EX-4.D 4 y83827exv4wd.txt APPLICATION ORD 99730 NY-1 EXHIBIT (4)(d) PRUCO LIFE INSURANCE COMPANY OF NEW JERSEY, STRATEGIC PARTNERS(SM) a Prudential Financial company ANNUITY ONE APPLICATION Flexible Payment Variable Deferred 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 OWNER INFORMATION Contract number (if any) _____________________________ [ ] Individual [ ] Corporation [ ] UGMA/UTMA [ ] Other 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 [ ] Male B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien). [ ] Resident alien I am a citizen of __________________________________________________ Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY). -------------------------------------------------------------------------------- 2 JOINT OWNER INFORMATION (if any) Do not complete if you are opening an IRA. Unmarried persons who wish to own the contract jointly should consult with their tax adviser. Name of joint owner, if any (first, middle initial, last name) _____________________________________________________________________________ Street (Leave address blank if same as owner.) Apt. ________________________________________________________ _________________ City State ZIP code __________________________________________ ________ _________-__________ Social Security number/EIN Date of birth (mo., day, year) Telephone number __________________________ _________ _________ __________ ____ ____-______ A. [ ] Female [ ] Male B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien). [ ] Resident alien I am a citizen of __________________________________________________ -------------------------------------------------------------------------------- 3 ANNUITANT INFORMATION Do not complete if you are opening an IRA. This section must be completed only if the annuitant is not the owner or if the owner is a trust or a corporation. Name of annuitant (first, middle initial, last name) _____________________________________________________________________________ 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 [ ] Male B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien). [ ] Resident alien I am a citizen of __________________________________________________ -------------------------------------------------------------------------------- Pruco Corporate Office: Pruco Life Insurance Company Ed. 5/2003 of New Jersey, Newark, NJ 07102 -------------------- ORD 99730 New York-1 Page 1 of 6 -------------------- -------------------------------------------------------------------------------- 4 CO-ANNUITANT INFORMATION (if any) Do not complete if you are opening an IRA or if the contract will be owned by a corporation or trust. Name of co-annuitant (first, middle initial, last name) _____________________________________________________________________________ Social Security number Date of birth (mo., day, year) Telephone number __________________________ _________ _________ __________ ____ ____-______ A. [ ] Female [ ] Male B. [ ] U.S. citizen [ ] I am not a U.S. person (including resident alien). [ ] Resident alien I am a citizen of __________________________________________________ -------------------------------------------------------------------------------- 5 BENEFICIARY INFORMATION Please add additional beneficiaries in section 18. [X] PRIMARY 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_______________________________________________________ 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_______________________________________________________ -------------------------------------------------------------------------------- 6 ELECTION OF CREDIT Complete this section if you want to elect Credit. The election of Credit to each purchase payment results in a higher insurance and administrative cost and higher withdrawal charges than if the Credit was not elected. The Credit that is allocated to the contract vests upon expiration of the the Right to Cancel period. We reserve the right to recapture any Credit granted within one year of the date of the owner's death. [ ] Yes, I want Credit. -------------------------------------------------------------------------------- 7 INCOME BENEFITS Check all that apply. The cost of each benefit is in parentheses immediately following the option. ONCE ELECTED, THE GUARANTEED MINIMUM INCOME BENEFIT (GMIB) CANNOT BE REVOKED. [ ] Yes, I would like to elect a Guaranteed Minimum Income Benefit (GMIB). (0.45%) [ ] Yes, I would like to elect the Income Appreciator Benefit (IAB). (0.25%) -------------------------------------------------------------------------------- 8 DEATH BENEFIT THIS SECTION MUST BE COMPLETED. Check one of the Death Benefit options below. The cost of each benefit is in parentheses immediately following the option. [ ] Base Death Benefit. (1.40% without credit; 1.50% with credit) [ ] Guaranteed Minimum Death Benefit (GMDB) with an annual Step-Up option. (1.65% without credit; 1.75% with credit) -------------------------------------------------------------------------------- 9 TYPE OF PLAN AND SOURCE OF FUNDS (minimum of $10,000) PLAN TYPE. Check only one: [ ] Non-qualified [ ] Traditional IRA [ ] Custodial account ----------------------------------------------------------------------------- SOURCE OF FUNDS. Check all that apply: [ ] 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: $ _______,_________,___________.______ -------------------------------------------------------------------------------- -------------------- ORD 99730 New York-1 Page 2 of 6 Ed. 5/2003 -------------------- -------------------------------------------------------------------------------- 10 PURCHASE PAYMENT ALLOCATION(S) Please write in the percentage of your payment that you want to allocate to the following options. total must equal 100 percent. IF CHANGES ARE MADE TO THE ALLOCATIONS LISTED BELOW, THE APPLICANT MUST INITAL THE CHANGES.
---------------------------------------------------------------------- INTEREST RATE OPTIONS CODES % ---------------------------------------------------------------------- 1 Year Fixed-Rate Option 1YRFXD ---------------------------------------------------------------------- Dollar Cost Averaging (DCA) 6 Month* DCA6 ---------------------------------------------------------------------- Dollar Cost Averaging (DCA) 12 Month* DCA12 ---------------------------------------------------------------------- 2 Year Market Value Adjustment Option** 2YRMVA ---------------------------------------------------------------------- 3 Year Market Value Adjustment Option** 3YRMVA ---------------------------------------------------------------------- 4 Year Market Value Adjustment Option** 4YRMVA ---------------------------------------------------------------------- 5 Year Market Value Adjustment Option** 5YRMVA ---------------------------------------------------------------------- 6 Year Market Value Adjustment Option** 6YRMVA ---------------------------------------------------------------------- 7 Year Market Value Adjustment Option** 7YRMVA ---------------------------------------------------------------------- 8 Year Market Value Adjustment Option** 8YRMVA ---------------------------------------------------------------------- 9 Year Market Value Adjustment Option** 9YRMVA ---------------------------------------------------------------------- 10 Year Market Value Adjustment Option** 10YMVA ---------------------------------------------------------------------- VARIABLE INVESTMENT OPTIONS ---------------------------------------------------------------------- Prudential Equity Portfolio STOCK ---------------------------------------------------------------------- Prudential Global Portfolio GLEQ ---------------------------------------------------------------------- Prudential Jennison Portfolio GROWTH ---------------------------------------------------------------------- Prudential Money Market Portfolio MMKT ---------------------------------------------------------------------- Prudential Stock Index Portfolio STIX ---------------------------------------------------------------------- Prudential Value Portfolio HIDV ---------------------------------------------------------------------- SP Aggressive Growth Asset Allocation Portfolio AGGGW ---------------------------------------------------------------------- SP AIM Aggressive Growth Portfolio AIMAG ---------------------------------------------------------------------- SP AIM Core Equity Portfolio AIMCEP ---------------------------------------------------------------------- SP Alliance Large Cap Growth Portfolio LARCP ---------------------------------------------------------------------- SP Alliance Technology Portfolio ALLTC ---------------------------------------------------------------------- SP Balanced Asset Allocation Portfolio BALAN ---------------------------------------------------------------------- SP Conservative Asset Allocation Portfolio CONSB ---------------------------------------------------------------------- SP Davis Value Portfolio VALUE ---------------------------------------------------------------------- SP Deutsche International Equity Portfolio DEUEQ ---------------------------------------------------------------------- SP Growth Asset Allocation Portfolio GRWAL ---------------------------------------------------------------------- SP INVESCO Small Company Growth Portfolio VIFSG ---------------------------------------------------------------------- SP Jennison International Growth Portfolio JENIN ---------------------------------------------------------------------- SP Large Cap Value Portfolio LRCAP ---------------------------------------------------------------------- SP MFS Capital Opportunities Portfolio MFSCO ---------------------------------------------------------------------- SP Mid Cap Growth Portfolio MFSMC ---------------------------------------------------------------------- SP PIMCO High Yield Portfolio HIHLD ---------------------------------------------------------------------- SP PIMCO Total Return Portfolio RETRN ---------------------------------------------------------------------- SP Prudential U.S. Emerging Growth Portfolio EMRGW ---------------------------------------------------------------------- SP Small/Mid Cap Value Portfolio SMDVL ---------------------------------------------------------------------- SP Strategic Partners Focus Growth Portfolio STRPR ---------------------------------------------------------------------- Janus Aspen Series Growth Portfolio-Service Shares JANSR ---------------------------------------------------------------------- TOTAL 100% ----------------------------------------------------------------------
* THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $2,000. ** THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $1,000. -------------------------------------------------------------------------------- 11 DOLLAR COST AVERAGING PROGRAM If you elect to use more than one Dollar Cost Averaging option, you must also complete a Request for Cost Averaging Enrollment or Change form (ORD 78275). [ ] DOLLAR COST AVERAGING: I authorize Prudential to automatically transfer funds as indicated below. TRANSFER FROM:(You cannot transfer from the 1 Year Fixed-Rate Option.) *If you selected the DCA6 or DCA12 option in section 10, only complete the TRANSFER TO information. Option code:_____________ $________,__________,_________. OR _________ % TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly TRANSFER TO: (You cannot transfer to the DCA Interest Rate options or any of the Market Value Adjustment options.) The total of the two columns must equal 100 percent. OPTION CODE PERCENT OPTION CODE PERCENT __________________ __________ % ___________________ ________ % __________________ __________ % ___________________ ________ % __________________ __________ % ___________________ ________ % -------------------------------------------------------------------------------- -------------------- ORD 99730 New York-1 Page 3 of 6 Ed. 5/2003 -------------------- -------------------------------------------------------------------------------- 12 AUTO-REBALANCING [ ] AUTO-REBALANCING: I want to maintain my allocation percentages. Please have my portfolio mix automatically adjusted as allocated in section 10 under my variable investment options. Adjust my portfolio: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly Please specify the start date if different than the contract date: _________ ______ ___________ month day year -------------------------------------------------------------------------------- 13 AUTOMATED WITHDRAWALS [ ] AUTOMATED WITHDRAWAL: I would like to elect automatic withdrawals from my annuity contract. Automated withdrawals can be made monthly, quarterly, semiannually, or annually. The amount of each withdrawal must be at least $100. You must complete the Request for Partial or Automated Withdrawal form (ORD 78276) in order to specify start date, frequency, and amount of withdrawals. NOTE:AUTOMATIC WITHDRAWALS CANNOT BE USED TO CONTINUE THE CONTRACT BEYOND THE MATURITY DATE. ON THE MATURITY DATE THE CONTRACT MUST ANNUITIZE. -------------------------------------------------------------------------------- 14 REPLACEMENT QUESTIONS AND DISCLOSURE STATEMENT THIS DISCLOSURE STATEMENT SECTION MUST BE COMPLETED IF STATE REPLACEMENT REGULATIONS REQUIRE. (Check one): [ ] I do have existing life insurance policies or annuity contracts. (You must complete the Important Disclosure Notice Regarding Replacement form (COMB 89216 NY), whether or not this transaction is considered Statement 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) ____________________________ ----------------------------------------------------------------------------- REPRESENTATIVE'S QUESTION THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE. 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 -------------------------------------------------------------------------------- 15 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, the ability to transfer among investment options without sales or withdrawal charges, 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. Furthermore, I (1) understand that any amount of purchase payments allocated to a variable investment option will reflect the investment experience of that option and, therefore, annuity payments and surrender values may vary and are not guaranteed as to a fixed dollar amount, and (2) acknowledge receipt of the current prospectus for this contract and the variable investment options. [ ] 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. (continued) -------------------------------------------------------------------------------- -------------------- ORD 99730 New York-1 Page 4 of 6 Ed.5/2003 -------------------- -------------------------------------------------------------------------------- 15 SIGNATURE(S) (continued) 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, including the right to make purchase payments to the contract. We must have both the owner's and annuitant's signatures even if this contract is owned by a trust, corporation, or other entity. If the annuitant is a minor, please provide the signature of a legal guardian or custodian. THOSE AMOUNTS ALLOCATED TO ANY MVA OPTION WILL BE SUBJECT TO A MARKET VALUE ADJUSTMENT IF WITHDRAWN OR TRANSFERRED AT ANY TIME OTHER THAN DURING THE 30-DAY PERIOD FOLLOWING THE INTEREST CELL'S MATURITY. A MARKET VALUE ADJUSTMENT CAN BE A POSITIVE OR NEGATIVE ADJUSTMENT. THERE IS NO MARKET VALUE ADJUSTMENT AT DEATH. I hereby represent that my answers to the questions on this 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__________________________________________________ _______ _____ ______ Joint owner's signature (if applicable) 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 -------------------------------------------------------------------------------- -------------------- ORD 99730 New York-1 Page 5 of 6 Ed. 5/2003 -------------------- -------------------------------------------------------------------------------- 16 REPRESENTATIVE'S SIGNATURE(S) Commission Option (For Retail Distribution only. Choose one.): 1. [ ] No Trail 2. [ ] Mid Trail 3. [ ] High Trail Note: If an option is not selected, the default option will be Option 1. This application is submitted in the belief that the purchase of this contract is appropriate for the applicant based on the 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 is true to the best of his or her knowledge. ___________________________________________ ___________________________ Representative's name (Please print) 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 -------------------------------------------------------------------------------- 17 ADDITIONAL REMARKS ANY REMARKS ENTERED INTO THIS SECTION MUST BE INITIALED AND DATED BY ALL PERSONS WHO HAVE SIGNED THIS APPLICATION IN SECTIONS 15 AND 16. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ -------------------------------------------------------------------------------- STANDARD PRUDENTIAL ANNUITY SERVICE OVERNIGHT PRUDENTIAL ANNUITY SERVICE MAIL TO: CENTER MAIL TO: CENTER PO BOX 7590 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. -------------------------------------------------------------------------------- -------------------- ORD 99730 New York-1 Page 6 of 6 Ed. 5/2003 --------------------