES o NO if a 1035 exchange is involved. 4 Complete all equested infomation fo each existing policy. 4 Is the poposed insued attempting to einstate o change a life o health policy? If YES, include the insuance company, the amount applied fo, and the total amount of coveage to be placed. 4 Is the poposed insued planning on tansfeing owneship of the policy to an investo o a life settlement company? If YES, povide full details. 4
APPLICATION FOR LIFE INSURANCE (ORD 96200) (continued) PART ONE: SECTIONS G H Section of Fom Did You Know? Instuctions G: Geneal Infomation H: Special Requests 4 Be sue to povide specific details about aviation, avocation, othe applications, ciminal offenses, diving violations, and tavel. IT IS CRITICAL TO FULLY AND ACCURATELY COMPLETE THIS SECTION. 4 Aviation: If yes, complete the aviation questionnaie (ORD 96200 Aviation). 4 Avocation/hobbies: If yes, complete the appopiate avocation fom (ORD 96200 Diving, Mountain Climbing, Racing, Geneal Avocation). 4 Tobacco: Include all foms of tobacco and list the fequency of use and the dates last used. 4 Dive s license: Complete in full. 4 Ciminal offense: If yes, povide details. 4 Residence o tavel outside of the U.S.: Povide details such as dates of tips, the counties visited, the fequency of tavel, the pupose, the duation of stay, etc. 4 Include all details to YES esponses fo Questions 4 6 on the lines in Question 7. 4 Ente infomation on items such as: Explanation of the policy change. Request fo additional policies. Beneficiay & owne infomation. APPLICATION FOR LIFE INSURANCE (ORD 96200) PART TWO: SECTIONS A B 4 Complete all of Pat Two if you ae using anothe company s exam. Section of Fom Did You Know? Instuctions A: Physician Infomation B: Physical Measuements 4 You don t need to complete all of Pat Two if the client is having a full exam on Pudential exam foms. It is still helpful, howeve, to complete Section A of Pat Two (In case the exam esults ae delayed, Pudential will at least have this infomation to know whethe an APS is equied). 4 You don t need to complete this section if a full Pudential exam has aleady been pefomed and you ae submitting the esults with the application. 4 Complete the physician infomation in full. 4 Ente the client s height and weight. 4Ente the full details egading any change in weight geate than 10 pounds. 5
C: Family Histoy 4 Question #1 is IT IS CRITICAL TO FULLY AND ACCURATELY fequently incomplete COMPLETE THIS SECTION! which can cause a 4Povide specific details fo immediate family membes SERVICE delay in the appoval (paents & siblings) only fo death o diagnosis of listed pocess. conditions befoe age 70. 4 You ae not equied 4Povide cuent age o age at time of death only fo APPLICATION FOR LIFE INSURANCE (ORD to complete 96200) this (continued) if a paents. PART TWO: SECTIONS C D Section of Fom Did You Know? It is helpful, howeve, Instuctions to still complete 4 Question #1 is fequently IT IS and CRITICAL TO FULLY AND ACCURATELY COMPLETE THIS SECTION. incomplete, which can submit cause the a family 4 Povide the specific details fo immediate family membes (paents and delay in the appoval histoy pocess. section siblings) even if only fo death o diagnosis of listed conditions befoe age 70. 4 You ae not equied the to exam is complete. 4 Povide the cuent age o age at time of death only fo paents. complete this if a full C: Family HistoyD: Medical Infomation Pudential exam has been completed. It is helpful, howeve, to still complete 4 Complete fo ALL NEW BUSINESS. 4 Watch fo state specific vaiables. If a question is NOT and submit the family histoy applicable in a cetain state, the question MUST NOT section even if the exam is complete. be asked no answeed and it MUST BE LEFT BLANK. D: Medical Infomation full Pudential exam has been completed. 4 Use the following page (sample page shown below) of 4 Complete fo ALL NEW BUSINESS. this fom / application to povide specific details fo any 4 Watch fo state-specific vaiables. If a potion of a question is NOT applicable in a questions cetain state, that only wee that answeed component yes. of the question should not be asked o answeed. The emainde of the question should be asked and answeed and not left blank. 4 Use the following page (sample page shown below) of this fom/ application to povide the specific details fo any questions that wee answeed YES. FOR THE EDUCATION OF PRODUCERS/BROKERS. NOT FOR USE WITH THE PUBLIC. 6 6
APPLICATION FOR LIFE INSURANCE (ORD 96200) (continued) 4 The state whee the application is physically signed and the policy will be deliveed detemines the state of sale and dictates which application vesion to use. The poduce must be licensed in this state. Section of Fom Did You Know? Instuctions Signatues Tax Cetification 4 If the owne is a tust, the tust should be in effect pio to submitting the application. 4 Fom (COMB 86044) must be submitted if the owne is a tust. 4 This line applies to both entities and individuals. Ensue this box is checked ONLY when the policyowne is subject to backup withholding. 4 This line applies to both entities and individuals. An entity should conside itself a U.S. peson if it is established as a United States domestic copoation. If this box is not checked, a W8 MUST be submitted fo the policyowne. 4 Ente the state whee signed and the cuent date. 4Signatue of the poposed insued. 4 Signatue of the policyowne. If the policyowne is an entity, list the name of the entity, obtain the signatue of the entity epesentative, and list the title of the entity epesentative. 4 Signatue of the poduce. 4 I am subject to backup withholding unde Section 3406(a)(1)(C) of the Intenal Revenue Code. 4 I am not a U.S. peson (including U.S. esident alien), submit the applicable Fom W-8 (BEN, BEN-E, ECI, EXP, o IMY). In most cases, Fom W-8BEN will be the appopiate fom. 7
AUTHORIZATION TO RELEASE INFORMATION (ORD 96200C) & LIMITED INSURANCE AGREEMENT (ORD 96200A) Note 4 When you pint the application packet, you will find one copy of both the Authoization to Release Infomation and the Limited Insuance Ageement. Once finished, povide a copy of the Authoization to Release Infomation and the Limited Insuance Ageement (if a pepayment was taken) to the client. Submit the oiginal(s) with the completed application. Section of Fom Did You Know? Instuctions Authoization to Release Infomation 4 Ente the name of poposed insued. 4 Ente the policy numbe (if available). 4 Poposed Insued MUST sign and date (paent/guadian when the poposed insued is unde 18). Limited Insuance Ageement (LIA) 4 Checks can be made payable to Pudential Insuance. 4 Complete this section if pepayment can and will be collected. 4 Ente the amount of insuance equested. 4 If a tem convesion, show the amount of the new policy in the amount of insuance equested. 4 If equesting a flex face incease (VAL) o a laye/slice (VUL), show only the amount of the flex face incease o laye/slice equested. 4 Ente the amount of pepayment. 4 Ente the poposed insued s name. 4 Pudential must eceive payment, the LIA, and the equest fo coveage on the same day. Pepayments ae not accepted afte the application is submitted. Signatues 4 If the owne is a business, a company office must sign and include thei title. 4 Poposed insued must sign and date this section/fom (if unde 18, paent/guadian signs). 4 If the policyowne is diffeent fom the insued, the policyowne must sign. 4 If a tust is the owne, all tustees must sign unless othewise stated in the tust o applicable state laws. They must also indicate tustee unde tust ageement dated. 4 The poduce must sign. 8
AGENT S REPORT (this fom MUST be submitted with the application in all cases) <Click Fo Detailed Instuctions> Section of Fom Did You Know? Instuctions Name of Poposed Insued 4 Ente name of the pimay poposed insued. Pupose of Life Insuance Poduce Infomation 4 Fequently, the pupose of the insuance is not clea, which can cause a delay in pocessing the application. 4 Check all that apply and explain. (The cove lette is a good place to include additional infomation about amounts, beakdowns, and pupose). 4 Povide all equested infomation applicable. Case Details 4 Check applicable boxes fo equiements. Knowledge of Poposed Insued 4 Answe all Questions. Check applicable boxes fo equiements. Suitability Declaations Souce of Funds Undewiting Categoy Quoted Pudential/Puco Policies Issued Within Thee Months Remaks Militay Poduce s Statement 4 Applicable only to vaiable poducts. 4 This section is often left blank yet emaks ae helpful to expedite pocessing (e.g., a cossefeence to elated applications on business patnes, o stating who suggested coveage, etc.). 4 Answe all questions. 4 Ente the souce of BOTH the initial and futue pemiums. 4 Answe questions 2 and 3 only pemiums (eithe initial o futue) ae coming fom any existing policies o contacts. 4 Check the applicable box. 4 This needs to be answeed only if a Pu/Puco policy was issued within thee months of the cuent application. 4 Ente any/all unusual details o subjective infomation you lean about all the poposed insueds in this section. 4 Both questions MUST be answeed on ALL cases. Fo any YES answes, povide appopiate disclosue foms at point of sale. 4 Sign and date. 4 Fo a non-face-to-face sale: Poduce should select NO in section I, question 1 of the Agent s Repot, noting the insued was NOT seen at the point of sale. 9
APPLICATION SIGNATURE REQUIREMENTS FORM: Authoization to Release Infomation (ORD 96200C) Section Poposed Insued Policyowne(s) Tustees Office Poduce If age 18 o ove; othewise, paent/ guadian. Include date signed. FORM: Limited Insuance Ageement (ORD 96200A) Section Poposed Insued Policyowne(s) Tustees Office Poduce If age 18 o ove; othewise, paent/ guadian. Include date signed. If diffeent fom the poposed insued. If a tust is the owne, all tustees must sign unless othewise stated in the tust o applicable state laws. Office of company, if owne is a business o copoation. FORM: Application fo Life Insuance (ORD 96200) Section Poposed Insued Policyowne(s) Tustees Office Poduce If diffeent fom the poposed insued. If the owne is an entity, give the entity s name. If a tust is the owne, all tustees must sign unless othewise stated in the tust o applicable state laws. They must also indicate tustee unde tust ageement dated. Office (include title) of company, if owne is a business o copoation. 10
OBTAINING FORMS Foms may be accessed on-line via the Foms tab at www.puxpess.com. Click on the Foms tab and then Launch Foms. Be caeful to select the appopiate state-specific vesion(s). ADDITIONAL FORMS Fom Name/Type Fom Numbe When To Use Aviation Supplement ORD 96200 Aviation Requied if the poposed insued has any duties aboad an aicaft, glide, balloon, o simila device. Diving Supplement ORD 96200 Diving Requied if the poposed insued paticipates in scuba diving. Mountain Climbing Supplement Motoized Vehicle Racing Supplement Geneal Avocation Supplement ORD 96200 Mountain Climbing ORD 96200 Racing ORD 96200 Avocation Requied if the poposed insued paticipates in mountain climbing. Requied if the poposed insued paticipates in any fom of motoized vehicle acing. Requied if the poposed insued paticipates in any hazadous activities othe than scuba diving, mountain climbing, o acing. Business Supplement ORD 96200 Business Requied when the owne o beneficiay of the policy is to be a business. Financial Supplement BenefitAccess Ride Supplement ORD 96200 Financial ORD 96200 BenefitAccess Ride Requied when the face amount is $5,000,000 o geate fo ages 18 to 70, $2,500,000 o moe fo ages 71 to 80, and $1,000,000 o moe fo age 80 and olde. Complete when submitting fo BenefitAccess Ride on UL Potecto (Type A death benefit), PuLife Index Advantage UL, PuLife Foundes Plus UL, PuLife Custom Pemie II o VUL Potecto poducts. Child Ride Supplement ORD 96200 Child Ride Requied when equesting a Child Ride. Policyowne Statement Supplement Policy Change Supplement Indexed Univesal Life Insuance Supplement Foundes Plus Univesal Life Insuance Supplement Vaiable Supplement Absolute Assignment to Effect a Section 1035 Exchange CVAT o GPT Selection Fom Request fo Initial Pemium (E-Pay) and/o to Establish Monthly Electonic Funds Tansfe (EFT) ORD 96200 Owne Statement ORD 96200 Change ORD 96200-2015 Indexed UL ORD 96200 Foundes Plus UL ORD 96200 Vaiable ORD 88649 ORD 99767 ORD 114416 Requied fo all non-vaiable plans when the age of the poposed insued is 70 o geate and the face amount is $1,000,000 o geate. Requied only when: The existing policyowne of the policy being conveted o changed is not the owne of the new o changed policy; o The ights estiction equies the beneficiay to sign all equests; o Thee is a collateal assignee. Requied when equesting an indexed poduct (such as Index Advantage Univesal Life). Requied when equesting Foundes Plus Univesal Life. Requied when equesting a vaiable poduct (such as VUL II o VUL Potecto). Complete only when equesting a 1035 Exchange fom a non-pudential contact. Requied when the application state is New Yok fo any poduct that offes a choice of definition of life insuance: CVAT: Cash Value Accumulation Test GPT: Guideline Pemium Test Complete if the policyowne wants to pay the initial pemium fom E-Pay and/o place the policy on the Electonic Funds Tansfe (EFT) pemium payment option. 11
ADDITIONAL FORMS (continued) Fom Name/Type Fom Numbe When To Use Illustation Cetification ORD 96599 A signed illustation is equied to be submitted with the application to satisfy NAIC Regulations. The Illustation Cetification Fom may be submitted with the application fo Univesal policies if the illustation shown to the applicant diffes fom the policy applied fo o a compute sceen illustation was shown to the client. If an Illustation Cetification is used, an illustation confoming to the policy as applied fo must be povided to the applicant within 48 hous. Impotant Notice Regading Replacements Living Needs Benefit SM Get the Most Out of You Life Insuance New Yok Definition of Replacement Pennsylvania Disclosue Statement Peliminay Statement of Policy Cost (Maine and New Yok) Pemium Povisions of Indeteminate Pemium Contacts (Montana and Texas) Tustee Statement and Ageement Fom Disclosue fo Militay Sales COMB 89216 ORD 87246 COMB 98774 NY COMB 96999 PA ORD 99607 ORD 99606 ORD 86890 COMB 86044 ORD 114442 Fom must be completed and submitted when: 4 Replacing existing life o annuity coveage as equied by state egulations. 4 The poposed insued has existing individual life o annuity coveage (even if not eplacing it) and the application state has adopted the NAIC s New Model Replacement Regulation. 4 Additional eplacement foms may also be equied. If applying fo the Living Needs Benefit (LNB), povide the pimay poposed insued with a copy of the LNB bochue (found on Puxpess). Requied to be completed/signed by the owne when the application is signed in the state of New Yok. (Applies to all poducts.) Requied fo all poducts except VUL II. Poduce completes the fom and povides a copy to the poposed insued and submits a copy to the Home Office only if eplacing an existing non-pudential policy. No signatues ae equied. 4 Maine: ORD 99607 must be completed fo all Tem policies. 4 New Yok: ORD 99606 must be completed and signed by both the owne and poduce fo all Tem policies with a copy submitted to the Home Office with the application. Requied fo Tem Essential in Montana and Texas. Fom must be signed by the owne and a copy must be submitted to the Home Office with the application. Use fo owneship in a tustee unde a tust ageement. COMB 86044 is pefeed ove a tust document. Requied when the militay question on the Agent s Repot is answeed YES. The Living Needs Benefit SM is an acceleated death benefit and is not a health, nusing home, o long-tem cae insuance benefit and is not designed to eliminate the need fo insuance of these types. Thee is no chage fo this ide but, when a claim is paid unde this ide, the death benefit is educed fo ealy payment, and a $150 pocessing fee ($100 in Floida) is deducted. If moe than one policy is used fo the claim, each policy will have a pocessing fee of up to $150 deducted ($100 in Floida). Potions of the Living Needs Benefit payment may be taxable, and eceiving an acceleated death benefit may affect eligibility fo public assistance pogams. The fedeal income tax teatment of payments made unde this ide depends upon whethe the insued is the ecipient of the benefit and is consideed teminally ill o chonically ill. We suggest that clients seek assistance fom a pesonal tax adviso egading the implications of eceiving Living Needs Benefit payments. This ide is not available in Minnesota to new puchases ove age 65 until the policy has been in foce fo one yea, and the nusing home option is not available in Connecticut, Floida, Massachusetts, New Yok o the Distict of Columbia. This ide is not available in Washington state. In Oegon, tem policies must include the waive of pemium benefit to be eligible fo this ide. The Pudential Insuance Company of Ameica, Newak, NJ. NOT FOR CONSUMER USE. 12