Special Executive Financial Security

Request to Claim the Chronic Illness Benefit

The Prudential Insurance Company of America Pruco Life Insurance Company of New Jersey

Pruco Life Insurance Company All are Prudential companies.

Instructions

1. The policyowner needs to complete sections 1, 2, and 4 of this form. 2. The insured must complete section 3 and sign the Authorization to Release Medical Information , section 5. 3. The licensed health care practitioner must complete and sign section 6. This should be the licensed health care practitioner currently treating the insured for the chronic condition. 4. If the licensed health care practitioner indicates that the insured is not mentally capable of handling his or her own affairs and the insured is the policyowner, the claim must be made by the insured’s legal representative as described in the signature portion of section 4. Please be sure to submit legal documents supporting that you are the legal representative for the insured.

1. Policy Information Please list the policy number(s) for which you are making the claim.

Name of policyowner

Telephone

Address of policyowner: Street

Apt

City

State

ZIP

Name of insured

Date of birth

SAMPLE 2. Information About the Benefit The letter that accompanies this claim form contains important information you must know before you complete this section. If you have any questions, please call the person named in the letter. If you request more than the maximum amount available, we will process your claim for the maximum amount available. Benefit amount you are requesting for each of the policies in Section 1. o Maximum annual benefit o Maximum monthly benefit o Other monthly benefit (must be at least $500) $ 3. History of Chronic Illness 1. W hat are the diagnoses and symptoms that prevent the insured from caring for himself or herself and which support eligibility for a chronic illness claim?

2. Has the insured been confined to any type of facility (e.g., hospital, nursing home, rehabilitation center) for this condition? If Yes, please list name, address and phone number of each facility and dates of confinement. Name of facility Address: Street City State Dates of confinement From / / To / /

o Yes o No

ZIP

Telephone number Name of facility Address: Street City Telephone number

Dates of confinement

From

/

/

To

/

/

State

ZIP

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COMB 115174-2

Ed. 10/2017