Beneficiary Change and Predetermined Payout Election Form
Variable Annuities are issued by Pruco Life Insurance Company, in New York, by Pruco Life Insurance Company of New Jersey
and The Prudential Insurance Company of America (PICA) (these entities are referred to as “Prudential” below). All are Prudential Financial, Inc. companies and each is solely responsible for its own financial condition and obligations. The Rock Prudential
Logo is a registered service mark of PICA and its affiliates.
This form is used to name or change your beneficiary(ies) or any predetermined payout options for your beneficiary(ies).
Changing your beneficiary(ies) could affect certain Optional Benefits that you already have in place on your contract. Please
refer to your prospectus, contract and/or riders for additional information. Confirmation of your beneficiary(ies) and any applicable restrictions submitted with an annuity application will be sent to you separately from your Annuity contract.
Instructions: All information must be typed or printed using blue or black ink.
SECTION 1
New Annuity
OWNER INFORMATION
Existing Annuity
Annuity Number
Owner Name (First, Middle, Last Name)
Owner Social Security/Tax I.D. Number
Telephone Number
Joint Owner Name (If applicable)
Joint Owner Name Social Security/Tax I.D. Number
If we require additional information to complete this request, please indicate who Prudential should contact:
Owner
Financial Professional
SECTION 2
REASON FOR THIS FORM
MUST CHECK ONE
If this change is a result of a divorce Prudential may require the Notification of Divorce and Division Form.
Add/change beneficiary(ies) only. Please complete Section 3 and proceed to Signature Page.This will remove
all existing beneficiaries and replace with those provided on this form unless otherwise indicated in the Section for Special
Remarks.
Add/change beneficiary(ies) with pre-determined payout options. Please complete Section 4 and then proceed to
the Signature Page. This will remove all existing beneficiaries and/or pre-determined payout options and replace with those
provided on this form unless otherwise indicated in the Section for Special Remarks.
This election is not available for contracts with either Highest Daily Lifetime Seven with Beneficiary Income Option
(Individual and Spousal) or Highest Daily Lifetime 7 Plus with Beneficiary Income Option (Individual and Spousal).
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SECTION 3
BENEFICIARY DESIGNATIONS ONLY
Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the
individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will
be split equally.
For contract owners with the following benefits:(Spousal Lifetime Five Highest Daily, Spousal Highest Daily Lifetime Seven,
Spousal Highest Daily Lifetime Seven with BIO, Spousal Highest Daily Lifetime 7 Plus, Spousal Highest Daily Lifetime 7 Plus
with BIO, Spousal Highest Daily Lifetime 6 Plus, Spousal Highest Daily Lifetime Income, Spousal Highest Daily Lifetime Income
2.0, Spousal Highest Daily Lifetime Income 2.0 with Highest Daily Death Benefit, Spousal Highest Daily Lifetime Income 2.0 with
Highest Annual Death Benefit, Spousal Highest Daily Lifetime Income v2.1, Spousal Highest Daily Lifetime Income v2.1 with
Highest Daily Death Benefit, Spousal Highest Daily Lifetime Income v2.1 with Highest Annual Death Benefit, Spousal Highest
Daily Lifetime Income v3.0, Spousal Highest Daily Lifetime Income v3.0 with Highest Daily Death Benefit or Spousal Highest
Daily Lifetime Income v3.0 with Highest Annual Death Benefit.) The beneficiary designation must remain the spouse or spouses
named equally.
For non-qualified contracts, if the contract has a HD7 with BIO or HD7 Plus with BIO benefit and a beneficiary other than an
individual is named, the beneficiary can not elect a payout beyond 5 years.
Note: Percentages must be in whole numbers and must total 100% within a class.
Primary
Contingent
Percent
Male
%
Female
Beneficiary Name
Social Security/Tax I.D. Number
Date of Birth or Date of Trust Inception (required)
Telephone Number
Month
Day
Year
Relationship to Owner (required)
Trustee Name
Beneficiary Address
Street
City
State
ZIP Code
(Continued)
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SECTION 3
BENEFICIARY DESIGNATIONS ONLY (continued)
Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the
individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will
be split equally.
Note: Percentages must be in whole numbers and must total 100% within a class.
Beneficiary
Primary
Contingent
Percent
Male
%
Female
Beneficiary Name
Social Security/Tax I.D. Number
Telephone Number
Date of Birth or Date of Trust Inception (required)
Month
Day
Year
Relationship to Owner (required)
Trustee Name
Beneficiary Address
Street
City
State
ZIP Code
Beneficiary
Primary
Contingent
Percent
Male
%
Female
Beneficiary Name
Social Security/Tax I.D. Number
Date of Birth or Date of Trust Inception (required)
Telephone Number
Month
Day
Year
Relationship to Owner (required)
Trustee Name
Beneficiary Address
Street
City
State
ZIP Code
IF YOU HAVE ADDITIONAL BENEFICIARIES, PLEASE ADD AND SUBMIT THEM ON A SEPARATE PIECE OF PAPER
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STOP
Section 4 should only be completed if you wish to elect a predetermined payout option for a beneficiary(ies). If you are
not electing a predetermined payout, please complete Section 3 and the Signature page only. If you choose to elect a
Predetermined Payout Option for any of your beneficiaries, please carefully review the following:
• The general provisions of your Annuity contract give the beneficiary(ies) choices ranging from an immediate lump sum
distribution to a variety of income streams payable for a period of years not to exceed the beneficiary(ies) life expectancy. This
form gives the Contract Owner(s) the ability to elect how their beneficiary(ies) will receive the death benefit value of the
contract. These elections are irrevocable upon your death*. Please note that restrictions must be expressly indicated. If no
restriction is noted, it is presumed that your beneficiary(ies) can elect any payout option available under your Annuity Contract.
• This form can be completed at any time prior to the Contract Owner’s death. It can be submitted with an Application for
a new contract, or as a beneficiary change request on an existing contract. This will revoke and replace any beneficiary
designations previously received unless an irrevocable beneficiary designation is on file.
• Pre-determining the Death Benefit Distribution is only available for Individuals and/or Grantor Trust(s) designated as
beneficiaries.
• If the Beneficiary is a Minor at the time of the claim, additional information may be required. Every state has different
requirements, which may vary depending upon the amount of the benefits payable. If your state requires a legal guardian for
the minor’s property and/or estate or custodian to accept payment on the minor’s behalf, a certified copy of the court
appointment will be required.
• Please note that the timing of your beneficiary(ies) claim may impede our ability to distribute the death benefit proceeds in
accordance with any restrictions elected on this form. Specifically, please note that due to Internal Revenue Service (IRS)
regulations, a claim must be made, and the first distribution must occur, within one year of the date the death benefit
becomes payable for non-qualified contracts and by 12/31 of the year following the year in which the death benefit becomes
payable for qualified contracts. We strongly recommend that you consult with your Financial Professional and tax advisor to
determine if a restriction is appropriate and if so, which best meets your and/or your beneficiary(ies) needs.
The following is a brief description of each Predetermined Payout Option available:
Note: The BCO is available for election on Prudential Premier, Premier Retirement, Premier Advisor and Strategic Partners
products. All eligibility requirements, including death benefit payout option minimums, must be met (see prospectus for more details). If the Beneficiary Continuation Option is not available on your contract, then the continuation will be administered through
a Beneficiary Annuity that we are selling at the time of the death benefit claim. The payment restriction options are the same for
both BCO or Beneficiary Annuity.
*Your beneficiary(ies) would still have the right to fully surrender their Beneficiary Annuity(ies).
Beneficiary Continuation Option(“BCO”) – This option will allow the beneficiary to receive payments over his/her life expectancy while maintaining the ability to allocate the death benefit proceeds among variable investment options. The beneficiary
will receive the minimum amount each year needed to satisfy IRS Requirements. The beneficiary may name successor beneficiaries and if the beneficiary dies prior to receiving all payments, their designated successor beneficiaries may continue receiving the payments or elect a lump-sum distribution. Beneficiary Continuation Option may not be permitted for use with the death
benefit proceeds from all deferred annuity contracts. Please contact your Financial Professional or the Annuity Service Center
with any questions.You have the ability to restrict your beneficiary from taking any withdrawals in excess of the Required Distributions. You may also restrict withdrawals until your beneficiary attains a specific age. If the “Age Restriction to withdraw Death
Benefit” option is elected with the BCO, no withdrawals (other than the Required Distributions) will be permitted until the beneficiary reaches the attained age that you provide.
Life Only Income – This option will restrict the beneficiary to receive payments over his/her life expectancy via a fixed immediate
annuity. No additional withdrawals are permitted. There is no death benefit value payable at the time of this beneficiary’s death.
Period Certain** – This option will restrict the beneficiary to receive fixed payments, for a period that you choose, until the
death benefit value has been depleted via a fixed immediate annuity. No additional withdrawals are permitted. If the beneficiary
dies prior to the end of the certain period the remaining amount will be passed to that beneficiary’s successor beneficiary(ies).
Life Income with a Period Certain** – This fixed immediate annuity option will restrict the beneficiary to receive payments over
his/her remaining life expectancy where you can predetermine a number of years of guaranteed payments. No additional withdrawals are permitted. If the beneficiary dies prior to the end of the certain period the remaining amount will be passed to that beneficiary’s successor beneficiary(ies). If the beneficiary dies after the end of the certain period there will be no death benefit payable.
Beneficiary’s Choice – This option will restrict the beneficiary to receive payments over his/her remaining life expectancy, but
will allow the beneficiary to choose any of the payout options described above.
Lump Sum in Combination with a Restriction – You may select a certain percentage of the death benefit to be paid in a
lump-sum to their designated beneficiary(ies). The remainder will be applied to the Death Benefit Distribution Option elected by
the Contract Owner(s).
Age Restriction Death Benefit Distribution Option – If the death benefit becomes payable when the beneficiary is below the
age indicated, the death benefit will be applied to the Death Benefit Distribution Option elected. If the death benefit becomes
payable after the beneficiary reaches the age indicated, these restrictions will no longer apply and the beneficiary can elect any
Death Benefit Option available at the time.
**Note: If a Period Certain option is chosen and it exceeds the beneficiary’s life expectancy at the time that the death benefit
becomes payable, the next longest duration not exceeding the beneficiary’s current life expectancy will be applied.
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SECTION 4
BENEFICIARY DESIGNATIONS WITH PREDETERMINED PAYOUT ELECTIONS
Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the
individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will
be split equally.
Note: Percentages must be in whole numbers and must total 100% within a class.
Beneficiary 1
Primary
Contingent
Percent
Male
%
Female
Beneficiary Name
Social Security/Tax I.D. Number
Telephone Number
Date of Birth or Date of Trust Inception (required)
Month
Day
Year
Relationship to Owner (required)
Trustee Name
Beneficiary Address
Street
City
State
ZIP Code
Beneficiary 1 : Predetermined Payout Options
Stretch Annuity Option. Please note that the Beneficiary Continuation Option is not available on all products.
Required Distributions only; no additional withdrawals are permitted
The beneficiary may take withdrawals in addition to the Required Distribution
Age Restriction to Withdraw Death Benefit: Required Distributions only. Once the beneficiary attains the age of
he/she may take withdrawals in addition to the Required Distributions
Life Only Annuity (not available for Beneficiary Annuities)
Period Certain1 (not available for Beneficiary Annuities)
Life Annuity with a Period Certain1 (not available for Beneficiary Annuities)
Beneficiary’s choice – Any of the above four options (not available for Beneficiary Annuities)
1
Period Certain Options:
5 years
10 years
15 years
20 years
,
25 years
Additional Options:
Lump Sum Distribution of
% of the death benefit to be paid to the beneficiary. Any remainder will be applied to
the Death Benefit Distribution Option elected above.
Age Restriction Death Benefit Distribution Option. Predetermined payout elections are in effect only until the beneficiary
attains
years of age.
(Continued)
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SECTION 4
BENEFICIARY DESIGNATIONS WITH PREDETERMINED PAYOUT ELECTIONS (continued)
Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the
individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will
be split equally.
Note: Percentages must be in whole numbers and must total 100% within a class.
Beneficiary 2
Primary
Contingent
Percent
Male
%
Female
Beneficiary Name
Social Security/Tax I.D. Number
Telephone Number
Date of Birth or Date of Trust Inception (required)
Month
Day
Year
Relationship to Owner (required)
Trustee Name
Beneficiary Address
Street
City
State
ZIP Code
Beneficiary 2 : Predetermined Payout Options
Stretch Annuity Option. Please note that the Beneficiary Continuation Option is not available on all products.
Required Distributions only; no additional withdrawals are permitted
The beneficiary may take withdrawals in addition to the Required Distribution
Age Restriction to Withdraw Death Benefit: Required Distributions only. Once the beneficiary attains the age of
he/she may take withdrawals in addition to the Required Distributions
Life Only Annuity (not available for Beneficiary Annuities)
Period Certain1 (not available for Beneficiary Annuities)
Life Annuity with a Period Certain1 (not available for Beneficiary Annuities)
Beneficiary’s choice – Any of the above four options (not available for Beneficiary Annuities)
1
Period Certain Options:
5 years
10 years
15 years
20 years
,
25 years
Additional Options:
Lump Sum Distribution of
% of the death benefit to be paid to the beneficiary. Any remainder will be applied to
the Death Benefit Distribution Option elected above.
Age Restriction Death Benefit Distribution Option. Predetermined payout elections are in effect only until the beneficiary
attains
years of age.
(Continued)
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SECTION 4
BENEFICIARY DESIGNATIONS WITH PREDETERMINED PAYOUT ELECTIONS (continued)
Indicate whether this change should be made to the primary and/or contingent beneficiary(ies). If neither is checked, the
individual will be deemed to be a primary beneficiary. If you do not indicate percentages, then all beneficiaries within a class will
be split equally.
Note: Percentages must be in whole numbers and must total 100% within a class.
Beneficiary 3
Primary
Contingent
Percent
Male
%
Female
Beneficiary Name
Social Security/Tax I.D. Number
Telephone Number
Date of Birth or Date of Trust Inception (required)
Month
Day
Year
Relationship to Owner (required)
Trustee Name
Beneficiary Address
Street
City
State
ZIP Code
Beneficiary 3 : Predetermined Payout Options
Stretch Annuity Option. Please note that the Beneficiary Continuation Option is not available on all products.
Required Distributions only; no additional withdrawals are permitted
The beneficiary may take withdrawals in addition to the Required Distribution
Age Restriction to Withdraw Death Benefit: Required Distributions only. Once the beneficiary attains the age of
he/she may take withdrawals in addition to the Required Distributions
Life Only Annuity (not available for Beneficiary Annuities)
Period Certain1 (not available for Beneficiary Annuities)
Life Annuity with a Period Certain1 (not available for Beneficiary Annuities)
Beneficiary’s choice – Any of the above four options (not available for Beneficiary Annuities)
1
Period Certain Options:
5 years
10 years
15 years
20 years
,
25 years
Additional Options:
Lump Sum Distribution of
% of the death benefit to be paid to the beneficiary. Any remainder will be applied to
the Death Benefit Distribution Option elected above.
Age Restriction Death Benefit Distribution Option. Predetermined payout elections are in effect only until the beneficiary
attains
years of age.
SECTION 5
SPECIAL REMARKS / ADDITIONAL BENEFICIARY REQUESTS
Use this section to name an additional beneficiary, a class or group. If additional space is needed you can attach additional
documentation with all the required information for each beneficiary.
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SECTION 6
ADDITIONAL INFORMATION
• If you are naming an Entity, (i.e., corporation, charity, etc.), as a beneficiary, you must include the complete address. If this
information is not included, the new beneficiary designation will not be completed as requested.
• Your resident state may be subject to the Uniform Unclaimed Property Act. This legislation requires that you complete all
information pertaining to your beneficiary(ies) i.e., address, Social Security number, date of birth.
• If you reside in AZ, CA, ID, LA, NV, NM, WA, WI and want to change the beneficiary on this contract your spouse’s consent
may be required. If the change is a result of marriage, divorce, or death, we will require your marriage certificate, divorce
decree, or death certificate.
• Massachusetts’ residents – state law requires that a disinterested adult who is not a party to the contract witness any
request to change the beneficiary arrangement. Note: Your Financial Professional can sign as a witness.
• For Federal tax purposes, the term “spouse” includes any individuals who are lawfully married under state law. Federal law
does not recognize domestic partnerships or civil unions that are not designated as “married” under state law.
SECTION 7
SIGNATURES
TRANSACTION CONFIRMATIONS
We may confirm regularly scheduled transactions, including, but not limited to, the Annual Maintenance Fee, electronic fund
transfer, Systematic Withdrawal/ Required Minimum Distribution / 72(t) / 72(q) programs, auto rebalancing, and Dollar Cost
Averaging in quarterly statements instead of confirming those transactions immediately.
By signing below, I (we):
• Agree to the request(s) made on this form;
• Certify that no other person has any claim or interest in the contract except for an assignee under any assignment now on
record with Prudential; and
• Understand that if I am married, and if this request applies to amounts held by a retirement plan described in Sections
401(a) or 403(b) of the Internal Revenue Code, then spousal consent and other requirements may apply.
I hereby authorize Prudential to act on instructions within this restriction form. I understand that it is my responsibility
to notify Prudential in writing of a change in or revocation of restriction.
Special Note: I understand that Prudential reserves the right, to terminate the restriction and pay a lump sum distribution,
if at the time the death benefit becomes payable, the Internal Revenue regulations, federal, or, state laws prohibit the
requested restriction.
SIGN HERE
Contract owner’s signature
Date of signature (Month / Day / Year)
Joint owner’s signature (if applicable)
Date of signature (Month / Day / Year)
Spouse’s signature (if applicable)
Date of signature (Month / Day / Year)
Witness’ signature (if applicable)
Date of signature (Month / Day / Year)
Name of Broker Dealer Firm
Telephone Number
SIGN HERE
SIGN HERE
SIGN HERE
This form, and the information contained within, is not intended as investment advice and is not a recommendation about
managing or investing your retirement savings. Neither Prudential Annuities, nor the Prudential entity(ies) set forth on this
form, are acting as your fiduciary as defined by any applicable laws and regulations. Please consult with your qualified
investment professional about managing or investing your retirement savings.
Annuities Service Center
Investor Line: 1-888-778-2888
Financial Professionals: 1-800-513-0805
8:00AM–7:00PM ET, Monday–Thursday
8:00AM–6:00PM ET, Friday
Fax: (800) 576-1217
www.prudentialannuities.com
Regular Mail Delivery
Annuities Service Center
P.O. Box 7960
Philadelphia, PA 19176
Overnight Service, Certified or
Registered Mail Delivery
Prudential Annuities Service Center
2101 Welsh Road
Dresher, PA 19025
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