Prudential Change Beneficiary – Fill Out and Use This PDF

Request to Change Beneficiary on Life Insurance Policies

The Prudential Insurance Company of America

Pruco Life Insurance Company of New Jersey

Pruco Life Insurance Company

All are Prudential Financial companies.

General Information and Instructions (Read the instructions about the change(s) you wish to make)

•Review the accuracy of any pre-filled information. Initial any corrections or deletions that you make to the preprinted text. If you do not, we may not be able to act upon your request.

•Return the completed form in its entirety. Do not send us your policy.

•We will record the change(s) and send a confirmation.

•On these pages, me, my, you, your, and I refer to the owner(s). We, us, and our refer to the Prudential company that issued the policy.

•This form does not provide for every arrangement. If the arrangement you want is not on this form, please contact our Customer Service Office.

Changing Your Beneficiary (Complete the Request to Change Beneficiary section)

1.To help facilitate payment when a claim is made, we need to have certain information about each beneficiary. The information we request for each beneficiary helps us identify and locate the beneficiary for payment. We recognize the confidential nature of the information requested, and we assure you that this information is for our internal use only and will not be shared.

2.Proceeds will be paid in a lump sum unless indicated otherwise in the Additional/Special Beneficiary Requests section. If information about a different method of payment was requested, we have enclosed A Word About Settlement Options. If you have not received it, contact our Customer Service Office.

3.It is important to understand the difference between primary (class 1), contingent (class 2), and tertiary (class 3) categories of beneficiaries.

•Primary beneficiaries will receive any proceeds payable at the insured’s death.

•If no primary beneficiary survives the insured, the contingent beneficiaries will receive any proceeds.

•If neither primary nor contingent beneficiaries survive the insured, tertiary beneficiaries will receive any proceeds.

4.If there is more than one beneficiary in the same class, they will be paid in equal shares or to the survivor(s) of them, unless specified otherwise.

5.Testamentary Trust (i.e., a trust that is established under a will) – A Testamentary Trust should only be named as a beneficiary if the insured’s last will and testament provides for the establishment of a trust. The death benefit can only be paid to a Testamentary Trust if the trust is named in the will and the will is probated. If the Insured’s last will and testament is not admitted to probate, under the terms of the beneficiary arrangement, we will not be able to pay the claim to the contingent beneficiary (or the insured’s estate if no contingent is named) until 18 months after the Insured’s death (or if permitted by law, a shorter period as requested in the Additional/Special Beneficiary Requests section.)

6.Our responsibility for the payment of the proceeds to a Trust ends with payment made to the Trustee(s); we have no responsibility regarding any subsequent distribution made by the Trustee(s).

Special Beneficiary Designations (Use the Additional/Special Beneficiary Requests section)

For the following designations, include the information shown in the quotations (as well as any other identifying information described in this section).

1. Children as a group. (This would include any legally adopted children.) Write“Children of the insured.”

2.Children by representation. (We do not use the term “per stirpes” in our beneficiary designations.)

If a child is not living and therefore not eligible to receive payment, and if any such child’s share is to be distributed equally to his or her surviving children, then write: “his (or her) children by representation” next to any beneficiary this will apply to.

For children as a group write “children of the Insured, their children by representation.”

3. Creditor Beneficiary or Funeral Home.

a.“(Business Name), of (city, state), its successors or assigns, creditor, as its interest may appear.” For entities other than a corporation omit ‘its successors or assigns’. or

b.“(Individual’s name), his/her estate, creditor of the Insured, as his/her interest may appear.”

For any creditor arrangement, be sure to indicate who is to receive any balance. “Pay balance, if any, to Jane Smith, wife.”

(continued)

Special Beneficiary Designations (Use the Additional/Special Beneficiary Requests section) (continued)

4. Dollars and Balance Arrangements. Note: Only one dollar amount can be shown.

•“Pay $80,000, or the proceeds, if less, to Jane Doe, wife, and the balance, if any, to John Doe, son.”

5. Percentages and Fractions.

•Percentage arrangement: “Pay 75% to Jane Doe, wife, and 25% to John Doe, son.”

•Fraction arrangement: “Pay ¾ to Jane Doe, wife, and ¼ to John Doe, son.”

In the examples above, if Jane Doe is not living when the insured dies, her share will not be payable to John Doe. If you want that share to be paid to the other beneficiary (or to someone else), then write:

“Pay 75% to Jane Doe, wife, if living, otherwise to John Doe, son; and 25% to John Doe, son, if living, otherwise Jane Doe, wife.”

6.Short Term Survivorship Provision.

If this provision is chosen, any beneficiary who dies after the insured (but within the period of days you specify) will be considered to have died before the insured. The specified period (from 1 to 30 days) must be indicated, as follows:

“Include Short Term Survivorship Provision of (1 to 30) days.”

For Kentucky Residents – Additional Information Regarding the Beneficiary Change

The State of Kentucky prohibits a beneficiary from collecting benefits under an insurance policy if convicted of taking the life of the decedent or of certain felonies involving abuse, neglect or financial exploitation of the decedent resulting in a loss to the decedent of more than $300 in financial or other resources, or both.

The forfeiture will not occur if:

•The insurance policy was executed prior to January 1, 2012.

•The felony was committed prior to January 1, 2012.

•The decedent, knowing of that person’s conviction, reaffirms that person’s right to receive the policy benefits by executing a new policy, or requesting a beneficiary change on an existing policy, which names that person as a beneficiary.

If a forfeiture occurs, and there are no other beneficiaries, the forfeited interest shall be paid to the State for deposit into the elder and vulnerable adult victims trust fund.

Important Notice – Civil Union Act

If your state has enacted a Civil Union Act or similar legislation, which provides that parties treat civil unions and marriages equally in all aspects, we are providing this notice to confirm that we comply with all states Civil Union Acts or similar legislation.

Request to Change Beneficiary on Life Insurance Policies

About Your Policy

You can use this form to make changes to more than one policy as long as each policy insures the same person(s) and has the same owner, and you are requesting the same changes for each policy.

Policy number(s) (eight or nine characters)

_______________________ _______________________ _______________________ _______________________

Name of insured (first, middle initial, last name)

Name of joint insured, if any (first, middle initial, last name)

Has your mailing address, telephone number(s), or e-mail address changed?

Complete this section only if you are requesting a permanent change in your mailing address, have a new telephone number(s), or e-mail address.

Full address

e-mail address

Mailing Instructions

Unless otherwise indicated in this section, confirmation of the change(s) will be mailed to the owner at the address in our records.

Name of Recipient of confirmation (first, middle initial, last name)

Full address

Request to Change Beneficiary (This revokes all prior beneficiary designations)

All beneficiaries need to be restated even if they are not being changed. For example, if you are changing only the contingent beneficiary, you must restate the primary beneficiary. If more space is needed for additional beneficiaries, use the Additional/Special Beneficiary Requests section.

A. To name individual beneficiary(ies), complete the following:

Initial any corrections or deletions that you make to the preprinted text.

Request to Change Beneficiary (continued)

B. To name a trustee under a living (inter-vivos) trust agreement , (the trust must already be in existence) complete the following:

Note: Whenever possible, include confirmation of the trust information by providing a copy of those pages of the trust documentation that show the name of the trust, name(s) of the trustee(s) and date of the trust.

C. To name a trust that will be established under the Insured’s Last Will and Testament (i.e. Testamentary Trust), check one of the following:

Note: You may wish to consult legal counsel before choosing this arrangement. Only choose this arrangement if the insured’s will provides for the establishment of a trust. Trusts that are established prior to the insured’s death are not testamentary trusts. To name a trust that has already been established as a beneficiary, complete B above. Please refer to #5 in the Changing Your Beneficiary section on Page A of Instructions for additional information.

D. To name the insured’s estate as your sole beneficiary, check the following:

E. To name a business/organization, complete the following:

Name of business/organization

Full address

Additional/Special Beneficiary Requests

Use this section to name an additional beneficiary, a class or group not shown in the Request to Change Beneficiary section, or to select a payment option for your beneficiary.

For each additional individual beneficiary or member of a class or group (i.e. Children of the Insured), please provide the class (primary, contingent, tertiary), their full name, relationship to the insured, date of birth, social security number, address, home and/or mobile (cell) telephone number(s) and e-mail address.

Initial any corrections or deletions that you make to the preprinted text.

Signature(s)/Signature Requirements (Always complete)

Your request cannot be processed without the correct signature(s), date, and applicable documentation.

•For individual policyowner(s), the person (or persons if there are joint owners) that owns the policy must sign.

•For corporations, an authorized officer must sign. Be sure to include the title of the officer and the company name.

•If president – no additional requirements

•If vice president – for policies over $1,000,000, provide a Corporate Secretary’s statement reflecting the vice president’s authority to sign

•If any other officer – provide a corporate resolution

•For limited liability companies (LLC), a copy of the document that identifies who is authorized to act on behalf of the LLC (e.g. operating agreement) must be submitted. The individual(s) authorized to act should sign and include his/her title and the company name.

•For partnerships (LP, LLP, and LLLP), the form should be signed by at least two general partners, followed by the title “general partner” after each signature. If the company only has one general partner, then the sole general partner should sign followed by the title “sole general partner”. Also, include the company name.

•For sole proprietorships, submit the signature of the owner, followed by “doing business as (company name), a sole proprietorship.“

•For trusts, the trustee(s) must sign and include the title “trustee” after their signature. The name of the trust must also be indicated in the space provided for Business/Trust name. All trustees must sign unless the trust itself or state law provides otherwise.

•A holder of a power of attorney for the policyowner must sign the form and include the title “attorney-in-fact for (owner’s name).” In addition, a copy of the power of attorney papers must be submitted along with the request.

•For guardian (conservator) of the estate - sign as “guardian of the estate of (name of ward)”. A copy of the guardianship papers must also be submitted. Depending on the rights granted by the guardianship papers or the state, a court order authorizing the change may also be required.

•For a policy containing a limitation of rights, the person or entity in whose favor the rights have been limited must also sign.

By signing this form, I:

•certify that I am authorized to sign this form,

•certify that the change(s) being requested are not subject to, or in conflict with, any prior agreement, legal proceeding, or court/administrative order, which restrict, limit, or otherwise prohibit such change(s), including, but not limited to divorce or bankruptcy proceedings,

•authorize all request(s) made on this form, both preprinted and handwritten, which are subject to the terms and conditions of the policy,

•request a waiver of any policy provision that requires me to send Prudential the policy for endorsement of the change(s),

•certify that the policy(ies) is/are in my possession and that no other person has any claim or interest in it/them, except for a collateral assignee under any assignment now on record with Prudential,

•certify that if the owner is a corporation or partnership, that it is not under receivership, trusteeship, or conservatorship, and/or has not been dissolved, and if a partnership, that no notice of disassociation has been filed by any partner, and

•understand that any endorsement that Prudential may issue will conform to its rules and practices.

X

Current owner’s signatureDate signed month/day/year

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For Massachusetts residents only

State law requires that a disinterested adult, who is not a party to the policy, witness any request to change the beneficiary arrangement. Your Prudential representative may sign as a witness.

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Witness’ signature (Massachusetts only)