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Document Preview Flexible Payment Variable Deferred Annuity |
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Title: |
Flexible Payment Variable Deferred Annuity |
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Date: |
2004 |
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$42 |
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#2382836 |
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PRUCO LIFE INSURANCE COMPANY, STRATEGIC PARTNERS(SM)
a Prudential Financial company ANNUITY ONE APPLICATION
Flexible Payment Variable Deferred Annuity
ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THE CONTRACT ARE VARIABLE
AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.
IF MONIES ARE ALLOCATED TO VARIABLE INVESTMENT OPTIONS, THAT PORTION OF THE
POLICY OR CONTRACT IS NOT PROTECTED BY THE MINNESOTA LIFE AND HEALTH INSURANCE
GUARANTY ASSOCIATION OR THE MINNESOTA INSURANCE GUARANTY ASSOCIATION. IN THE
CASE OF INSOLVENCY, PAYMENT OF CLAIMS IS NOT GUARANTEED. ONLY THE ASSETS OF THE
INSURER WILL BE AVAILABLE TO PAY YOUR CLAIM.
On these pages, I, you, and your refer to the contract owner. We, us, and our
refer to Pruco Life Insurance Company.
1 CONTRACT OWNER INFORMATION
Contract number (if any)
--------------------------------------------------------
[ ] Individual [ ]Corporation [ ]UGMA/UTMA [ ]Other
TRUST: [ ]Grantor [ ]Revocable [ ]Irrevocable
TRUST DATE (mo., day, yr.)
---- ---- --------
If a corporation or trust is indicated above, please check the following as it
applies. If neither box is checked, we will provide annual tax reporting for the
increasing value of the contract.
[ ] Tax-exempt entity under Internal Revenue Code 501
[ ]Trust acting as agent for an individual under Internal Revenue Code 72(u)
Name of owner (first, middle initial, last name)
--------------------------------------------------------------------------------
Street Apt.
-------------------------------------------------------------- --------------
City State ZIP code
-
--------------------------------- ----------- ------------------------------
Social Security number/EIN Date of birth (mo., day, year) Telephone number
-
--------------------------- ------ ------- --------------- ----------------
A. [ ] Female B. [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. person (including resident alien). I am a citizen of
--------------------------------------------------------------------------------
Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY).
2 JOINT OWNER INFORMATION (if any)
Do not complete if you are opening an IRA.
Unmarried persons who wish to own the contract jointly should consult with their
tax adviser.
Name of joint owner, if any (first, middle initial, last name)
--------------------------------------------------------------------------------
Street (Leave address blank if same as owner.) Apt.
------------------------------------------------------------ ----------------
City State ZIP code
-
----------------------------- ------------------- --------------------------
Social Security number/EIN Date of birth (mo., day, year) Telephone number
-
--------------------------- -------- ------- ------------- ----------------
A. [ ] Female B. [ ] U.S. citizen
[ ] Male [ ] Resident alien
[ ] I am not a U.S. person (including resident alien). I am a citizen of
--------------------------------------------------------------------------------
3 ANNUITANT INFORMATION
Do not complete if you are opening an IRA.
This section must be completed only if the annuitant is not the owner or if the
owner is a trust or a corporation.
Name of annuitant (first, middle initial, last name)
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