G R O U P I N S U R A N C E
The Prudential Insurance
Company of America
Evidence of Insurability
Instructions for Employer/Association
1. Complete the form below.
2. Also complete all sections of the form noted “PART A”
including product related information as applicable to the
plan(s) requiring medical evidence of insurability.
3. The entire package should then be given to your employee
or member for completion of Part B.
In the space below, insert mailing address to which the
notice of action should be sent.
Branch subsidiary location & name
Employer/Association Name & Address:
Please make sure that you provide the name
of your employer and not the branch subsidiary
123 Elm Street
Group Contract No.
Please include your company’s 5 digit
contract number on all applications.
Signed for Employer/Association by:
Please complete so we can call
you if we have questions.