MISSING ANY ONE OF THESE ITEMS WILL GENERATE A NEWLY TYPED
POSITIVE DELIVERY APPLICATION TO BE SIGNED AT DELIVERY
1. PRIMARY INSURED, OWNER, AND BENEFICIARY:
Social Security number of the insured Relationship of owner/beneficiary
Owner’s SS/TIN Trust Owner/Beneficiary: Full name and date (mm/dd/yyyy)
2. SIGNATURES, PAGE 6:
IRS Certification questions must be answered Application not completed on appropriate state version
Altered application date White out used
State is required
MISSING ANY OF THESE ITEMS WILL GENERATE A 10164 AMENDMENT AT POLICY DELIVERY.
FIVE OR MORE MISSING ITEMS WILL GENERATE A COMPUTER-PRODUCED APPLICATION.
3. PROPOSED INSURED DATA, SECTION A:
Proposed insured’s earned income and net worth Date of birth
Occupation and duties of the proposed insured Answer to question #8 U.S. Citizen/Resident Alien?
4. PREMIUMS, SECTION C:
Should the premium notices be sent to the policyowner’s address or should another address be used?
Please advise if the policyowner or someone else should receive the premium notices. If other than the owner,
please provide full name and address.
For non-term plans, billed premium amount
Premium payment mode
5. COVERAGE/INSURANCE HISTORY, SECTION F:
Does the proposed insured have any existing insurance or annuity?
Will this insurance replace any existing insurance or annuity?
Provide the product type (Life or Annuity) for the product listed as “existing coverage”
Provide the amount of coverage listed as “existing coverage”
Are you applying for or reinstating life insurance with any company? (Total amount to be placed)
6. AGENT’S REPORT:
Section F, Additional Coverage: Leave blank if the client has not placed an existing life insurance policy with
Prudential within the past three months. If answered yes or no, will generate a newly typed application to be signed
7. BUSINESS & FINANCIAL SUPPLEMENTS: Missing items will potentially generate an amendment. Missing signatures will
generate a newly typed business or financial supplement on delivery.
Completing your applications right the first time will let you see improved cycle times, greater efficiencies, and no need for signatures upon delivery. These tips will help you complete your applications full