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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:

FRAUD WARNING 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.

DECLARATIONS AND SIGNATURE

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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Your legal name

Your email address

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Timestamp

Audit

August 12, 2022 9:50 am CDT

Prudential Activation Form Uploaded by John kohrs - kohrsj@driasi.com IP 136.228.217.166, 136.228.217.166