Fill and Sign the Commercial Lease Application Form

PRUDENTIAL DATA TRANSMITTAL FORM ANNUITANT INFORMATION FAX: ANNUITANT 1: MAIL: 200 Wood Avenue South Mailstop 219 Iselin, NJ 08830 732-482-8935 Last Name First Name M.I. Date of Birth Sex M F JOINT MEASURING LIFE 1 (If Applicable): SS# Last Name Street Address First Name City State Date of Birth Zip Code M.I. Sex M F SS# PAYMENT INFORMATION (If other than Annuitant) Payee Name Street Address City State Zip Code BENEFICIARY INFORMATION ALL FIELDS MUST BE COMPLETED. IF A BENEFICIARY IS NOT NAMED, THEN THE ESTATE WILL BE NAMED THE BENEFICIARY. 1. If more than one primary or contingent beneficiary, benefits will be paid equally or to the survivor unless otherwise stated. 2. If annuitant is a minor, beneficiary must be the Estate of the minor unless beneficiary is named in the Court Order. 3. Payments will only be made to contingent beneficiary if all primary beneficiaries are no longer living at the time of the annuitant’s death. PRIMARY BENEFICIARY: Last Name First Name Social Security Number Date of Birth M.I. Relationship to Annuitant Last Name First Name Social Security Number Date of Birth M.I. Relationship to Annuitant CONTINGENT BENEFICIARY (IF APPLICABLE): Last Name First Name Social Security Number Date of Birth M.I. Relationship to Annuitant Last Name First Name Social Security Number Date of Birth M.I. Relationship to Annuitant OWNER INFORMATION SALES INFORMATION / AGENT OF RECORD Owner Name Brokerage Firm Street Address Office Location City Agent Last Name State Zip Code Agent First Name Owner Tax ID Agent M.I. Sales Jurisdiction COMMISSIONS Is there a commission sharing agreement on this case? YES NO If “yes,” please attach a copy of the split agreement and indicate which office will handle all paperwork. TYPE OF SETTLEMENT Liability Workers Compensation MSA Attorney’s Fee DATE COMPLETED STATE DISCLOSURE REQUIREMENT MN FL MA Disclosure Mailed GUFM004 Printed 05/2010