EX-4.A 4 y64338exv4wa.txt FORM OF APPLICATION Exhibit 4(a) PRUCO LIFE INSURANCE COMPANY OF NEW JERSEY, STRATEGIC PARTNERS(SM) a Prudential Financial company HORIZON APPLICATION Modified Guaranteed Annuity -------------------------------------------------------------------------------- On these pages, I, you, and your refer to the contract owner. We, us, and our refer to Pruco Life Insurance Company of New Jersey. -------------------------------------------------------------------------------- 1 CONTRACT Contract number (if any) OWNER / / Individual / / Corporation / / UGMA/UTMA / / Other INFORMATION TRUST: / / Grantor / / Revocable / / Irrevocable TRUST DATE (mo., day, yr.) If a corporation or trust is indicated above, please check the following as it applies. If neither box is checked, we will provide annual tax reporting for the increasing value of the contract. / / Tax-exempt entity under Internal Revenue Code 501 / / Trust acting as agent for an individual under Internal Revenue Code 72(u) Name of owner (first, middle initial, last name) --------------------------------------------------------------- Street Apt. --------------------------------------------------------------- City State ZIP code --------------------------------------------------------------- Social Security number/EIN Date of birth (mo., day, year) --------------------------------------------------------------- Telephone number --------------------------------------------------------------- A. / / Female B. / / U.S. citizen / / I am not a U.S. person (including / / Male / / Resident alien resident alien). I am a citizen of ------------------------------------- Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY).
-------------------------------------------------------------------------------- 2 ANNUITANT This section must be completed only if the annuitant is not the INFORMATION owner or if the owner is a trust or a corporation. Do not Name of annuitant (first, middle initial, last name) complete if you are --------------------------------------------------------------- opening an IRA. Street (Leave address blank if same as owner.) Apt. --------------------------------------------------------------- City State ZIP code --------------------------------------------------------------- Social Security number Date of birth (mo., day, year) --------------------------------------------------------------- Telephone number --------------------------------------------------------------- A. / / Female B. / / U.S. citizen / / I am not a U.S. person (including / / Male / / Resident alien resident alien). I am a citizen of -------------------------------------
-------------------------------------------------------------------------------- Pruco Corporate Office: Pruco Life Insurance Company of New Jersey, Newark, NJ 07102 Ed. 1/2003 ORD 99720 New York Page 1 of 4 -------------------------------------------------------------------------------- 3 CO-ANNUITANT Name of co-annuitant (first, middle initial, last name) INFORMATION (if any) --------------------------------------------------------------- Do not complete Social Security number Date of birth (mo., day, year) if you are opening an IRA --------------------------------------------------------------- or if the Telephone number contract will be owned --------------------------------------------------------------- by a corporation or trust. A. / / Female B. / / U.S. citizen / / I am not a U.S. person (including / / Male / / Resident alien resident alien). I am a citizen of -------------------------------------
-------------------------------------------------------------------------------- 4 BENEFICIARY /X/ PRIMARY CLASS INFORMATION Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee's name. --------------------------------------------------------------- TRUST: / / Revocable / / Irrevocable Trust date (mo., day, year) ---------------------------------- Beneficiary's relationship to owner ---------------------------- Social Security number ----------------------------------------- CHECK ONLY ONE: / / Primary class / / Secondary class Name of beneficiary (first, middle initial, last name) If trust, include name of trust and trustee's name. --------------------------------------------------------------- TRUST: / / Revocable / / Irrevocable Trust date (mo., day, year) ---------------------------------- Beneficiary's relationship to owner ---------------------------- Social Security number ----------------------------------------- PLEASE ADD ADDITIONAL BENEFICIARIES IN SECTION 10. -------------------------------------------------------------------------------- 5 TYPE OF PLAN TYPE. PLAN AND SOURCE OF Check only one: / / Non-qualified / / Traditional IRA FUNDS --------------------------------------------------------------- (minimum of SOURCE OF FUNDS. Check all that apply: $5,000) / / Total amount of the check(s) included with this application. (Make checks payable to Prudential.) $ , , . / / IRA Rollover $ , , .
If Traditional IRA new contribution(s) for the current and/or previous year, complete the following: $ , . Year $ , . Year / / 1035 Exchange (non-qualified only), estimated amount: $ , , . / / IRA Transfer (qualified), estimated amount: $ , , . / / Direct Rollover (qualified), estimated amount: $ , , .
-------------------------------------------------------------------------------- 6 GUARANTEE Please choose only one: PERIOD / / 3 years / / 7 years / / 5 years / / 10 years -------------------------------------------------------------------------------- Ed. 1/2003 ORD 99720 New York Page 2 of 4 -------------------------------------------------------------------------------- 7 REPLACEMENT THIS DISCLOSURE STATEMENT SECTION MUST BE COMPLETED IF STATE QUESTIONS REPLACEMENT REGULATIONS REQUIRE. (Check one): AND DISCLOSURE / / I do have existing life insurance policies or annuity STATEMENT contracts. (You must complete the Important Notice Regarding Replacement form (COMB 89216 NY), whether or not this transaction is considered a replacement.) / / I do not have existing life insurance policies or annuity contracts. Will the proposed annuity contract replace any existing insurance policy(ies) or annuity contract(s)? / / Yes / / No If "Yes," provide the following information for each policy or contract and attach all applicable Prudential disclosure and state replacement forms. Company name --------------------------------------------------------------- Policy or contract number Year of issue (mo., day, year) --------------------------------------------------------------- Name of plan (if applicable) --------------------------------------------------------------- --------------------------------------------------------------- REPRESEN- THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE. TATIVE'S QUESTION Do you have, from any source, facts that any person named as the owner above is replacing or changing any current insurance or annuity in any company? / / Yes / / No -------------------------------------------------------------------------------- 8 SIGNATURE(S) If applying for an IRA, I acknowledge receiving an IRA disclosure statement and understand that I will be given a financial disclosure statement with the contract. I understand that tax deferral is provided by the IRA, and acknowledge that I am purchasing this contract for its features other than tax deferral, including the lifetime income payout option, the Death Benefit protection, and other features as described in the prospectus. No representative has the authority to make or change a contract or waive any of the contract rights. I understand that if I have purchased another non-qualified annuity from Prudential or an affiliated company this calendar year that they will be considered as one contract for tax purposes. I believe that this contract meets my needs and financial objectives. / / If this application is being signed at the time the contract is delivered, I acknowledge receipt of the contract. / / Check here to request a Statement of Additional Information. MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE REQUIRED MINIMUM DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE PAID TO PRUDENTIAL: I understand it is my responsibility to remove the minimum distribution from the purchase payment PRIOR TO sending money to Prudential with this application. Unless we are notified otherwise, Prudential will assume that the owner has satisfied their required minimum distributions from other IRA funds. By signing this form, the trustee(s)/officer(s) hereby represents that the trustee(s)/officer(s) possess(es) the authority, on behalf of the non-natural person, to purchase the annuity contract and to exercise all rights of ownership and control over the contract. I UNDERSTAND THAT THE PURCHASE PAYMENT WILL BE SUBJECT TO A MARKET VALUE ADJUSTMENT IF THERE IS A WITHDRAWAL, ANNUITIZATION, OR SETTLEMENT ON ANY DATE OTHER THAN WITHIN THE 30 DAY PERIOD IMMEDIATELY PRECEDING THE END OF THE GUARANTEE PERIOD. A MARKET VALUE ADJUSTMENT CAN BE A POSITIVE OR NEGATIVE ADJUSTMENT. THERE IS NO MARKET VALUE ADJUSTMENT AT DEATH. (continued) -------------------------------------------------------------------------------- Ed. 1/2003 ORD 99720 New York Page 3 of 4 -------------------------------------------------------------------------------- 8 SIGNATURE(S) I hereby represent that my answers to the questions on this (continued) application are correct and true to the best of my knowledge and belief. I acknowledge receipt of current product and fund prospectuses. -------------------------------------------------- SIGNED AT (CITY, STATE) X -------------------------------------------------- Contract owner's signature and date month day year X -------------------------------------------------- Annuitant's signature (if applicable) and date month day year X -------------------------------------------------- Co-annuitant's signature (if applicable) and date month day year
OWNER'S TAX CERTIFICATION Under penalty of perjury, I certify that the taxpayer identification number (TIN) I have listed on this form is my correct TIN. I further certify that the citizenship/residency status I have listed on this form is my correct citizenship/residency status. I HAVE / / HAVE NOT / / (check one) been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting of interest or dividends. X -------------------------------------------------- Contract owner's signature and date month day year
-------------------------------------------------------------------------------- 9 REPRESEN- This application is submitted in the belief that the purchase TATIVE'S of this contract is appropriate for the applicant based on the SIGNATURE(S) information provided and as reviewed with the applicant. Reasonable inquiry has been made of the owner concerning the owner's overall financial situation, needs, and investment objectives. The representative hereby certifies that all information contained in this application (including the representative's replacement question in section 7) is true to the best of his or her knowledge. --------------------------------------------------- Representative's name (Please print) Agency Code Rep's contract/FA number X --------------------------------------------------- Representative's signature and date month day year --------------------------------------------------- Second representative's name (Please print) Rep's contract/FA number X --------------------------------------------------- Second representative's signature and date month day year -------------------------------------------------- Branch/field office name and code Representative's telephone number
-------------------------------------------------------------------------------- 10 ADDITIONAL ANY REMARKS ENTERED INTO THIS SECTION MUST BE INITIALED AND REMARKS DATED BY ALL PERSONS WHO HAVE SIGNED THIS APPLICATION IN SECTIONS 8 AND 9. --------------------------------------------------------------- --------------------------------------------------------------- --------------------------------------------------------------- --------------------------------------------------------------- --------------------------------------------------------------- --------------------------------------------------------------- -------------------------------------------------------------------------------- STANDARD PRUDENTIAL ANNUITY SERVICE CENTER OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER MAIL TO: PO BOX 7590 MAIL TO: 2101 WELSH ROAD PHILADELPHIA, PA 19101 DRESHER, PA 19025
If you have any questions, please call the Prudential Annuity Service Center at (888) 778-2888, Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern time. -------------------------------------------------------------------------------- Ed. 1/2003 ORD 99720 New York Page 4 of 4