Authorizations & Disclosures

 

Authorization to Release Information

You authorize Prudential or its authorized representatives to disclose policy and benefits information, including but not limited to the claim status and the amount of insurance benefit proceeds, in its explanation of benefits to beneficiaries, funeral home representatives, and assignees of the insurance benefits or in response to inquiries from these individuals. For the purpose of processing and payment of claims in an efficient and prompt manner, You authorize Prudential to consolidate and disclose completed claim forms and documents to appropriate associates for each and every one of Prudential Financial, Inc.’s affiliates or business units for which a claim for payment or distribution is made.

 

No Guarantee of Coverage

You acknowledge that submission of a digital claim does not guarantee coverage or payment of any kind.

 

Tax Withholding Election Information

Federal and some state tax laws require us to withhold income taxes from certain cash payments unless you elect out of withholding or certain other circumstances apply. We are required to withhold federal income taxes and certain state income taxes from the taxable portion of any payment from a non-qualified annuity, an IRA, a section 403(b) tax-deferred annuity, and some section 401(a) plans. If your payment is from an IRA, federal taxes will be withheld at a 10 percent rate unless you elect not to have income tax withheld from your payment. If your payment is from a non-governmental section 457 plan, withholding on your payment will be like wage withholding. If your payment is from a section 403(b) tax-deferred annuity, a section 401(a) qualified plan, or a governmental section 457 plan and is an “eligible rollover distribution,” you will not be able to elect out of federal income tax withholding. Federal taxes will be withheld at a flat 20 percent rate, unless you elect to have your eligible rollover distribution directly rolled over to an IRA or to another qualified plan. Federal and state income taxes may be withheld if you do not provide a U.S. residential address. You will not be able to elect out of withholding if we are notified that your taxpayer identification number (TIN) is incorrect. We have presented this information based on our understanding of tax law. You may wish to consult with a tax or legal adviser because neither we nor our representatives can provide tax or legal advice.

 

Estimated tax and possible penalties:

If you elect to have no income tax withheld from your payment, or if you do not have enough income tax withheld, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. You may be subject to Internal Revenue Service penalties, including fines and imprisonment, if you fail to provide your correct TIN, fail to report taxable interest or dividends on your tax return, or give false tax information.

 

Tax Certification

 

Taxpayer Identification Number (TIN)

You must include a TIN for the beneficiary, this is:

• A Social Security number (SSN) if the beneficiary is an individual or the owner of a sole proprietorship;
• The employer identification number (EIN) if you represent a trust, estate, corporation, partnership, or tax-exempt organization;
• The TIN of the grantor/trustee if you represent a grantor trust, or that of the actual owner of a trust-like entity not recognized as a legal or valid trust under state law.
• If you are a guardian completing this form for someone else, including a minor, be sure to provide that person’s SSN.

 

Backup Withholding

You must tell us if the IRS has notified you that you are subject to backup withholding because you didn’t report all your taxable interest and dividends on your tax return. You are not subject to backup withholding if either (a) you did not receive such a notice from the IRS, (b) the IRS told you that you are no longer subject to a backup withholding order, or (c) you are exempt from such withholding. If you have been notified that you are subject to backup withholding, please indicate accordingly.

 

Foreign Account Tax Compliance Act (FATCA)

Any entity making a payment of U.S. source income must consider whether it is subject to FATCA. A payer must collect documentation about the payee’s status or withhold at 30%. Nontaxable payments, such as income tax free death benefits from nonqualified life insurance contracts are not subject to FATCA.

 

Citizenship

You must indicate if you are not a U.S. person (including resident alien). In that case, you must state the country in which you are a citizen and submit the applicable IRS Form W-8(BEN, BEN-E, ECI, EXP, IMY). In most situations, the IRS Form W-8BEN will be the appropriate IRS Form W-8.

 

Claim Fraud Warnings

 

Alabama Residents

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

 

Arizona Residents

For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

 

Arkansas, District of Columbia, Louisiana, and Rhode Island Residents

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.

 

California and Texas Residents

For your protection, California and Texas law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

 

Florida Residents

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

 

Kentucky Residents

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

 

Maine and Washington Residents

Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits.

 

Maryland Residents

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

 

New Hampshire Residents

Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

 

New Jersey Residents

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

 

New York Residents

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

 

North Carolina Residents

Any person who, with the intent to injure, defraud, or deceive an insurer or insurance claimant, presents or causes to be presented a written or oral statement, as part of, or in support of, a claim for payment or other benefit pursuant to an insurance policy, knowing that the statement contains false information concerning a fact or matter material to the claim may be guilty of a Class H felony.

 

Pennsylvania and Utah Residents

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

Puerto Rico Residents

Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

 

Vermont Residents

Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law.

 

Virgina Residents

Any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

 

Residents of All Other States and Jurisdictions

Warning - Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application 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 be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto.