city of escondido · enroll when first eligible to get guaranteed coverage! ifs-a090156...

Enroll when first eligible to get guaranteed coverage!

Ed. 09.2010 ECEd.09.2010-10581 Exp. 03.2012IFS-A090156 0181193-00003-00 108309

The Prudential Insurance Company of America

CITY OF ESCONDIDOAll Full Time Active Employees

Optional Term Life InsuranceOptional Dependent Life Insurance

Why you may need more life insurance

Why you should buy it at work

How much you may need

How much insurance can I buy?

How much it will cost

How to enroll

Plus, plan features and answers to common questions

WHAT'S INSIDE

2

Why you may need more life insurance...........................................................................................................3

Why you should buy it at work....................................................................................................................... 4

How much you may need...............................................................................................................................6

How much insurance can I buy?......................................................................................................................7

How much it will cost......................................................................................................................................8

How to enroll................................................................................................................................................12

Why you may need more life insurance...........................................................................................................3

Why you should buy it at work....................................................................................................................... 4

How much you may need...............................................................................................................................6

How much insurance can I buy?......................................................................................................................7

How much it will cost......................................................................................................................................8

How to enroll................................................................................................................................................12

3

Why you may need more life insurance

"Why do I need life insurance?"

Life is full of pleasant surprises and, at the same time, life holds uncertainties.It's easier to plan for happy events you know will occur, and more difficult toplan for the unexpected--such as a death.

If you were no longer there to help support your family, how would they beable to…

ü Pay off loans--credit cards, mortgage, and auto?

ü Maintain their standard of living--utilities, food, clothing, and personalexpenses?

ü Pay monthly rent or mortgage?

ü Provide for your children's future--tuition for their education andweddings?

ü Pay your final expenses--medical care, burial, estate settlement, andinheritance taxes?

A sufficient amount of life insurance can give you peace of mind now and helpyour family financially recover from your loss during a very stressful time.

"I already have life insurance--why do I need more?"

Research has shown that 77% of households, earning between $35,000 and$125,000 per year, say they do not have adequate resources to replace lostincome. Thirty-four percent of households within the same range of earningsreport not having enough life insurance.1

You may be underinsured if your salary has increased since you last purchasedinsurance. Plus, when you consider new family responsibilities - a new home orchild - and inflation, the life insurance coverage you have now may not offerenough protection for your family.

"How can I help protect my loved ones?"

Buy life insurance at work. Your employer offers you the opportunity topurchase Optional Term Life Insurance issued by The Prudential InsuranceCompany of America.

As millions of Americans have discovered, insurance at group rates fromPrudential is a smart choice.

1LIMRA's Factbook, 2009 Trends in the United States

ENROLL NOW with theenclosed Enrollment Form!

4

Why you should buy it at work

"What are the advantages of buying life insuranceat work?"

ü It's convenient. There are no confusing quotes to sort through. Andwith automatic payroll deductions, you never have to worry about latepayments.

ü It's economical. The cost of group insurance may be lower thaninsurance you could find on your own.

ü It's flexible. You may choose the level of coverage that's right for youand your family.

ü It's convertible. You and your family can convert your coverage to anindividual Prudential insurance policy if you leave the company for anyreason.

Read on to select theamount of insurancethat's right for you!

Peace of Mindfrom Prudential

Prudential's resources, financialstrength, and stability allow us tohonor long-term commitments,which means that we'll be herewhen you and your family need us.We've been a top insuranceprovider for over 130 years.

Plus, we have caring professionalsto provide your beneficiaries withthe kind of customer support theywant and deserve. Our CustomerService Representatives arewell-trained, knowledgeableprofessionals who can quicklyanswer your family's questions.

By choosing the insuranceprotection from Prudential, yougive yourself peace of mind,knowing you are providing for yourloved ones.

For more information aboutPrudential's Group Insurance, visitus online at:www.prudential.com/gi.

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"What does group insurance offer my family?"

You get affordable premiums for yourself, your spouse, and each of yourchildren. Plus, you'll get the special features mentioned below.

Accelerated Benefit Option- If terminally ill, you can get a partial payment ofyour group term life insurance benefit. You can use this payment as you see fit.In the event of your death, your beneficiary will receive a benefit payout whichhas been reduced by the amount you receive.

Prudential's Alliance Account®3 - This settlement option is a convenient wayfor beneficiaries to manage their benefit payout during a stressful time. Once aclaim is approved, we establish an interest-bearing Alliance Account in thebeneficiary's name. Beneficiaries can leave the money in the account to earncontinuous interest, withdraw the entire amount immediately, or write drafts("checks") against the balance.

Waiver of Premium - Payment of your premium can be waived if you meet allthese conditions: 1) you are less than 60 years old when your disability begins,2) you are totally disabled and unable to work for at least 6 continuous months,and 3) you continue to be totally disabled. The Waiver of Premium Benefitterminates at age 65. This provision may vary by state.

Conversion to Individual Insurance Coverage - Upon termination ofemployment, you may convert your coverage to a Prudential individual lifeinsurance policy, without having to provide evidence of good health.

Portability of Group Insurance Coverage - Upon termination ofemployment, you may continue a certain level of your employee anddependent coverage, without having to provide evidence of good health.

3 Open Solutions Inc. is the Service Provider of the Prudential Alliance Account Settlement Option, a contractualobligation of The Prudential Insurance Company of America, located at 751 Broad Street, Newark, NJ07102-3777. Check clearing is provided by JPMorgan Chase Bank, N.A. and processing support is provided byFirst Data Payment Services (FDPS). Alliance Account balances are not insured by the Federal Deposit InsuranceCorporation (FDIC). Open Solutions Inc., JPMorgan Chase Bank, N.A., and First Data Payment Services are notPrudential Financial companies.

The Booklet-Certificateyou will receive after yourinsurance becomes effective givesmore details.

For your convenience,visit our website to use an onlinelife insurance needs calculator.

www.prudential.com/howmuchdoineed

"How much life insurance is enough?"

The right amount of insurance can help your family. It helps replace your income for a number of years tomaintain their standard of living and pay for major financial obligations, such as home mortgage and collegetuition.

According to a recent LIMRA report, 39% of households believe they do not have enough life insurance ("LifeInsurance in a Tough Economy," LIMRA, 2010). While rules of thumb may be helpful, they do not take eachindividual's personal situation into consideration. This worksheet provides a simple method to estimate theamount of life insurance you may need.

Income Needs

1. Your annual income. (What your family would need if you die today.) Enter a number that’sbetween 60–70% of your total income.

1. $

2. Annual replacement income. (Available to your family after you die.) Enter a number thatincludes Social Security benefits, if applicable.

2. $

3. Total annual income to be replaced. Subtract line 2 from line 1. 3. $

4. Funds needed to provide income for_____ years. Choose the number of years your familyneeds your replacement income. Multiply line 3 by the appropriate factor below.†

10 yrs x 8.1 15 yrs x 11.1 20 yrs x 13.6 25 yrs x 15.6 30 yrs x 17.3 35 yrs x 18.7 40 yrs x 20.0

4. $

Expenses

5. Burial expenses. (The average cost of an adult funeral is about $10,000.) 5. $

6. Mortgage and other major debts. Include mortgage, credit card debt, car loan, home equity loans, etc. 6. $

7. College costs.‡ (Current cost of a 4 year education: public—$62,264; private—$127,664.)Multiply the college costs by the appropriate factor, based on the number of years between now andwhen your child begins college.

5 yrs x .82 10 yrs x .68 15 yrs x .56 20 yrs x .46

Child 1: $ Child 3: $

Child 2: $ Child 4: $

7. $

8. Total capital required. Add lines 4, 5, 6 and 7. 8. $

Assets

9. Savings and investments. Include bank accounts, CDs, stocks, bonds, mutual funds,real estate/rental property, etc.

9. $

10. Retirement savings. Include 401(k) plans, Keogh, pension and profit sharing plans. 10. $

11. Present amount of life insurance. Include group insurance and personal insurance purchasedon your own.

11. $

12. Total of all assets. Add lines 9, 10 and 11. 12. $

13. Estimated amount of life insurance needed. Subtract line 12 from line 8. 13. $

† Inflation is assumed to be 4%. The rate of return on investments is assumed to be 8%.

‡ The College Board, Trends in College Pricing 2005. Costs include tuition, room, board, books andsupplies, transportation, and other expenses.

How much you may need

6

How much insurance can I buy?

7

"How much insurance can I buy?"

You can customize coverage to fit your family's needs. Your salary determines the maximum coverage amountavailable to you. See the chart below for details.

Coverage Options

EMPLOYEE

Ÿ Purchase coverage in increments of $10,000 to $500,000, not to exceed 5 times your covered annual earnings.

Ÿ New Hires: Get the lesser of 2.0 times your covered annual earnings not to exceed $200,000 - no medical questionsasked - when enrolling when first eligible.

Ÿ Current Participants: Your current coverage amount will be continued. Evidence of insurability satisfactory to ThePrudential Insurance Company of America is required for all increases in coverage amounts.

Ÿ Current Employees who were denied coverage in the past or Late Entrants Evidence of insurability satisfactoryto The Prudential Insurance Company of America is required for all coverage amounts.

Ÿ Coverage will be reduced as you age - by 35% at age 70 and 50% at age 75.

SPOUSE5

Ÿ Purchase coverage for your spouse in increments of $5,000 to $250,000, not to exceed 50% of your Optional Term Lifecoverage amount.

Ÿ New Hires: Get up to $20,000 - no medical questions asked - when enrolling when first eligible.

Ÿ Current Spouse Participants: Your spouse's current coverage amount will be continued. Evidence of insurabilitysatisfactory to The Prudential Insurance Company of America is required for all increases in coverage amounts.

Ÿ Current Employees whose spouse has been denied coverage in the past or Late Entrants: Evidence ofinsurability satisfactory to The Prudential Insurance Company of America is required for all coverage amounts.

Ÿ Coverage will be reduced as you age - by 35% at age 70 and 50% at age 75.

5 California Residents: Coverage is extended to include California Registered Domestic Partners.

CHILDREN

Ÿ Purchase coverage for your children in increments of $2,000 to $10,000, not to exceed 50% of your Optional Term Lifecoverage amount. There are no health requirements for this coverage.

Ÿ Coverage begins from live birth, and continues to age 25, if unmarried.

How much it will cost

"How much does life insurance cost?"

Use the grids below to find the cost of insurance for yourself, your spouse, and each of your children. Theserates are effective 01/01/2011.

8

Optional Term Life - Employee Monthly Cost per Coverage Amount

Age $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000

0-24 $0.71 $1.42 $2.13 $2.84 $3.55 $4.26 $4.97 $5.68 $6.39 $7.10 $7.81 $8.52 $9.23

25-29 $0.85 $1.70 $2.55 $3.40 $4.25 $5.10 $5.95 $6.80 $7.65 $8.50 $9.35 $10.20 $11.05

30-34 $0.95 $1.90 $2.85 $3.80 $4.75 $5.70 $6.65 $7.60 $8.55 $9.50 $10.45 $11.40 $12.35

35-39 $1.27 $2.54 $3.81 $5.08 $6.35 $7.62 $8.89 $10.16 $11.43 $12.70 $13.97 $15.24 $16.51

40-44 $1.41 $2.82 $4.23 $5.64 $7.05 $8.46 $9.87 $11.28 $12.69 $14.10 $15.51 $16.92 $18.33

45-49 $2.12 $4.24 $6.36 $8.48 $10.60 $12.72 $14.84 $16.96 $19.08 $21.20 $23.32 $25.44 $27.56

50-54 $3.26 $6.52 $9.78 $13.04 $16.30 $19.56 $22.82 $26.08 $29.34 $32.60 $35.86 $39.12 $42.38

55-59 $6.08 $12.16 $18.24 $24.32 $30.40 $36.48 $42.56 $48.64 $54.72 $60.80 $66.88 $72.96 $79.04

60-64 $9.33 $18.66 $27.99 $37.32 $46.65 $55.98 $65.31 $74.64 $83.97 $93.30 $102.63 $111.96 $121.29

65-69 $15.30 $30.60 $45.90 $61.20 $76.50 $91.80 $107.10 $122.40 $137.70 $153.00 $168.30 $183.60 $198.90

70-74 $26.82 $53.64 $80.46 $107.28 $134.10 $160.92 $187.74 $214.56 $241.38 $268.20 $295.02 $321.84 $348.66

75-100 $26.82 $53.64 $80.46 $107.28 $134.10 $160.92 $187.74 $214.56 $241.38 $268.20 $295.02 $321.84 $348.66

Age $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000

0-24 $9.94 $10.65 $11.36 $12.07 $12.78 $13.49 $14.20 $17.75 $21.30 $24.85 $28.40 $31.95 $35.50

25-29 $11.90 $12.75 $13.60 $14.45 $15.30 $16.15 $17.00 $21.25 $25.50 $29.75 $34.00 $38.25 $42.50

30-34 $13.30 $14.25 $15.20 $16.15 $17.10 $18.05 $19.00 $23.75 $28.50 $33.25 $38.00 $42.75 $47.50

35-39 $17.78 $19.05 $20.32 $21.59 $22.86 $24.13 $25.40 $31.75 $38.10 $44.45 $50.80 $57.15 $63.50

40-44 $19.74 $21.15 $22.56 $23.97 $25.38 $26.79 $28.20 $35.25 $42.30 $49.35 $56.40 $63.45 $70.50

45-49 $29.68 $31.80 $33.92 $36.04 $38.16 $40.28 $42.40 $53.00 $63.60 $74.20 $84.80 $95.40 $106.00

50-54 $45.64 $48.90 $52.16 $55.42 $58.68 $61.94 $65.20 $81.50 $97.80 $114.10 $130.40 $146.70 $163.00

55-59 $85.12 $91.20 $97.28 $103.36 $109.44 $115.52 $121.60 $152.00 $182.40 $212.80 $243.20 $273.60 $304.00

60-64 $130.62 $139.95 $149.28 $158.61 $167.94 $177.27 $186.60 $233.25 $279.90 $326.55 $373.20 $419.85 $466.50

65-69 $214.20 $229.50 $244.80 $260.10 $275.40 $290.70 $306.00 $382.50 $459.00 $535.50 $612.00 $688.50 $765.00

70-74 $375.48 $402.30 $429.12 $455.94 $482.76 $509.58 $536.40 $670.50 $804.60 $938.70 $1,072.80 $1,206.90 $1,341.00

75-100 $375.48 $402.30 $429.12 $455.94 $482.76 $509.58 $536.40 $670.50 $804.60 $938.70 $1,072.80 $1,206.90 $1,341.00

Rates may change as the insured enters a higher age category. Also, rates may change if planexperience requires a change for all insureds.

"How much it will cost" (continued from previous page)

9

Optional Dependent Life - Spouse Monthly Cost per Coverage Amount

Spouse rate is based on spouse's age

Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000

0-24 $0.36 $0.71 $1.07 $1.42 $1.78 $2.13 $2.49 $2.84 $3.20 $3.55 $3.91 $4.26 $4.62

25-29 $0.43 $0.85 $1.28 $1.70 $2.13 $2.55 $2.98 $3.40 $3.83 $4.25 $4.68 $5.10 $5.53

30-34 $0.48 $0.95 $1.43 $1.90 $2.38 $2.85 $3.33 $3.80 $4.28 $4.75 $5.23 $5.70 $6.18

35-39 $0.64 $1.27 $1.91 $2.54 $3.18 $3.81 $4.45 $5.08 $5.72 $6.35 $6.99 $7.62 $8.26

40-44 $0.71 $1.41 $2.12 $2.82 $3.53 $4.23 $4.94 $5.64 $6.35 $7.05 $7.76 $8.46 $9.17

45-49 $1.06 $2.12 $3.18 $4.24 $5.30 $6.36 $7.42 $8.48 $9.54 $10.60 $11.66 $12.72 $13.78

50-54 $1.63 $3.26 $4.89 $6.52 $8.15 $9.78 $11.41 $13.04 $14.67 $16.30 $17.93 $19.56 $21.19

55-59 $3.04 $6.08 $9.12 $12.16 $15.20 $18.24 $21.28 $24.32 $27.36 $30.40 $33.44 $36.48 $39.52

60-64 $4.67 $9.33 $14.00 $18.66 $23.33 $27.99 $32.66 $37.32 $41.99 $46.65 $51.32 $55.98 $60.65

65-69 $7.65 $15.30 $22.95 $30.60 $38.25 $45.90 $53.55 $61.20 $68.85 $76.50 $84.15 $91.80 $99.45

70-74 $13.41 $26.82 $40.23 $53.64 $67.05 $80.46 $93.87 $107.28 $120.69 $134.10 $147.51 $160.92 $174.33

75-100 $13.41 $26.82 $40.23 $53.64 $67.05 $80.46 $93.87 $107.28 $120.69 $134.10 $147.51 $160.92 $174.33

Age $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000

0-24 $4.97 $5.33 $5.68 $6.04 $6.39 $6.75 $7.10 $8.88 $10.65 $12.43 $14.20 $15.98 $17.75

25-29 $5.95 $6.38 $6.80 $7.23 $7.65 $8.08 $8.50 $10.63 $12.75 $14.88 $17.00 $19.13 $21.25

30-34 $6.65 $7.13 $7.60 $8.08 $8.55 $9.03 $9.50 $11.88 $14.25 $16.63 $19.00 $21.38 $23.75

35-39 $8.89 $9.53 $10.16 $10.80 $11.43 $12.07 $12.70 $15.88 $19.05 $22.23 $25.40 $28.58 $31.75

40-44 $9.87 $10.58 $11.28 $11.99 $12.69 $13.40 $14.10 $17.63 $21.15 $24.68 $28.20 $31.73 $35.25

45-49 $14.84 $15.90 $16.96 $18.02 $19.08 $20.14 $21.20 $26.50 $31.80 $37.10 $42.40 $47.70 $53.00

50-54 $22.82 $24.45 $26.08 $27.71 $29.34 $30.97 $32.60 $40.75 $48.90 $57.05 $65.20 $73.35 $81.50

55-59 $42.56 $45.60 $48.64 $51.68 $54.72 $57.76 $60.80 $76.00 $91.20 $106.40 $121.60 $136.80 $152.00

60-64 $65.31 $69.98 $74.64 $79.31 $83.97 $88.64 $93.30 $116.63 $139.95 $163.28 $186.60 $209.93 $233.25

65-69 $107.10 $114.75 $122.40 $130.05 $137.70 $145.35 $153.00 $191.25 $229.50 $267.75 $306.00 $344.25 $382.50

70-74 $187.74 $201.15 $214.56 $227.97 $241.38 $254.79 $268.20 $335.25 $402.30 $469.35 $536.40 $603.45 $670.50

75-100 $187.74 $201.15 $214.56 $227.97 $241.38 $254.79 $268.20 $335.25 $402.30 $469.35 $536.40 $603.45 $670.50

Rates may change as the insured enters a higher age category. Also, rates may change if planexperience requires a change for all insureds.

Optional Dependent Life - Children Monthly Cost per Coverage AmountOne premium rate covers all eligible children

$2,000 $4,000 $6,000 $8,000 $10,000

$0.18 $0.36 $0.54 $0.72 $0.90

Rates may change if plan experience requires a change for all insureds.

IMPORTANT NOTICE

A record of your beneficiary is required forBasic Term Life Insurance, Basic AD&D Insurance, and Optional Term Life Insurance

10

11

"Who can answer my questions?"

Here are the answers to some common questions regarding these insurancecoverages. For additional information, contact your Human ResourcesDepartment or Benefits Administrator.

"Does this plan pay Optional Term Life benefits in addition to my basicplan?"

Yes, this plan pays in addition to any Basic Term Life Insurance coverage offeredby your employer.

"When can I enroll for life insurance coverage?"

The easiest way to enroll and guarantee a certain level of coverage is to sign upwhen first eligible. If you enroll at any other time or for more than theguaranteed coverage amount, you will need to provide evidence of goodhealth satisfactory to Prudential.

"Can I drop this life insurance coverage at any time?"

Yes, subject to your employer's administrative policies.

"What is the difference between a primary and contingent beneficiary?"

Your primary beneficiary is the person you designate to receive your lifeinsurance benefit when you die. You can name more than one primarybeneficiary and assign a different percentage of your benefit to each, if youlike. If you name a contingent beneficiary, that person will receive the lifeinsurance benefit when you die only if all primary beneficiaries are not living atthe time of your death. You can name more than one contingent beneficiaryand assign different percentages to them, too.

"What if I want to change my beneficiary?"

Beneficiary Change Forms and related information may be obtained bycontacting your Human Resources Department or Benefits Administrator.

"When is a medical exam required and who pays for it?"

A medical exam may be required if you elect more coverage than theguaranteed amount. We will pay the cost of any required medical exam whenyou are first eligible. Late entrants must pay for medical exams. Generally,medical exams are conducted by an examiner who is chosen by Prudential.

IFS-A090156

12

Ed. 09.2010 ECEd.09.2010-10581 Exp. 03.2012

"When will coverage go into effect?"

For your coverage to become effective, you must be actively at work during theenrollment period and on the effective date of your coverage. If you apply foran amount that requires evidence of good health, you must be actively at workon the date of approval for the amount requiring evidence of good health. Ifyour dependents are confined for medical treatment at home or elsewhere,their coverage will begin when confinement ends. Refer to theBooklet-Certificate for details.

"Can I increase my coverage in the future?"

Yes, you can increase your coverage up to your plan's maximum coverageamount. However, evidence of good health satisfactory to Prudential will berequired as previously noted.

How to enroll

"How can I enroll?"

To enroll, simply complete the Enrollment Form with Beneficiary Designations.Then, return it as instructed. After the date your group insurance becomeseffective, you will receive a Booklet-Certificate that details your plan provisions.

Implementation of the insurance plan(s) will depend upon having a specific percentage of alleligible employees enrolling in the plan(s). In the event the minimum participation level is notmet, Prudential retains the right to re-evaluate the rates, require a re-enrollment, reduce the rateguarantee period, or terminate coverage.

Receipt of accelerated death benefits may affect eligibility for public assistance programs andmay be taxable. There is no administrative fee to accelerate death benefits. The acceleratedamount is not discounted.

All benefit features may not be available in all states.

Group Term Life coverage is issued by The Prudential Insurance Company ofAmerica, a New Jersey Company, 751 Broad Street, Newark, NJ 07102. LifeClaims: 1-800-524-0542. Prudential, the Prudential logo, and the Rock symbolare service marks of The Prudential Insurance Company of America, Newark,NJ, and its related entities, registered in many jurisdictions worldwide. Thisbrochure is intended to be a summary of your benefits and does not include allplan provisions, exclusions and limitations. Please refer to theBooklet-Certificate, which is made a part of the Group Contract, for all plandetails, including any exclusions, limitations and restrictions which may apply. Ifthere is a discrepancy between this document and theBooklet-Certificate/Group Contract issued by The Prudential InsuranceCompany of America, the Group Contract will govern. Contract provisionsmay vary by state. Contract Series: 83500. California COA # 1179 NAIC #68241

The Prudential Insurance Company of America - Enrollment Form751 Broad Street • Newark, NJ 07102

CITY OF ESCONDIDO

Enrollment Form continued on next page.

GL.2007.194 Ed. 09.2010 ECEd.09.2010-10581 Exp. 03.2012

(For office use only)

Effective Date of Coverage:Control No.:44959

Return Completed Application to:

Human Resources

1. Employee Information

Last Name First Name MI

Street Address City State Zip Code

Social Security Number Marital Status Your Date of Birth (mm/dd/yyyy)o Single o Marriedo Divorced o Widowed / /

Date Employed (mm/dd/yyyy) Your Annual Earnings Spouse Date of Birth (mm/dd/yyyy)$ / // /

2. Coverage ElectionsPlease make your supplemental enrollment selections below.

Check Each Applicable Box Coverage Amount Chosen Payroll Deduction

Yes No

o o Optional Term Life Insurance $ $

o o Optional Dependent Life Insurance - Spouse $ $

o o Optional Dependent Life Insurance - Children $ $

Total Cost $

For coverage to become effective, you must be actively at work on the effective date of the plan. If you apply for an amount that requiresevidence of good health, you must be actively at work on the date of approval for the amount requiring evidence of good health. In the future, ifyou wish to enroll for employee-paid insurance, increase coverage amounts, or add dependent coverage, you may be required to furnishevidence of insurability for yourself and/or your spouse. If your dependents are confined for medical treatment at home or elsewhere, coveragewill begin when confinement ends.

GL.2007.194 Ed. 09.2010 ECEd.09.2010-10581 Exp. 03.2012

3. Authorization

Yeso

Noo

I am enrolling for insurance issued by The Prudential Insurance Company of America as indicated on the previous page andauthorize my employer to deduct the required contribution from my paycheck. I certify that the information contained in thisenrollment form is true and complete, and understand that my contribution is based on that information. I also understand that thereare criminal and civil penalties for giving false information, including but not limited to fines and confinement in prison. Detailed andstate-specific warnings appear below.

IMPORTANT NOTICE:For residents of all states except District of Columbia, Florida, Kentucky, New Jersey, New York, Pennsylvania, Utah, Virginia, Vermontand Washington -WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that heis facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insuranceapplication or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may beprosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. Inaddition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicantconceals, for the purpose of misleading, information concerning any fact material thereto.

Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. There is noadministrative fee to accelerate death benefits. The accelerated amount is not discounted.

Employee Signature (Sign in ink.) Date

Group Term Life coverage is issued by The Prudential Insurance Company of America, a New Jersey Company, 751 Broad Street, Newark, NJ07102. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions,limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issuedby The Prudential Insurance Company of America, the Group Contract will govern. Contract provisions may vary by state. Contract Series:83500. California COA # 1179 NAIC # 68241

Prudential and the Rock logo are registered sevice marks of The Prudential Insurance Company of America and its affiliates.

Please indicate your beneficiary designation(s) on the next page.

4. Employee Beneficiary Designations

Last Name First Name MI Social Security Number

I designate the following beneficiary(ies) to receive my insurance proceeds. I understand that the primary beneficiary(ies) will receive paymentupon my death. If all primary beneficiaries predecease me, the insurance will be paid to the contingent beneficiary(ies). If no beneficiary isnamed, or no beneficiary survives me, payment will be made according to the terms of the Group Contract. I can change my beneficiary in thefuture by completing a new Beneficiary Designation Section. Insurance proceeds from Dependent Term Life Insurance coverage will be paid tome.

Primary Beneficiary

Last Name First Name MI Social Security NumberRelationship

to You

Share to

Beneficiary*(Use %, $ amount,

or fractions)

No. Street City State ZIP Code1

Primary Beneficiary


to You

Share to


or fractions)


Contingent Beneficiary


to You

Share to


or fractions)




to You

Share to


or fractions)




to You

Share to


or fractions)




to You

Share to


or fractions)


*If more than one primary or contingent beneficiary is designated, the total shares must equal 100% of your death benefit.

Employee Signature (Sign in ink.) Date

Group Term Life coverage is issued by The Prudential Insurance Company of America, a New Jersey Company, 751 Broad Street, Newark, NJ07102. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions,limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issuedby The Prudential Insurance Company of America, the Group Contract will govern. Contract provisions may vary by state. Contract Series:83500. California COA # 1179 NAIC # 68241

GL.2007.195 Ed. 09.2010 ECEd.09.2010-10581 Exp. 03.2012

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IFS-A090156 Ed. 09.2010 ECEd.09.2010-10581 Exp. 03.2012

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