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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)
- Accident Insurance Claim Form PDF opens in new window
- Accident Insurance Beneficiary Statement PDF opens in new window
- Accident Insurance Electronic Funds Transfer Authorization PDF opens in new window
- Accident Insurance Preferential Beneficiary Statement PDF opens in new window
- Critical Illness Insurance Claim Form PDF opens in new window
- Critical Illness Insurance Electronic Funds Transfer Authorization PDF opens in new window
- Wellness Benefit Claim Form PDF opens in new window
Voluntary Benefits (FOR GROUPS ISSUED AFTER 7/1/2019 ONLY)
- Accident Claim Form Treatment Based PDF opens in new window
- Accident Insurance Beneficiary Statement PDF opens in new window
- Critical Illness PDF opens in new window
- Hospital Indemnity Claim Form PDF opens in new window
- Wellness Benefit Claim Form PDF opens in new window
- Accident Continuation Form PDF opens in new window
- Critical Illness Continuation Form PDF opens in new window
- Hospital Indemnity Continuation Form PDF opens in new window
- Accident Reinstatement Form PDF opens in new window
- Critical Illness Reinstatement Form PDF opens in new window
General-Beneficiary
- Beneficiary Statement - For All Other Employer Contracts PDF opens in new window
- Beneficiary Statement - NH Only PDF opens in new window
- Beneficiary Statement - RI Only PDF opens in new window
- Beneficiary Statement - NJ only PDF opens in new window
- Beneficiary Statement - KY Only PDF opens in new window
- Beneficiary Designation-for all products PDF opens in new window
- Beneficiary Designation (French)-for all products PDF opens in new window
- Beneficiary Designation (Spanish)-for all products PDF opens in new window
- Preferential Beneficiary Statement PDF opens in new window
NY disability contract cases only
Survivor Benefit Election Form PDF opens in new window
NY Paid Family Leave (PFL)
- Release of Personal Health Information Under the NY Paid Family Leave (PFL) Law (Based on Form PFL-3) PDF opens in new window
- Request for NY Paid Family Leave (PFL) Bonding Certification (Based on Form PFL-2) PDF opens in new window
- Request for NY Paid Family Leave (PFL) Health Care Provider Certification For Care Of Family Member With Serious Health Condition (Based on Form PFL-4) PDF opens in new window
- Request for NY Paid Family Leave (PFL) Military Qualifying Event (Based on Form PFL-5) PDF opens in new window
- Request for NY Paid Family Leave (PFL) (Based on Form PFL-1) – Employer Version PDF opens in new window
- Request for NY Paid Family Leave (PFL) (Based on Form PFL-1) – Employee Version PDF opens in new window
- NY Paid Family Leave (PFL) Voluntary Tax Withholding Request PDF opens in new window
- NY Paid Family Leave (PFL) Statement of Rights PDF opens in new window
General-Dependents Coverage
- Statement of Dependent Eligibility-Limiting Age 19 PDF opens in new window
- Statement of Dependent Eligibility-Limiting Age 23 PDF opens in new window
- Statement of Dependent Eligibility-Limiting Age 25 PDF opens in new window
- Statement of Dependent Eligibility-Limiting Age 26 PDF opens in new window
General-Conversion
- 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)
- Short Term Disability and Long Term Disability Claimant Statement PDF opens in new window
- Short Term Disability and Long Term Disability Claimant Statement (Spanish)PDF opens in new window
- Social Security Authorization PDF opens in new window
- Attending Physician's Statement PDF opens in new window
- Attending Physician's Statement (Spanish) PDF opens in new window
- Medical Authorization PDF opens in new window
- Medical Authorization (Spanish)PDF opens in new window
- Address Verification PDF opens in new window
- Tax Notice PDF opens in new window
- EFT Authorization PDF opens in new window
- EFT Authorization (Spanish) PDF opens in new window
- Psychotherapy Medical Authorization PDF opens in new window
- Certification of Health Care Provider for Family Member’s Serious Health Condition PDF opens in new window
- Certification of Health Care Provider for Employee Serious Health Condition PDF opens in new window
- Certification of Health Care Provider for Employee’s Serious Health Condition for Disability and Family Leave Act PDF opens in new window
- Family & Medical Certification Request for Military Exigency Leave PDF opens in new window
- Family & Medical Certification Request for Care of Covered Service Member PDF opens in new window
- FMLA Employee Rights and Responsibilities Under the Family and Medical Leave Act PDF opens in new window
- Authorization for Release of Health-Related Information for Own Serious Health Condition PDF opens in new window
- Authorization for Release of Health-Related Information for Care of Family Member PDF opens in new window
General-Life Claims
- Absolute Gift Assignment to Individual PDF opens in new window
- Absolute Gift Assignment to Trustee PDF opens in new window
- Absolute Assignment For Value PDF opens in new window
- Accelerated Benefit Option Claim Form 6 month life exp PDF opens in new window
- Accelerated Benefit Option Claim Form 12 month life exp PDF opens in new window
- Accelerated Benefit Option Claim Form 24 month life exp PDF opens in new window
- Accelerated Benefit Option Claim Form (NY)-Employee or Dependent (6) PDF opens in new window
- Accelerated Benefit Option Claim Form (NY)-Employee or Dependent (12) PDF opens in new window
- Group Life Accidental Injury Claim Form - Attending Physician Statement PDF opens in new window
- HIPAA Privacy Authorization Form PDF opens in new window
- Group Life Claim Form for Survivor Benefits - Survivor Statement PDF opens in new window
Group Universal Life (GUL)
- Paid-up Insurance Surrender Request PDF opens in new window
- Loan Request PDF opens in new window
- Withdrawal Request PDF opens in new window
- Request to End Coverage PDF opens in new window
- Lump Sum Payment/Contribution PDF opens in new window
- Loan Payment/Contribution PDF opens in new window
Group Variable Universal Life (GVUL)
- Paid-up Life Insurance Surrender Request PDF opens in new window
- Withdrawal Request PDF opens in new window
- Loan Request PDF opens in new window
- Lump Sum Payment or Loan Repayment PDF opens in new window
- Change Allocation Request PDF opens in new window
- Dollar Cost Averaging Election PDF opens in new window
- Dollar Cost Averaging Cancellation PDF opens in new window
- Transfer Request PDF opens in new window
- Request to End Coverage PDF opens in new window
- GUL/GVUL Change of Name and Address Request PDF opens in new window
- GUL/GVUL Gift Assignment to Individual PDF opens in new window
- GUL/GVUL Gift Assignment to Trustee PDF opens in new window
Waiver of Premium
- Waiver of Premium - Attending Physician's Statement GI/ILI Combo Form PDF opens in new window
- Waiver of Premium Authorization Form GI/ILI Combo Form PDF opens in new window
- Waiver of Premium Claimant Form GI/ILI Combo Form PDF opens in new window
Disclaimer
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
104229-1007-web