Long, Randi J. - Pruco Life Policy #V2 583 539

Pruco Life Insurance Company a Prudential Financial company

V2583539

POLICY NUMBER (IF KNOWN):

RANDI J LONG

PRIMARY PROPOSED INSURED:

1. Has a member of the medical profession ever treated you for or diagnosed you with: a. amyotrophic lateral sclerosis (ALS, Lou Gehrig’s Disease), Huntington’s chorea, ataxia, transverse myelitis or myasthenia gravis? b. chronic, recurrent, or persistent memory loss or confusion; senility, cognitive impairment, dementia or organic brain disease?

o Yes o No o Yes o No o Yes o No o Yes o No o Yes o No x x x x x

c. amputation of more than one limb?

d. more than one transient ischemic attack (TIA, mini stroke)?

e. osteoporosis with compression fracture(s) or other related fracture(s), post polio syndrome or chronic pain syndrome?

2. Within the past 2 years, have you: a. been advised by a member of the medical profession to discontinue the driving of an automobile?

o Yes o No x

b. fallen more than once, been in a long term care facility, nursing home, required the services of a home health care provider, or attended adult day care? c. been declined for long term care insurance including coverage offered as a rider to a life insurance or other policy? 3. Do you currently: a. need, or have you been advised to receive, help or supervision with personal hygiene, toilet use, eating, taking medication, getting in or out of a bed or chair, walking, dressing or bathing? b. use a wheelchair, motorized scooter, walker, quad cane, stairlift, oxygen, respirator, catheter or dialysis machine? c. need help or supervision with laundry, cleaning, shopping, using the telephone, meal preparation, managing finances, managing your medication, use of transportation or yard work?

o Yes o No o Yes o No x x

o Yes o No o Yes o No x x

o Yes o No o Yes o No o Yes o No x x x

d. receive any long term care benefits?

e. have or have you applied for a handicap placard or handicap license plate?

Give complete details of any “Yes” answer(s) to questions 1-3 including: Question number, diagnosis/condition, date, treatment, and the name, address and telephone number of all attending physicians and hospitals. Question # Diagnosis/Condition Date Treatment Physician/Hospital Name, Address & Phone Number

ORD 96200-2013AP

BENEFITACCESS RIDER

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