Solutions for Individuals Solutions for Businesses and Employees
Employee Forms
Forms may be downloaded by using Adobe Acrobat software. Forms should be completed and then mailed to Prudential Group Insurance at the address indicated on each form. Obtain the plug-in and instructions for installation free of charge. Get Adobe Acrobat Reader.

General–Beneficiary
Beneficiary Statement - Arkansas, Colorado and Nevada employer contracts only 
Beneficiary Statement - all other employer contracts 
Beneficiary Designation—for all products 
Preferential Beneficiary's Affidavit 

General–Dependents Coverage
Statement of Dependent Eligibilty

General–Conversion
Generic Conversion
Request for Electronic Funds Transfer

Disability Claims
Short Term Disability and Long Term Disability Claimant Statement
Social Security Authorization
Attending Physician's Statement
Medical Authorization
Address Verification
Tax Notice
EFT Authorization
Psychotherapy Medical Authorization

General–Life Claims
Attending Physician's Statement Waiver of Premium
Claimant's Statement /Attending Physician Statement
Gift Assignment to Individual
Gift Assignment to Trustee
Gift Assignment for Value
Accelerated Benefit Option Claim Form 6 month life exp
Accelerated Benefit Option Claim Form 12 month life exp
Accelerated Benefit Option Claim Form 24 month life exp
Accelerated Benefit Option Claim Form (NY) - Employee or Dependent (6)
Accelerated Benefit Option Claim Form (NY) - Employee or Dependent (12)
Group Life Claim Form for Total Disability Benefits - Employee Statement Waiver of Premium
HIPAA Privacy Authorization Form


Group Universal Life (GUL)
Paid-up Insurance Surrender Request
Loan Request
Withdrawal Request
Request to End Coverage
Lump Sum Contribution
Lump Sum Payment or Loan Repayment


Group Variable Universal Life (GVUL)
Paid-up Life Insurance or Surrender Request
Partial Withdrawal Request
Loan Request
Lump Sum Payment or Loan Repayment
Change Allocation Request
Dollar Cost Averaging Election
Dollar Cost Averaging Cancellation
Transfer Request
Request to End Coverage
GUL/GVUL Change of Name and Address Request
GUL/GVUL Gift Assignment to Individual
GUL/GVUL Gift Assignment to Trustee
 
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104229-1007-web
IFS-A112113 Ed. 01/2008

Group Variable Universal Life is offered through Prudential Investment Management Services, LLC, Three Gateway Center, 14th Floor, Newark, NJ 07102-4077.

Group coverages are issued by The Prudential Insurance Company of America, a New Jersey Company, 751 Broad Street, Newark, NJ 07102. The Booklet-Certificate contains all details, including any policy exclusions, limitations and restrictions which may apply.  Contract Series: 83500, 89759 or 96945.

California COA #1179 NAIC Code #68241

All rights reserved. The Prudential Insurance Company of America is a Prudential Financial company.

Prudential is authorized to transact business in all U.S. states and the District of Columbia. Product availability varies by state.

PRUDENTIAL FINANCIAL, PRUDENTIAL, PRU, the Rock Logo and Growing and Protecting Your Wealth are registered service marks of The Prudential Insurance Company of America and its affiliates.

© 2008 Prudential Financial, Inc., Newark, NJ, USA. All rights reserved.