Prudential Activation Form


Request for Insurance From: 

The Prudential Insurance Company of America
751 Broad Street
Newark, NJ  07102

Group Policy G-54170-IL

Activation Form for Group Accidental Death and Dismemberment Insurance

Name:



,

Coverage Selected:  

Amount Selected:
(Insurance Benefit reduces by 50% at age 70 and by 75% at age 75.)

Premium: $ per month

Date of Birth:   

Gender:  

Email Address:

Beneficiary Information:
(If no beneficiary is on record, benefits will be paid per the “Beneficiary Death Benefit” provision as outlined in your Certificate of Insurance.)

Relationship:
Name:

 

Before signing this enrollment form, please read the warning for the state where the contract under which you are applying for coverage was issued.
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.

I hereby enroll for the Group Accidental Death and Dismemberment Policy issued by The Prudential Insurance Company of America. I understand that to enroll for the insurance being offered, I must have an account with . I authorize the premiums due to be remitted monthly to Prudential Insurance Company or its designee using payment information I have provided. This authority is to remain in effect until I cancel it by written notification to the administrator at least 30 days in advance of the intended date of cancellation. *A $.95 administrative fee will be added each month for automatic account billing. I hereby acknowledge that I have read and understand the exclusions and limitations of this program and the boxed disclosure, which appears on this form.

 

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Signature Certificate
Document name: Prudential Activation Form
lock iconUnique Document ID: 0a58dd6df7d2ff0728ef4b52571bce07e653ece2
Timestamp Audit
August 12, 2022 9:50 am CSTPrudential Activation Form Uploaded by John kohrs - kohrsj@driasi.com IP 136.228.217.166, 136.228.217.166