Fillable Prudential Group Life Enrollment / Change Card (Page 2 of 2) in pdf

contribution for coverage.

I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above

named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish evidence of

insurability for myself and/or my dependents.

I have read and understand the terms and requirements of the fraud warnings included as part of this form.

Employee Signature __________________________________________ Date (Month/Day/Year)________ / ________ / _______

For residents of all states except District of Columbia, Florida, Kentucky, New Jersey, New York, Pennsylvania, Utah,

Vermont, Virginia and Washington; 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.

DISTRICT OF COLUMBIA 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.

KENTUCKY RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance containing any materially false information or conceals, for the purpose of misleading, information containing

any fact material thereto commit a fraudulent insurance act, which I a crime.

NEW JERSEY RESIDENTS - Any person who includes any false or misleading information on an application for an insurance

policy is subject to criminal and civil penalties.

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.

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.

VIRGINIA RESIDENTS - 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 a statement of claim for payment of a loss or benefit may have violated state law, is 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.

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.

Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. There is no

administrative fee to accelerate death benefits. The accelerated amount is not discounted.

Employee Signature _____________________________________ Date (Month, Day, Year) ___________________________

MICHIGAN RESIDENTS ONLY – If you wish to enroll your spouse and/or eligible child 18 years of age or older for $10,000 or

more of Dependent Term Life Insurance coverage, your spouse and/or each of your eligible child age 18 years or older must

acknowledge consent for such coverage below.

Spouse Signature _____________________________________ Date (Month, Day, Year) ___________________________

Child Signature ______________________________________ Date (Month, Day, Year) ___________________________

GL.2010.068

Ed 4.2010

Prudential Group Life Enrollment / Change Card Page 2

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