Y O U R E N R O L L M E N T K I T
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Y O U R E N R O L L M E N T K I T
GROUP
INSURANCE
Optional Term Life Insurance
Dependent Term Life Insurance
Optional Accidental Death & Dismemberment Insurance
Issued by The Prudential Insurance Company of America
IFS-A091258 Ed.12/2007 ECEd.04.2008-2117
EXP.10.2009
2
Help Protect
the Most Important
People
in Your Life...
Life is full of pleasant surprises and, at the same time, life
holds many uncertainties. It’s easier to plan for happy events
you know will occur, such as buying a home, paying for a
wedding or saving for college tuition costs. It’s more difficult
to plan for the unexpected — a serious accident or death.
For these times, it’s important that you have enough life
insurance coverage for you and your family. Your current life
insurance plans may not offer enough protection.
Together with your employer, The Prudential Insurance
Company of America offers you the opportunity to purchase
additional term life insurance which can help further
safeguard your earnings and cover your financial obligations
in the event of your death.
...by participating in our voluntary
group term life plans.
Choice of Coverage –
Our plan offers you the opportunity to obtain additional life
insurance protection and to choose the level of coverage that’s right for you.
Guaranteed Coverage –
You can obtain coverage under most of our plans without
providing any medical information when you enroll within a specified period.
Economical Group Rates –
Our plan is available to you at group rates, which are
competitive with individual rates.
Convenient Payroll Deduction –
Your premium contributions are deducted from your
paycheck, so there’s no check writing or mail delays.
Coverage Conversion –
If your employment ends, your coverage may be converted
to an individual life insurance policy issued by The Prudential Insurance
Company of America.
?
Peace of Mind –
Having a plan for the unexpected can give both you and your family
peace of mind.
Please review the information in this kit so you can make an
informed decision about participating in this program.
3
Optional Term Life Insurance
100% Employee Paid
Employee Coverage
?
Coverage is available for one, two, three, four, five, or six times your benefits-eligible pay,
not to exceed $3,000,000.
?
You can elect to enroll for up to the lesser of three times your covered annual earnings or
$750,000 without providing evidence of insurability satisfactory to The Prudential
Insurance Company of America, if you apply within 60 days of eligibility.
?
Late Entrants: Evidence of insurability satisfactory to The Prudential Insurance Company
of America is required to enroll for coverage.
?
If you are terminally ill, you can get a partial payment of your group life insurance benefit.
You can use this payment as you see fit. The payment to your beneficiary will be reduced
by the amount you receive with the Accelerated Benefit Option*. Refer to the plan booklet
for details.
?
Payouts to your beneficiaries are deposited into Prudential Alliance Account ®, a
personalized, interest-bearing account, under the beneficiary’s name. The payout earns
interest from the date the account is opened and the beneficiary can transfer or withdraw
funds at any time.
?
If your employment ends due to termination – not retirement or disability – you may
continue your Optional Term Life coverage under the portability provision
?
, provided you
are less than age 70. You will be advised of the cost of this coverage. Portability is not
available in all states. Ported benefits will reduce to 60% at age 65, 50% at age 70 and
terminate at age 80. As an alternative to continuing coverage under a portability
provision
?
, you may convert your insurance to a Prudential individual life insurance policy.
?
If your employment ends due to retirement (age 55 or older with 10 or more years service,
or age 65) or while receiving disability benefits under Trane’s Long Term Disability plan,
you may continue your Optional Term Life coverage at the same rate as active employees.
* Important Notice: The acceleration of life insurance benefits offered under this certificate are intended to
qualify for favorable tax treatment under the Internal Revenue Code of 1986 (under IRC Section 101(g)).
If the acceleration of life insurance benefits qualify for such favorable treatment, the benefits will be
excludable from your income and not subject to Federal taxation. Tax laws relating to acceleration of life
benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under
which you could receive acceleration of life insurance benefits that are excludable from income under
Federal law.
?
MN residents: You may elect to continue coverage at your expense if your employment is terminated
either voluntarily or involuntarily, or if you are laid off, as long as the group policy is still in force with the
employer. Coverage may be continued until you obtain coverage under another group policy or you return
to work from lay-off; however, the maximum period that coverage may be continued is 18 months. At the
expiration of your continued coverage, you may convert all or part of your insurance to an individual life
insurance contract. Portability is not available to Minnesota residents.
Open Solutions BIS, Inc. is the Administrator of the Prudential Alliance Account Settlement Option, a
contractual obligation of The Prudential Insurance Company of America, located at 751 Broad Street,
Newark, NJ 07102-3777. Check clearing is provided by JPMorgan Chase Bank, N.A. and processing
support is provided by Integrated Payment Systems, Inc. Alliance Account balances are not insured by
the Federal Deposit Insurance Corporation (FDIC). Open Solutions BIS, Inc., JPMorgan Chase Bank,
N.A., and Integrated Payment Systems, Inc. are not Prudential Financial companies.
4
Dependent Term Life Insurance
100% Employee Paid
Spouse Coverage
?
Coverage is available for your spouse in increments of $10,000 to $100,000.
?
You may elect to enroll your spouse for up to $30,000, without providing evidence of
insurability satisfactory to The Prudential Insurance Company of America, if you enroll
your spouse within 60 days of eligibility.
?
Late Entrants: Evidence of insurability satisfactory to The Prudential Insurance Company
of America is required to enroll for coverage.
?
Rates are based on your spouse’s age.
?
If your spouse is confined for medical care or treatment at home or elsewhere, coverage
will begin when confinement ends.
?
Coverage will end on your termination of employment or as specified in the plan booklet.
Insurance may be converted to an individual life insurance policy issued by The Prudential
Insurance Company of America.
Child(ren) Coverage
?
Dependent Term Life coverage has one premium rate that covers all eligible children.
?
Coverage is available for all your children from live birth for $2,000 or $4,000.
?
No evidence of insurability satisfactory to The Prudential Insurance Company of America
is required.
?
If your dependent children are confined for medical care or treatment at home or
elsewhere, coverage will begin when confinement ends.
?
Coverage begins at live birth and continues to age 19, if unmarried. If the child is unmarried,
dependent on you, and regularly attending school, coverage continues to age 23.
?
Coverage will end on your termination of employment or as specified in the plan booklet.
Insurance may be converted to an individual life insurance policy issued by The Prudential
Insurance Company of America.
Coverage is extended to include same-sex Domestic Partners.
5
Optional AD
&
D
100% Employee Paid
Employee, Spouse
and Child(ren) Coverage
?
Employee Only: Coverage is available for one, two, three, four, five or six times your
benefits-eligible pay, not to exceed $3,000,000.
?
Employee and Family: Coverage is available for one, two, three, four, five or six times
your benefits-eligible pay, not to exceed $3,000,000. Your spouse’s coverage amount is
50% of your Optional AD&D coverage amount. Your child(ren)’s coverage amount is
10% of your Optional AD&D coverage amount.
?
Coverage will end on termination of employment or retirement.
Benefits are paid at certain percentages of your coverage amount for specific accidental losses,
as indicated in the chart below. Not more than 100% of your coverage amount is payable for all
losses due to the same accident.
Life
Sight in both eyes
Both hands or both feet
One hand & one foot
Sight in one eye & one hand or one foot
Speech & hearing in both ears
Quadriplegia
100%
100%
100%
100%
100%
100%
100%
Paraplegia
Hemiplegia
One hand or one foot
Sight in one eye
Speech
Hearing in both ears
Thumb & index finger on the same hand
75%
50%
50%
50%
50%
50%
25%
Seat Belt Benefit - The plan pays an additional benefit of 10% of your coverage amount,
up to a maximum of $10,000.
Air Bag Benefit - The plan pays an additional benefit of 10% of your coverage amount,
up to a maximum of $10,000.
Optional AD&D Exclusions - A loss is not covered if it results from suicide or attempted suicide;
intentionally self-inflicted injuries or an attempt at same; sickness; medical or surgical treatment
of sickness; certain bacterial or viral infections (unless the infection was the result of an
accidental injury or bacterial infection which results from the accidental ingestion of contaminated
substances); act of war; certain full-time military duty; commission of, or attempt to commit a
felony; legal intoxication or drug use; certain hazardous sports; injury rising out of, or in the
course of, any work for wage or profit (this exclusion only applies with non-occupational plans);
certain travel or flight in a vehicle used for aerial navigation (This provision may vary by state.
Refer to the plan booklet for details).
For your coverage to become effective, you must be actively at work during the enrollment period and on
the effective date of the plan. If you apply for an amount that requires satisfactory evidence of insurability
to The Prudential Insurance Company of America, you must be actively at work on the date of approval for
the amount requiring satisfactory evidence of insurability. Refer to the plan booklet for details.
Coverage is extended to include same-sex Domestic Partners.
All benefit features may not be available in all states.
R A T E S H E E T
Trane
Issued by The Prudential Insurance Company of America
Rates Effective: January 1, 2007
Optional Term Life* (Employee) and Dependent Term Life* (Spouse )
Age
(Initial rates based on
age as of effective date
of your coverage. Rates
will change based on the
following age schedule.)
Monthly Cost of Insurance
(Rates per $1,000 of Coverage)
For Employee
Monthly Cost of Insurance
(Rates per $1,000 of Coverage)
For Spouse
(Spouse rate is based on spouse’s age.)
Under 30
$ 0.050
$ 0.050
30-34
$ 0.067
$ 0.067
35-39
$ 0.077
$ 0.077
40-44
$ 0.087
$ 0.087
45-49
$ 0.142
$ 0.142
50-54
$ 0.230
$ 0.230
55-59
$ 0.411
$ 0.411
60-64
$ 0.660
$ 0.660
65-69
$ 1.270
$ 1.270
70+
$ 2.060
$ 2.060
Dependent Term Life* (Child(ren) - Regardless of the number of children)
Coverage Amount
Monthly Cost of Insurance
$ 2,000
$ 0.12
$ 4,000
$ 0.24
Optional AD
&
D*
Insured
Monthly Cost of Insurance
(Rates per $1,000 of Coverage)
Employee
$ 0.020
Employee and Family
$ 0.032
*This is optional coverage and the entire cost of coverage is employee paid.
Coverage is extended to include same-sex Domestic Partners.
Cost of insurance for all coverages, which are deducted from your paycheck, may increase or decrease
in the future based upon the claims experience of participants. All provisions that apply to these
coverages are governed by the Certificate. Rates may be subject to change.
IFS-A091258 Ed.12/2007
ECEd.04.2008-2117
6
How Much Does This Insurance Cost?
Term Life (Employee or Spouse )
Follow this worksheet to determine your monthly cost of insurance. Refer to the attached Rate
Sheet to find the monthly rate per $1,000 of coverage based on your or your spouse’s age.
Steps to Determine Cost of Insurance
Worksheet
1. Select desired amount of coverage.
$ _________
2. Locate your or your spouse’s age on the
Rate Sheet and note the corresponding
monthly rate.
The monthly rate per $1,000 is $ _________
3. Divide your selected amount of coverage
by $1,000. Then multiply the result by the
monthly rate for your age. The answer is
your monthly cost of insurance.
$ ________ divided by $1,000 = $ _____
$ _____ multiplied by $_____ = $_______
Monthly Cost of Insurance = $ _________
Optional AD
&
D (Employee or Family )
Follow this worksheet to determine your or you and your family’s Optional AD&D monthly cost of
insurance. Refer to the attached Rate Sheet to find the monthly rate per $1,000 of coverage.
Steps to Determine Cost of Insurance
Worksheet
1. Select your desired amount of coverage.
$ _________
2. Locate your monthly rate on the Rate
Sheet.
The monthly rate per $1,000 is $ _________
3. Employee Only: Divide your selected
amount of coverage by $1,000. Then
multiply the result by the monthly rate. The
answer is your monthly cost of insurance.
OR
Employee and Family: Divide your
selected amount of coverage by $1,000.
Then multiply the result by the family
monthly rate. The answer is your monthly
cost of insurance for you and your family.
$ ________ divided by $1,000 = $ _____
_____ multiplied by $_____ = $_______
Monthly Cost of Insurance for You
= $ _________
$ ________ divided by $1,000 =$ _____
$ _____ multiplied by $_____ = $_______
Monthly Cost of Insurance for Your Family
= $ _________
Coverage is extended to include same-sex Domestic Partners.
Cost of insurance for all coverages, which are deducted from your paycheck, may increase or decrease in
the future based upon the claims experience of participants. All provisions that apply to these coverages
are governed by the Certificate. Rates may be subject to change.
IFS-A091258 Ed.12/2007
ECEd.04.2008-2117
7
8
About The Prudential Insurance Company of America
Prudential’s famous Rock logo has been one of America’s best-
known icons. It’s a symbol of the strength and trust that millions of
Americans have placed in us to help them meet their most
important financial goals.
The Prudential Insurance Company of America, is one of the
leading providers of group insurance in the United States. Our
resources, financial strength and stability allow us to honor long-
term commitments to employers and employees alike.
Start The Process Of Enrolling In This Valuable Insurance
TODAY!
To enroll, simply complete the Enrollment Form, including the
Beneficiary Designations, and return it as instructed.
Group Term Life and Accidental Death and Dismemberment coverages are issued by The Prudential
Insurance Company of America, 751 Broad Street, Newark, NJ 07102. Life Record Keeping: 1-800-778-
3827. Prudential Financial and the Rock logo are registered service marks of The Prudential Insurance
Company of America and its affiliates. This brochure is intended to be a summary of your benefits and
does not include all plan provisions, exclusions and limitations. Please refer to the Booklet-Certificate,
which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and
restrictions which may apply. If there is a discrepancy between this document and the Booklet-
Certificate/Group Contract issued by The Prudential Insurance Company of America, the terms of the
Group Contract will govern. Contract provisions may vary by state. Contract Series: 83500.
IFS-A091258 Ed.12/2007
ECEd.04.2008-2117
Enrollment Form – Trane
Page 1 of 3
General Information (Employee)
Effective Date of Coverage (for office use only) ____/____/____
Last Name First Name Middle Initial
Address City State Zip Code
Social Security No.
Marital Status
Date of Birth
______ – ______ – _______
Single
Divorced
Married
Widowed
Month Day Year
_____/_____/_____
Date Employed
Month Day Year
_______/_______/________
Your Annual Earnings
$________________
Spouse Date of Birth
Month Day Year
_____/_____/_____
(For Prudential Use Only)
Control # 99494
Optional Term Life
(Please indicate your coverage selections)
Choose one (up to a maximum of $3,000,000):
One times benefits-eligible pay
Two times benefits-eligible pay
Three times benefits-eligible pay
Four times benefits-eligible pay
Five times benefits-eligible pay
Six times benefits-eligible pay
No coverage chosen.
Dependent Term Life
(Please indicate your coverage selections)
Choose one:
Choose one:
Spouse
Children
Coverage amount chosen: $______________
Available in increments of $10,000 to $100,000.
$ 2,000
$ 4,000
No coverage chosen.
No coverage chosen.
Optional Accidental Death
&
Dismemberment (Optional AD
&
D)
(Please indicate your coverage selections)
Choose one (up to a maximum of $3,000,000) from the following:
Employee Only:
One times benefits-eligible pay
Two times benefits-eligible pay
Three times benefits-eligible pay
Four times benefits-eligible pay
Five times benefits-eligible pay
Six times benefits-eligible pay
Employee & Family:
Spouse coverage amount is 50% of the chosen amount of coverage.
Child(ren) coverage amount is 10% of the chosen amount of coverage.
One times benefits-eligible pay
Two times benefits-eligible pay
Three times benefits-eligible pay
Four times benefits-eligible pay
Five times benefits-eligible pay
Six times benefits-eligible pay
No coverage chosen.
Mail completed forms to:
Prudential, PO Box 13676, Philadelphia, PA 19176
If you have any questions, please call Life Record Keeping: 1-800-778-3827
The Prudential Insurance Company of America
751 Broad Street, Newark, New Jersey 07102
Group Life and Accidental Death and Dismemberment coverages are issued by The Prudential Insurance Company of
America, a New Jersey company, 751 Broad Street, Newark, NJ 07102. Life Record Keeping: 1-800-778-3827. Please refer
to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations
and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group
Contract issued by Prudential, the terms of the certificate will govern. Contract provisions may vary by state. California COA
#1179, NAIC#68241. Contract Series: 83500. Prudential Financial and the Rock logo are registered service marks of The
Prudential Insurance Company of America and its affiliates.
GL. 2005.055
Ed.12/2007
ECEd.04.2008-0819 EXP.10.2009
Enrollment Form –
Trane
Page 2 of 3
Employee General Information
Last Name First Name Middle Initial
Social Security No.
______ – ____ – ______
Acceptance or Waiver of Coverage
I am enrolling for coverage and I authorize my employer to deduct from my earnings until further notice my
contributions for insurance under a contract issued by The Prudential Insurance Company of America. I understand
that if I desire to increase the amount of my insurance or add dependent coverage hereafter, I may be required to
furnish evidence of insurability for myself and/or my dependents. To the best of my knowledge and belief, I declare the
statement above is true and understand it is the basis for determining the monthly contribution for coverage. I also
understand that for coverage to become effective, I must be actively at work during the enrollment period and on the
effective date of the plan. If I apply for an amount that requires evidence of insurability satisfactory to The Prudential
Insurance Company of America, I must be actively at work on the date of approval for the amount requiring
satisfactory evidence of insurability.
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 satisfactory evidence of insurability to The Prudential Insurance Company of America for myself and/or my
dependents.
FOR RESIDENTS OF ALL STATES EXCEPT FLORIDA, 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.
FLORIDA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third
degree.
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.
NEW YORK 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 fact material thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation. This warning ONLY applies to accident coverage.
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.
Continued on the next page.
Mail completed forms to:
Prudential, PO Box 13676, Philadelphia, PA 19176
If you have any questions, please call Life Record Keeping: 1-800-778-3827
GL. 2005.055
Ed.12/2007
ECEd.04.2008-0819 EXP.10.2009
Enrollment Form –
Trane
Page 3 of 3
Employee General Information
Last Name First Name Middle Initial
Social Security No.
______ – ____ – ______
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.
VIRGINIA RESIDENTS: Will this proposed insurance replace an existing life insurance policy? Yes No
REPLACING YOUR LIFE INSURANCE POLICY?
Are you thinking about buying a new policy and discontinuing or changing an existing policy? If you are, your decision
could be a good one -- or a mistake. You will not know for sure unless you make a careful comparison of your existing
policy and the proposed policy. Make sure you understand the facts. You should ask the company or agent that sold
you your existing policy to give you information about it. Hear both sides before you decide. This way you can be sure
you are making a decision that is in your best interest.
Employee Signature ________________________________ Date (Month, Day, Year) ____________________
Spouse Signature ________________________________ Date (Month, Day, Year) ____________________
(Michigan Residents Only: When enrolling for Spouse Dependent Term Life coverage, the spouse must sign above to
acknowledge consent for the coverage.)
You must also complete a separate beneficiary designation form.
Mail completed forms to:
Prudential, PO Box 13676, Philadelphia, PA 19176
If you have any questions, please call Life Record Keeping: 1-800-778-3827
GL. 2005.055
Ed.3/2005
ECEd.04.2008-0819 EXP.10.2009
Beneficiary Designation –
Trane
Control # 99494
Employee General Information
Last Name First Name Middle Initial
Social Security No.
_____________________________________________________________________
_____ – _____ – _____
Beneficiary Designation
If more than one beneficiary is desired, please write their name(s) and relationship(s) on the lines below. If more than one
primary beneficiary is designated, settlement will be made in equal shares to the designated beneficiaries (or beneficiary)
who are then still living, unless their shares are specified. If no named beneficiary, or no beneficiary survives the insured,
settlement will be made in accordance with the terms of your Group Contract.
Optional Term Life
&
Optional AD
&
D - Primary Beneficiary Designation
First Name
MI Last Name
Address
(Street, City, State, ZIP)
Relationship Soc. Sec. #
and
Date of Birth
% Share
1)
2)
Optional Term Life
&
Optional AD
&
D - Contingent Beneficiary Designation
First Name
MI Last Name
Address
(Street, City, State, ZIP)
Relationship Soc. Sec. #
and
Date of Birth
% Share
1)
2)
Employee
Signature
____________________________
Date (Month, Day, Year)
______________
If you have any questions, please call Life Record Keeping: 1-800-778-3827
Mail completed forms to:
Prudential, PO Box 13676, Philadelphia, PA 19176
If you have any questions, please call Life Record Keeping: 1-800-778-3827
The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ 07102. Life Record Keeping: 1-800-778-
3827. Prudential Financial and the Rock logo are registered service marks of The Prudential Insurance Company of
America and its affiliates.
GL. 2005.289
Ed.12/2007
ECEd.04.2008-0716 EXP.10.2009
Please answer these questions by checking “Yes” or “No.”
Do you currently have any disorder, condition (including pregnancy), disease, or defect or are you currently taking
medication prescribed or provided by a medical or other practitioner for any disorder, condition (including
pregnancy), disease, or defect other than a cold, cough, flu, or allergies?
During the last five years, have you been in a hospital, sanitarium, or other institution for observation, rest,
diagnosis, or treatment?
During the last five years, have you had life, disability, or health insurance declined, postponed, changed,
rated-up, cancelled, or withdrawn?
Within the last five years, have you been diagnosed with, or treated by a member of the medical profession for,
Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC), or have you been treated for or
had any trouble with any of the following: heart, chest pain, high blood pressure, cancer or tumors, diabetes,
lungs, kidneys, liver?
Yes
No
Prudential reserves the right to request additional health information on the basis of the responses given to the above questions.
IMPORTANT NOTICE:
In all states except Arkansas, Colorado, Florida, Maine, Maryland, Massachusetts, Ohio, Oregon, New York, New Jersey,
Tennessee, Virginia, Washington, and the District of Columbia: 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 fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
In Arkansas, Colorado, Maine, Maryland, New York, Ohio, Tennessee, and the District of Columbia: 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 fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Employee/Member First Name MI Last Name
Applicant First Name MI Last Name
City
State ZIP Code
Street
Apt.
Sex
Height
Weight
Employee/Member Social Security Number
Male
Female
ft.
in.
lbs.
Date of Birth
Social Security Number
Yes
No
Yes
No
Yes
No
GL.98.761-G Ed. 4/2006 Page 1 of 2
4/2006-PDF
Employer/Association Name:
G R O U P I N S U R A N C E
The Prudential Insurance Company of America
Group Contract No(s):
Short Form Health Statement Questionnaire
Mail the completed form to:
The Prudential Insurance Company of America
Group Medical Underwriting, P.O. Box 8796
Philadelphia, PA 19176
Or fax the completed form to: 877-605-6671
0 0
Trane
99494
In addition, any person who commits such a fraudulent act:
• may be subject to fines and confinement in prison under Arkansas law.
• is subject to penalties that may include imprisonment, fines, denial of insurance, and civil damages under Colorado law. Also, any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information
to a policyholder or claimant for the purpose of defrauding, or attempting to defraud, the policyholder or claimant with regard to a
settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
• may be subject to penalties that may include imprisonment, fines, or a denial of insurance benefits under Maine law.
• may be found guilty of insurance fraud under Maryland law.
• is subject to civil penalties, with such penalties not exceeding $5,000 and the stated value of the claim for each such
violation under New York law. This notice ONLY applies to disability income coverage in New York.
• is guilty of insurance fraud under Ohio law.
• is subject to penalties including imprisonment, fines, and denial of insurance benefits under Tennessee law.
• may be subject to imprisonment and/or fines under the law of the District of Columbia.
In Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
In New Jersey: Any person who includes false or misleading information on an application for insurance under a group contract is
subject to criminal and civil penalties.
In Virginia: Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company has committed a crime. Penalties include imprisonment, fines, and denial of insurance benefits.
In Massachusetts: 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 fact material thereto commits a fraudulent insurance act, which may subject such person to criminal and civil penalties.
In Oregon: 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 fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to
criminal and civil penalties.
In Washington: 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.
I declare that, to the best of my knowledge and belief, the statements made in this application are complete and true. I agree that
the coverage applied for is subject to the terms of the plan and shall become effective on the date or dates established by the plan,
provided the evidence of good health is satisfactory.
_________________________________________________________________________________________________ ______________________________
Applicant’s Signature (unless a minor)
Date
_________________________________________________________________________________________________ ______________________________
If applicant is a minor, Signature of Parent, Guardian,
Relationship
Date
or Person Liable for Support of Applicant
GL.98.761-G Ed. 4/2006 Page 2 of 2
100922-4/2006-PDF
Prudential Financial is a service mark of The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ 07102, USA
and its affiliates.
Group Life and Disability Income Medical Underwriting
NOTICE
Thank you for choosing The Prudential Insurance Company of America (Prudential) for
your insurance needs. Before we can issue coverage we must review your
application/enrollment form. To do this, we need to collect and evaluate personal
information about you. This notice is being provided to inform you of certain
practices Prudential engages in, and your rights, with regard to your personal
information. We would like you to know that:
•
Personal information may be collected from persons other than yourself or other
individuals, if applicable, proposed for coverage;
•
This personal information as well as other personal or privileged information
subsequently collected by us may in certain circumstances be disclosed to third
parties without authorization;
•
You have a right of access and correction with respect to personal information we
collect about you; and
•
Upon request from you, we will provide you with a more detailed notice of our
information practices and your rights with respect to such information. Should
you wish to receive this notice, please contact:
The Prudential Insurance Company of America
Group Medical Underwriting
P.O. Box 8796
Philadelphia, PA 19176
Any information we obtain regarding a person’s insurability will be treated as
confidential. We may, however, make a brief report of it to the Medical Information
Bureau (the Bureau), a non-profit membership organization of life insurance companies,
which operates an information exchange on behalf of its members. When you apply for
life, disability, or health insurance to any company, including Prudential, which is a
member of the Bureau, or submit a claim for benefits to such a company, the Bureau will,
on request, give the company the information in its files. In addition, upon receipt of a
request from you, the Bureau will arrange disclosure of any information it may have in
your file. If the information came from the Bureau and you question the accuracy of the
information in the Bureau’s files, you may contact the Bureau and seek a correction in
accordance with the procedures set forth in the Federal Fair Credit Reporting Act. The
address of the Bureau’s information office is: P.O. Box 105, Essex Station, Boston, MA
02112, (617) 426-3660.
Please keep this notice for your records.
