Forms may be downloaded by using Adobe Acrobat software. Forms should be completed and then mailed to Prudential's Group Insurance at the address indicated on each form. Obtain the plug-in and instructions for installation free of charge. Get Adobe Acrobat Reader Opens in new window .
Voluntary Benefits (FOR GROUPS ISSUED 6/1/19 and PRIOR)
Voluntary Benefits (FOR GROUPS ISSUED AFTER 7/1/2019 ONLY)
NY disability contract cases only
Survivor Benefit Election Form PDF opens in new window
NY Paid Family Leave (PFL)
- Application For Conversion of Group Life Insurance for residents in AZ, CA, CT, DC, DE, FL, GU, ND, NY, SD, VI PDF opens in new window
- Application For Conversion of Group Life Insurance for residents in all other states PDF opens in new window
- Request for Electronic Funds Transfer PDF opens in new window
- Group Long Term Disability Insurance Conversion Plan Kit PDF opens in new window
Disability and Absence Claims (Includes Massachusetts Paid Family & Medical Leave)
Group Universal Life (GUL)
Group Variable Universal Life (GVUL)
Waiver of Premium
Group Variable Universal Life (GVUL) coverages are issued by The Prudential Insurance Company of America and GVUL is distributed through Prudential Investment Management Services LLC ("PIMS"). Both are Prudential Financial companies, Newark, NJ. Contract series number 89759.
For Compliance only California COA #1179 NAIC Code #68241