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Long-Term Care Insurance(2)

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					Long-Term Care Insurance
This booklet is intended to be a summary of State of New Jersey Long-Term
Care (LTC) Insurance benefits from The Prudential Insurance Company of America and does
not include all plan provisions, exclusions and limitations. Details of your LTC coverage can
be found in your certificate. If there are any discrepancies between this booklet and the
certificate, the certificate governs. This coverage may not be available in all states.

The long-term care insurance described in this booklet is intended to be federally tax
qualified long-term care insurance as defined by the Internal Revenue Code Section
7702B (b). As such, the benefits you may receive under this plan may not be considered
taxable income. In addition, some or all of the premiums you may pay toward this
coverage may be tax deductible as a medical expense subject to certain limitations.
Consult a tax advisor for more information concerning this deduction.

Important: Within 30 days of receipt, if you decide you do not want this Long-Term
Care coverage, you may return it to: The Prudential Insurance Company of America,
Long-Term Care Customer Service Center, P.O. Box 8526, Philadelphia, PA 19176.
Your coverage will be canceled as of the Effective Date and any premium paid will be
returned to you within 10 days of receiving your cancellation request. If premiums are
not returned within 30 days, Prudential will pay you interest on any premiums paid
from the date Prudential receives notice of your cancellation.

State of New Jersey Long-Term Care Insurance, underwritten by The Prudential
Insurance Company of America, is a logical step in a comprehensive blueprint to help with
sound financial planning. Just as you would not wait until your house is on fire
before getting a good homeowner’s policy, it makes sense not to put off planning
for something as probable as needing long-term care.

There is a good chance that some day, you may need to cover the care that you or
someone you love may need—at home, in an assisted living facility, or in a nursing home.

Take a look at the rates in this booklet. You’ll see that long-term care insurance
premiums can be affordable and won’t increase solely because you age or your
health deteriorates. Premiums can only be increased on a rate-class basis.
What Is Long-Term Care Insurance?
          And Why Do You Need It?

          Long-term care refers to a very broad range of medical,
          personal and social services provided to people who are
          unable to care for themselves over a relatively long period
          of time. It usually involves assistance in performing every-
          day functions such as toileting, bathing, eating and
          dressing. You may even know people who need this kind of
          care. Contrary to what most people believe, long-term care
          is not limited to a nursing home. Services are often provided
          in an assisted living facility or at home by caregivers such
          as home health care workers, nurses or therapists, or in
          community-based settings such as adult day care centers.

          Long-term care insurance helps you pay for costs associated
          with these kinds of services, whether at home, in an assisted
          living facility or adult day care center, or in a nursing home.

          The ultimate purpose of long-term care insurance is to help
          individuals retain their independence as long as possible,
          help assure that they may have freedom and choice in where
          they receive assistance, and help preserve their assets.
Before you can understand what long-term care insurance covers, you need
some understanding of the current long-term care situation in our country,
what long-term care is and what the chances are that you’ll need it. Some
of these facts are sobering:

                  60% of all Americans who reach age 65
            may need long-term care at some point in their lives.1
                     That’s more than a 1-in-2 chance!

              We all have a good chance of reaching age 65.
       Of the American population, 1 in 8 is now age 65 and older.2

                       The annual cost of a nursing home stay
                             is approximately $61,000.3

              Home health care is costly as well. Just three home
               health visits per week can cost $30,000 per year.4

                      It’s not just an issue for older people.
                    40% of people receiving long-term care are
                             between ages 18 and 64.5



As you give this issue your attention and hopefully decide to act now, here is
another fact you’ll want to take particular note of:

According to a survey by the Health Insurance Association of America
(HIAA), over 98% of employees purchasing long-term care insurance
through their employers say the policies make them feel more secure
about their future. Employees cite protecting assets, leaving an estate,
preserving financial independence and guaranteeing that they will be
able to get needed services as the more important reasons for buying
long-term care insurance.6




1 The Looming Crisis, American Health Care Association, 2000.
2 Senior Living: Beyond the Nursing Home, American Demographics, November 2000, p. 60.
3 Prudential Financial Long Term Care Cost Survey, 2004.
4 Prudential Financial Long Term Care Cost Survey, 2004.
5 Americans for Long Term Care Security (ALTCS), “Did You Know”,
  webpage, http://www.ltcweb.org/learn.html, 7/26/01.
6 Insurance Letter, November 9, 2001.
Once you are familiar with what long-term care is and the many reasons why
you may want to have this important coverage, you’ll want to feel confident
that Prudential’s plan could be a good one for you. With Prudential’s Long
Term CareSM Insurance plan, you select the amounts you would like to be
reimbursed for daily nursing home and home and community-based care.
The benefits you receive are determined by your Daily Maximum option
and your Lifetime Maximum option. Once you qualify for benefits, you must
satisfy the waiting period. Please review the plan details for specifics on your
plan. There are also many valuable features offered through Prudential’s plan
you’ll want to familiarize yourself with in the Plan Details section.

I M P O R TA N T P O I N T S A B O U T T H E P L A N
PREMIUMS
You may be asking yourself, “Why do I need to worry about long-term care
insurance right now? Can’t this wait until I am older?” Your premium is
based on your age when you enroll. Enrolling now at your current age allows
for a lower premium than if you wait to enroll when you are older. This
premium can change only if Prudential changes premiums for all members
of your insured class.

PORTABILITY
You may keep this coverage even if you decide to change jobs. Your coverage
will remain in effect as long as you continue to pay your premiums on a
timely basis and do not exhaust your benefits.

QUALIFYING FOR BENEFITS
In order to qualify for benefits, you must be confirmed as having a Chronic
Illness or Disability. A Chronic Illness or Disability is defined as an illness or
disability certified by a Licensed Health Care Practitioner in which there is
(1) a loss of the ability to perform, without Substantial Assistance, at least
two Activities of Daily Living. This loss must be expected to continue for 90
days. Activities of daily living include bathing, continence, dressing, eating,
toileting, and transferring; (2) a severe cognitive impairment which requires
Substantial Supervision to protect you from threats to health or safety.
Once you are determined to be eligible for benefits and have satisfied the waiting
period, benefits will be payable according to the Plan of Care developed for you
by the Licensed Health Care Practitioner responsible for your care.

ACCESSING BENEFITS?
Prudential wants to make using your benefits as easy as possible. To begin the
benefits process, call our Long-Term Care Customer Service Center toll-free at
1-877-582-4865 before you incur charges for long-term care services. You can
arrange for your own assessment or Prudential can do it for you.

HOW DO I ENROLL?
To enroll, simply complete the appropriate enrollment form(s) included in the
Forms section of this kit. Return the completed enrollment form(s) to Prudential
using the envelope provided. A separate form must be submitted for each
person who applies for coverage. For more information about your plan, go
to Prudential’s website at https://gltc.prudential.com/gltc/nj


Prudential’s customer service representatives are here to help if you have any
questions or needed additional enrollment kits. You may call Prudential at
1-877-582-4865.

ABOUT PRUDENTIAL
Prudential has been a trusted and reliable source of insurance and employee
benefits products for most of the last century. As a provider of group life
insurance coverage since 1916 and a provider of group long-term care
insurance since 1986, Prudential Financial’s distinctive Rock logo and the
Prudential name are among the most enduring brands in U.S. corporate
history. Prudential is recognized for services and product features that meet
diverse employee needs.




Prudential Long Term CareSM Insurance is underwritten by The Prudential Insurance Company of America,
751 Broad Street, Newark, NJ 07102. (800) 732-0146. Please refer to your Booklet-Certificate for all plan details,
including any exclusions, limitations and restrictions which may apply. Contract Series: 83500. The Prudential
Insurance Company of America is a Prudential Financial company.

INST-A008617
Standard Provisions and Plan Features for:
         THE STATE OF NEW JERSEY LONG TERM CARE INSURANCE PLAN
Underwritten by The Prudential Insurance Company of America
Eligibility to        To participate, you must be a State of New Jersey Public Employee, actively-at-work
Participate           full-time or part-time employee, retiree or the: spouse, domestic partner* of an active or retired
                      employee, parent, step-parent, parent-in-law, step-parent-in-law, adult child, adult step-child,
                      adult child’s spouse/domestic partner, grandparent, step-grandparent, grandparent-in-law,
                      step-grandparent-in-law and retirees, retirees spouse, domestic partner and surviving annuitants.
                      You must be at least 18 but less than age 85 to be eligible to enroll.
                      *ID – Domestic Partner coverage available to Opposite-Sex Partner only in Idaho.
                      *VA - Domestic Partner coverage is not available to residents of Virginia.
Coverage Amounts
                          Daily Benefit       Nursing Home & Assisted       Home & Community             Lifetime Maximum
                            Options             Living Facility Daily        Based Care Daily                 Options**
                                                    Maximum*                 Maximum Options                  3yr & 5yr
                                                                              50% & 75% *
  3yr 50% HHC                Plan   1                    $100                        $50                    $109,500
                             Plan   2                    $150                        $75                    $164,250
                             Plan   3                    $200                       $100                    $219,000
                             Plan   4                    $250                       $125                    $273,750
  3yr 75% HHC                Plan   5                    $100                       $ 75                    $109,500
                             Plan   6                    $150                       $113                    $164,250
                             Plan   7                    $200                       $150                    $219,000
                             Plan   8                    $250                       $188                    $273,750
  5 yr 50% HHC              Plan     9                   $100                       $ 50                    $182,500
                            Plan    10                   $150                       $ 75                    $273,750
                            Plan    11                   $200                       $ 100                   $365,000
                            Plan    12                   $250                       $ 125                   $456,250
  5 yr 75% HHC              Plan    13                   $100                       $ 75                    $182,500
                            Plan    14                   $150                       $ 113                   $273,750
                            Plan    15                   $200                       $ 150                   $365,000
                            Plan 16                      $250                       $ 188                   $456,250

                     If you are interested in the Unlimited Lifetime Maximum please call the Prudential Long Term Care
                     Customer Service Center at 877/LTC-4UNJ (877/582-4865) for additional information or visit the website
                     at http://www.state.nj.us/treasury/pensions/ltchomepg.htm

                       *Benefits are paid up to the Daily Maximum
                       **All benefits paid will be deducted from the Lifetime Maximum
                       Note: Applicants age 72 and older will receive an in-person assessment to supplement the information
                      provided on the enrollment form.
Medical Evidence      State of New Jersey Public Employees, Actively at work, Full-time, Part-time Employees,
Requirements          Retired Employees and eligible family members, must complete a medical questionnaire.
                      See “Who Can Enroll For This Coverage” on the Enrollment Instructions
Information/          Prudential is dedicated to helping provide you with as much freedom as possible when it comes
Referral Services     to making your long term care decisions. Information/referral services, and advice and care
                      counseling are provided by Prudential Care Counselors who are available to Insureds at any time,
                      even if an Insured has not yet been determined eligible to receive benefits. Prudential Care
                      Counselors may be reached toll free at 1-800-732-0416 Monday through Friday 8am to 8pm
                      EST.
                      In the event you decide you would rather use care management services other than Prudential
                      Care Counselors, Prudential will reimburse you for private care management consultations up to
                      the calendar year limit equal to the elected Institutional Care Daily Maximum times six.
Benefit Waiting/      Before benefits are payable, you must satisfy the 90-day Benefit Waiting/Elimination Period.
Elimination Period    This period is counted in calendar days and begins on the date you contact Prudential to arrange
                      for an assessment, assuming you are determined to be eligible for benefits. You do NOT need to
                      receive formal long term care services to satisfy the waiting period. This waiting period needs to
                      be satisfied only once during your lifetime.
                      Note: There is no waiting period for Hospice Care, Independence Support, Caregiver
                      Training, Information and Referral Services or Private Care Management.
Waiver of             Once an Insured satisfies the Benefit Waiting/Elimination Period, Prudential will waive the
Premium               Insured’s premium payments.
Restoration of       If a claimant returns to normal activities (no Activity of Daily Living limitations or cognitive
Benefits             impairment) for at least six months, the Lifetime Maximum will be restored to the level in effect
                     as if the Insured had never made a claim.
Independence         Very often, a few modifications to one’s home can mean the difference between going to a
Support Benefit      Nursing Home/Assisted Living Facility and remaining at home – the place many people would
                     prefer to receive care if given the choice. This benefit allows Insureds who are not in a Nursing
                     Home/Assisted Living Facility to receive benefits for expenses such as home modifications or
                     medical alert systems to help maintain their independence. An Insured must meet Prudential’s
                     benefit eligibility criteria to be eligible. No waiting period is required. This benefit will
                     reimburse the Insured up to five times the elected Institutional Care Daily Maximum for costs
                     incurred for such things as home modifications and medical alert systems.
Bed Reservation    Families may spend a great deal of time and effort locating a suitable Nursing Home or Assisted
Benefit            Living Facility only to lose the bed because of a short absence due to a hospital stay. This benefit
                   helps to reserve the Insured’s bed in a Nursing Home or Assisted Living Facility for up to 21 days
                   for each hospital stay.
Death Benefit      If the Insured should die before the age of 75, a portion of the premiums may be refunded to the
                   Insured’s spouse, domestic partner (if applicable, otherwise to the Insured’s estate). The
                   percentage of premiums to be refunded is based on the Insured’s age at death. The refund will be
                   reduced by any benefits paid.
                                            Age                                    % of Premium Refunded
                                                                                        (less benefits paid)
                                      69 or Younger                                             50%
                                             70                                                 40%
                                             71                                                 30%
                                             72                                                 20%
                                             73                                                 10%
                                             74                                                 10%
                                        75 & Older                                               0%
Respite Care       This benefit provides a family member who normally provides unpaid care to the Insured. The
                   Plan pays for up to 21 days of Respite Care per calendar year. The benefits are paid up to the
                   elected Institutional Care Daily Maximum regardless of the type of services used. Prudential must
                   be notified prior to using services in order to access this benefit.
Informal Care      This benefit helps compensate an unpaid person, typically a family member or friend, who
                   regularly provides home health care or personal care to the Insured at home. This includes
                   assistance with activities of daily living. The Calendar Year Maximum Benefit for informal care
                   equals 25% of the elected Institutional Care Daily Maximum, multiplied by 30.
Caregiver Training If someone who will be providing care for the Insured but requires training in how to be
                    a caregiver, there is a benefit equal to a $500 Lifetime Maximum per Insured for this training,
                   and no waiting period is required.
Alternate Plan of    Prudential recognizes there are emerging trends in the delivery of long term care. This Plan takes
Care                 into account the current Institutional and Home and Community-Based Care settings that are
                     available. Prudential will consider a claim for benefits for care received in an alternate setting or
                     for non-institutional services designed to help an eligible Insured remain independent in his or
                     her home. Determination of eligibility for this benefit amount will be made on an individual
                     basis at the sole discretion of Prudential.
Periodic Inflation   As part of the Plan, inflation protection will be offered every 3 years to anyone who does not
Protection           elect the optional Automatic Inflation Protection (see Optional Features section). No medical
                     underwriting is required unless an Insured declines two consecutive inflation offerings.
                     Coverage amounts are increased by 5% per year, compounded annually. Rates for this additional
                     coverage will be based on the age of the Insured at the time the inflation offer is accepted.
  Optional Features
  Automatic Compound Inflation             It is very likely that you may not need to make use of your long term
  Increase Option                          care insurance coverage for 10, 20, maybe even 30 years. For this
                                           reason, we offer you the choice of inflation protection. This feature
                                           will help protect your benefits against the effects of inflation
                                           regardless of changes in your future health status.

                                           Should you elect this option, your benefits will automatically increase by
                                           5% compounded annually, while your premiums remain constant. If you
                                           do not elect this option, Prudential will offer you opportunities to
                                           increase your coverage over time, but the rates for the increase will be
                                           based on your age when the increase takes effect.
 Non-Forfeiture Benefit –                  Some people feel more comfortable knowing they may get something
 “Shortened Benefit                        out of their insurance plan even if they decide to stop paying premiums
 Period Option”                            at some point in the future. This option will allow the Insured to retain
                                           access to a portion of the insurance benefits in the event the Insured
                                           ceases making premium payments. The Insured must pay premiums for
                                           at least 3 full years to accrue these non-forfeiture benefits. If the Insured
                                           stops paying premiums, the Insured’s new Lifetime Maximum will be
                                           equal to the amount of premiums the Insured paid less any benefits
                                           received under the plan (but not less than 30 times the Institutional Care
                                           Daily Maximum).
Other options are also available:
             o    Monthly Benefit – This benefit converts Home and Community Based Care from a
                                    Daily Benefit Maximum to a Monthly Benefit Maximum.
                                     Example: $50 Home & Community-Based Care Benefit
                                                   x 30 days, equals a $1500 Monthly Benefit
             o    365 Day Benefit Waiting Elimination Period

         If you are interested in the Monthly Benefit Rider or 365 Day Benefit Waiting/Elimination Period, please call the
         Prudential Long Term Care Customer Service Center at 877/LTC-4UNJ (877/582-4865) or visit the website at
         http://www.state.nj.us/treasury/pensions/ltchomepg.htm


Important Points To Keep In Mind:

Delay of Effective Date – This limitation applies only to those individuals who are eligible for simplified underwriting and
complete the Short Enrollment Form. The effective date of your insurance will be delayed if on the date your insurance
would otherwise take effect you are not actively at work. The effective date will be delayed until the first day of the month
following the date you, as an Employee, return to work.

Coordination of Benefits – The benefits of this plan may be coordinated with certain other coverages that provide benefits
for the same services covered by this insurance. Consult your insurance certificate for more details.

The Plan Details and other sections of this booklet contain terms related to the State of New Jersey Long Term Care
Insurance Plan that you may want to see defined. This section is intended to do that. Some state variations may apply.
Since benefits may vary by state, please carefully review the outline of coverage and your insurance certificate for possible
state variations.

Exclusions
This plan is designed to provide coverage to pay for the long term care you need when you need it. However, there are
some special circumstances that limit or exclude the availability of benefits under this plan. While state variations may
apply to specific limitations and exclusions, generally, no benefits will be payable if any of the following situations apply:

Work-connected Conditions Charge: A charge covered by a workers compensation law, occupational disease law or
similar law.

Government Plan Charge: A charge for a service or supply (a) furnished by or for the United States government or any
other government, unless payment of the charge is required by law; or (b) to the extent that the service or supply, or any
benefit for the charge, is provided by any law or governmental plan under which the patient is or could be covered. This
(b) does not apply to a state plan under Medicaid or to any law or plan when, by law, its benefits are excess to those of any
private insurance program or other non-governmental program. When this (b) is applied to Medicare, the benefits provided
by Medicare will be deemed to include any amount that would have been payable by Medicare in the absence of a
deductible or coinsurance requirement under that program.
Self-inflicted Injury or Suicide: Charges arising from intentionally self-inflicted injury or attempted suicide, while sane or
suffering from inorganic-based insanity.
Services and Supplies Outside the United States: Charges for services or supplies outside of the United States and its
possessions.
Treatment for Chronic Alcoholism or Chemical Dependency: Charges in connection with the treatment of chronic
alcoholism or chemical dependency.
War, Felony, Riot or Insurrection: Charges for a condition due to war or any act of war while you are insured or due to
the insured’s participation in an act of felony, riot or insurrection. War means declared or undeclared war and includes
resistance to armed aggression. Riot means a wild, violent, public disturbance of the peace.
The Plan Details and other sections of this booklet contain terms related to the State of New Jersey Long Term Care
Insurance Plan that you may want to see defined. This section is intended to do that. Some state variations may apply.
Since benefits may vary by state, please carefully review the outline of coverage and your insurance certificate for possible
state variations.

Definitions
The following are definitions of terms and phrases used in this Plan. Some state variations may apply.           Please carefully
review your insurance certificate for possible state variations in these definitions.

Activities of Daily Living
Bathing – Washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of
the tub or shower.
Continence – The ability to maintain control of bowel and bladder function, or, when unable to maintain control of
bowel or bladder function, the ability to perform associate personal hygiene (including caring for catheter or
colostomy bag).
Dressing – Putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.
Eating – Feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by feeding
tube or intravenously.
Toileting – Getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.
Transferring – Sufficient mobility to move into or out of a bed, chair or wheelchair, or to move from place to place,
either by walking, using a wheelchair or by other means.

Adult Day Care Facility
An Adult Day Care Facility is a facility that is licensed or certified as an Adult Day Care Facility by the state in which the
services are rendered. If a state does not license or certify an Adult Day Care Facility, the adult day care program must be
licensed or certified by the state in which services are rendered.

Assessor
A Licensed Health Care Practitioner who is qualified to evaluate conditions relevant to your functional or cognitive ability.
Qualifications are based on training and experience, and may include health care industry, state or national standards.

Assisted Living Facility
For an Assisted Living Facility that is located in a state that licenses or certifies such a facility, an Assisted Living Facility
is one which is licensed or certified by the state in which the facility is located. For facilities located in states that do not
license or certify Assisted Living Facilities, an Assisted Living Facility is one that meets, in Prudential’s judgment, the
following minimum criteria.

1)       It is a group residence that maintains records for services to each resident.
2)       It provides services and oversight on a 24 hour a day basis which support a resident in a
       manner that promotes dignity, independence, and privacy.
3)       It provides a combination of housing, supportive services, and personal assistance
       designed to respond to the resident’s need for help with Activities of Daily Living
       and instrumental activities of daily living.
4)       It provides, at a minimum, assistance with Bathing, Dressing, and help with medications.
5)       It is NOT licensed as a Nursing Home.
The criteria is based on established, national industry standards such as those developed by The Assisted Living Quality
Coalition, The Assisted Living Federation of America, The American Association of Homes and Services for the Aging,
and The Joint Commission on the Accreditation of Health Organizations.
Chronic Illness or Disability
A Chronic Illness or Disability is defined as an illness or disability certified by a Licensed Health Care Practitioner in
which there is (1) a loss of the ability to perform, without Substantial Assistance, at least two Activities of Daily Living.
This loss must be expected to continue for 90 days. (Activities of Daily Living include bathing, continence, dressing,
eating, toileting and transferring); or (2) a severe cognitive impairment which requires Substantial Supervision to protect
you from threats to health or safety.

Cognitive Impairment
A loss or deterioration in intellectual capacity that is (a) comparable to and includes Alzheimer’s Disease and similar forms
of irreversible dementia; and (b) measured by clinical evidence and standardized tests that reliably measure impairment in
the individual’s (i) short-term or long-term memory, (ii) orientation as to people, places, or time, and (iii) deductive or
abstract reasoning.

Daily Maximum
The maximum amount payable for one day’s worth of covered long term care services. This amount varies based on the
services provided.

Home & Community-Based Care
Home and Community-Based Care is Home Health Care or Personal Care received from a Home Health Care Agency, a
Licensed Referral Agency, a licensed Nurse Registry or informal caregiver, or provided by an Independent Health Care
Professional and Adult Day Care received from an Adult Day Care Facility.

Informal Caregiver
An informal caregiver is an unpaid person, typically a family member or friend, who regularly provides Home Health Care
or Personal Care to you in your home. This would include assistance with the Activities of Daily Living.

Licensed Health Care Practitioner
A Licensed Health Care Practitioner is a Physician, a Registered Nurse, a licensed social worker, or another professional
individual who meets the requirements prescribed by the United States Secretary of the Treasury.

Long Term Care
Long Term Care is medical, social and/or Personal Care services required over a long period of time by a person with a
Chronic Illness or Disability. Long Term Care can include care in an Assisted Living Facility or Nursing Home, Adult
Day Care, Home and Community-Based Care, Hospice Care, or Respite Care.

Nursing Home
A Nursing Home is a facility that provides skilled, intermediate, or custodial care and meets at least one of the following
criteria: (1) is Medicare-approved as a Provider of skilled nursing care services, (2) is licensed by the state in which it is
located as a skilled nursing home, an intermediate care facility, or a custodial care facility, or (3) meets all the following
criteria: (a) its main function is to provide skilled, intermediate or custodial nursing care, (b) it is engaged in providing
continuous room and board accommodations for three or more persons, (c) it has a Physician on staff or available to it
under contract, (d) it is under the supervision of a Registered Nurse or Licensed Practical Nurse, (e) it maintains medical
records for each patient, and (f) it maintains control of and records of all medications dispensed.

Plan of Care
A written plan that: (1) has been developed for you, (2) describes the type, the frequency, and the duration of Long Term
Care that you need, (3) describes the types of providers that are needed, and (4) is signed by the Licensed Health Care
Practitioner responsible for your care.

Private Care Manager
A Private Care Manager is a private Licensed Health Care Practitioner, not associated with Prudential, who is qualified to
coordinate your necessary Long Term Care, medical care, personal care and social services. Qualifications are based on
training and experience and can include health care industry, state or national standards.

Substantial Assistance
The physical assistance of another person without which you would not be able to perform an Activity of Daily Living or
the constant presence of another person within arms reach which is necessary to prevent, by physical intervention, injury to
you while you are performing an Activity of Daily Living.

Substantial Supervision
Continual oversight that may include cueing by verbal prompting, gestures or other demonstrations by another person and
which is necessary to protect you from threats to your health or safety.
This brochure has been designed to provide you with a brief summary of the important provisions of the Prudential Long Term CareSM
Insurance plan. This is not an insurance policy or contract. Issuance of coverage may be subject to Prudential’s underwriting requirements.
The insurance certificate you will receive, if you are approved for coverage, describes in detail the benefit, limitations, and exclusions of this
coverage. Since benefits vary by state, please carefully review your insurance certificate for possible state variations. The Prudential Insurance
Company of America is licensed in all states. All plans and options may not be available in your state. Coverage is issued under Prudential
Long Term CareSM Insurance 83500 contract series. If there are any discrepancies between this brochure and the certificate, the certificate
governs. Please be sure to review the Outline of Coverage for definitions of important terms and more details of Prudential Long Term
CareSM Insurance and its features.

Prudential Long Term CareSM Insurance is underwritten by The Prudential Insurance Company of America; 751 Broad Street, Newark,
NJ 07102-3777. (800) 732-0416. Contract Series: 83500

Prudential Financial is a registered service mark of The Prudential Insurance Company of America, Newark, NJ and affiliates.

The Prudential Insurance Company of America is a Prudential Financial company.

INST-A008619 SNJ
          How To Determine Your Rate
1. Select the plan below that best meets your needs (see Plan Details for a
   description of Optional Plan Features).

                      Basic Plan
                      Basic Plan plus Shortened Benefit Period
                      Basic Plan plus Automatic Inflation
                      Basic Plan plus Automatic Inflation & Shortened Benefit
                      Period


2. Select the Plan Number for the Daily Maximum Option and Lifetime
   Maximum that best meets your needs.

                         Institutional  Home &
                             Care      Community
                             Daily     Based Care           Lifetime
                          Maximum Daily Maximum             Maximum
         Plan 1              $100          $50              $109,500
         Plan 2              $150          $75              $164,250
         Plan 3              $200         $100              $219,000
         Plan 4              $250         $125              $273,750
         Plan 5              $100          $75              $109,500
         Plan 6              $150         $113              $164,250
         Plan 7              $200         $150              $219,000
         Plan 8              $250         $188              $273,750
         Plan 9              $100          $50              $182,500
         Plan 10             $150         $75               $273,750
         Plan 11             $200         $100              $365,000
         Plan 12             $250         $125              $456,250
         Plan 13             $100         $75               $182,500
         Plan 14             $150         $113              $273,750
         Plan 15             $200         $150              $365,000
         Plan 16             $250         $188              $456,250
3. Locate your age on the appropriate rate sheet and read across to your selected
   plan [from Step 1]. Then locate your selected Plan Number within that plan
   [from Step 2].


4. The total annual premium payable may vary based on the frequency of
   premium payment and the method of payment (payroll deduction, direct billing,
   EFT). To calculate the total annual premium cost of each of the options
   available to you, multiply your monthly premium rate (from Step 3 or Step 4)
   by the appropriate factor from the table below:

                          Payment         Annual Cost
                            Mode            Factor
                          Direct Bill
                           Annual             11.33
                          Direct Bill
                         Semi-Annual          11.66
                          All Other
                           Modes              12.00

EXAMPLE
    If you select the Basic Plan Option, Plan 1, $100, and if you are 35 years
    old, your monthly premium rate will be $8.33.

       If you elect to make two premium payments per year (semi-annual
       premium payments), your annual premium cost would be $8.33 x 11.66 =
       $97.13.




If you would prefer to have a Prudential Customer Service operator assist you with
these calculations, you may call 1-800-732-0416.
                                                     Monthly Long Term Care Premium Rates
                                                             For State of New Jersey
                                                             50% Home Health Care
                                                           3 Year Lifetime Maximum
                                                             90 Day Waiting Period


                                                     Basic Plan                               Basic Plan                           Basic Plan
                      Basic                             Plus                                    Plus                        Plus Automatic Inflation
                      Plan                     Shortened Benefit Period                   Automatic Inflation              & Shortened Benefit Period
        Plan 1   Plan 2   Plan 3   Plan 4   Plan 1    Plan 2   Plan 3   Plan 4   Plan 1     Plan 2   Plan 3     Plan 4   Plan 1   Plan 2   Plan 3   Plan 4
Age     $100     $150     $200     $250     $100       $150    $200     $250     $100       $150     $200       $250     $100     $150     $200     $250
18-30    6.43     9.55    12.66    15.78     7.12      10.58   14.03     17.49    30.35      45.43    60.50      75.58   33.67     50.41    67.13    83.87
 31      6.81    10.12    13.42    16.73     7.54      11.21   14.87     18.55    31.53      47.20    62.86      78.53   34.98     52.37    69.75    87.15
 32      7.19    10.69    14.18    17.68     7.96      11.84   15.72     19.60    32.71      48.97    65.22      81.48   36.29     54.33    72.37    90.42
 33      7.57    11.26    14.94    18.63     8.38      12.48   16.56     20.66    33.89      50.74    67.58      84.43   37.60     56.30    74.99    93.70
 34      7.95    11.83    15.70    19.58     8.80      13.11   17.41     21.71    35.07      52.51    69.94      87.38   38.91     58.26    77.61    96.97
 35      8.33    12.40    16.46    20.53     9.22      13.74   18.25     22.77    36.25      54.28    72.30      90.33   40.22     60.23    80.23   100.24
 36      8.71    12.97    17.22    21.48     9.65      14.37   19.09     23.82    37.43      56.05    74.66      93.28   41.53     62.19    82.85   103.52
 37      9.09    13.54    17.98    22.43    10.07      15.01   19.94     24.88    38.61      57.82    77.02      96.23   42.84     64.16    85.47   106.79
 38      9.47    14.11    18.74    23.38    10.49      15.64   20.78     25.93    39.79      59.59    79.38      99.18   44.14     66.12    88.09   110.07
 39      9.85    14.68    19.50    24.33    10.91      16.27   21.62     26.98    40.97      61.36    81.74     102.13    45.45    68.09    90.71   113.34
 40     10.26    15.29    20.32    25.35    11.37      16.95   22.53     28.12    42.11      63.07    84.02     104.98    46.72    69.99    93.24   116.51
 41     11.04    16.46    21.88    27.30    12.23      18.25   24.26     30.28    43.85      65.68    87.50     109.33    48.65    72.88    97.10   121.33
 42     11.82    17.63    23.44    29.25    13.10      19.55   26.00     32.45    45.59      68.29    90.98     113.68    50.58    75.78   100.97   126.16
 43     12.60    18.80    25.00    31.20    13.96      20.85   27.73     34.61    47.33      70.90    94.46     118.03    52.51    78.68   104.83   130.99
 44     13.38    19.97    26.56    33.15    14.83      22.14   29.46     36.77    49.07      73.51    97.94     122.38    54.45    81.57   108.69   135.82
 45     14.16    21.14    28.12    35.10    15.70      23.44   31.19     38.94    50.81      76.12   101.42     126.73   56.38     84.47   112.55   140.65
 46     14.94    22.31    29.68    37.05    16.56      24.74   32.92     41.10    52.55      78.73   104.90     131.08   58.31     87.37   116.42   145.48
 47     15.72    23.48    31.24    39.00    17.43      26.04   34.65     43.27    54.29      81.34   108.38     135.43   60.24     90.27   120.28   150.31
 48     16.50    24.65    32.80    40.95    18.29      27.34   36.39     45.43    56.03      83.95   111.86     139.78   62.17     93.16   124.14   155.13
 49     17.28    25.82    34.36    42.90    19.16      28.64   38.12     47.60    57.77      86.56   115.34     144.13   64.10     96.06   128.01   159.96
 50     18.09    27.04    35.98    44.93    20.06      29.99   39.92     49.85    59.50      89.15   118.80     148.45   66.02     98.93   131.85   164.76
 51     20.18    30.17    40.16    50.15    22.38      33.47   44.56     55.64    64.03      95.95   127.86     159.78   71.05    106.48   141.90   177.33
 52     22.27    33.31    44.34    55.38    24.70      36.95   49.20     61.45    68.56     102.74   136.92     171.10   76.08    114.02   151.96   189.90
 53     24.36    36.44    48.52    60.60    27.02      40.43   53.84     67.24    73.09     109.54   145.98     182.43   81.11    121.57   162.02   202.48
 54     26.45    39.58    52.70    65.83    29.34      43.91   58.48     73.05    77.62     116.33   155.04     193.75   86.14    129.10   172.07   215.04
 55     28.54    42.71    56.88    71.05    31.66      47.39   63.11     78.84    82.15     123.13   164.10     205.08   91.16    136.65   182.13   227.62
 56     30.63    45.85    61.06    76.28    33.98      50.87   67.75     84.65    86.68     129.92   173.16     216.40   96.19    144.19   192.19   240.18
 57     32.72    48.98    65.24    81.50    36.30      54.35   72.39     90.44    91.21     136.72   182.22     227.73   101.22   151.74   202.24   252.76
 58     34.81    52.12    69.42    86.73    38.62      57.83   77.03     96.25    95.74     143.51   191.28     239.05   106.25   159.27   212.30   265.32
 59     36.90    55.25    73.60    91.95    40.94      61.31   81.67    102.04   100.27     150.31   200.34     250.38   111.28   166.82   222.36   277.90
                                                   Monthly Long Term Care Premium Rates
                                                           For State of New Jersey
                                                           50% Home Health Care
                                                         3 Year Lifetime Maximum
                                                           90 Day Waiting Period


                                                   Basic Plan                               Basic Plan                             Basic Plan
                    Basic                             Plus                                    Plus                          Plus Automatic Inflation
                    Plan                     Shortened Benefit Period                   Automatic Inflation                & Shortened Benefit Period
      Plan 1   Plan 2   Plan 3   Plan 4   Plan 1    Plan 2   Plan 3   Plan 4   Plan 1     Plan 2   Plan 3     Plan 4     Plan 1   Plan 2   Plan 3   Plan 4
Age   $100     $150     $200     $250     $100      $150     $200     $250     $100       $150     $200        $250      $100     $150     $200      $250
 60    39.00    58.40   77.80     97.20    43.27     64.80    86.34   107.87   104.78     157.07   209.36      261.65    116.28   174.33   232.37    290.41
 61    43.15    64.63   86.10    107.58    47.87     71.72    95.55   119.39   111.93     167.80   223.66      279.53    124.22   186.24   248.24    310.26
 62    47.30    70.85   94.40    117.95    52.48     78.62   104.76   130.90   119.08     178.52   237.96      297.40    132.16   198.14   264.11    330.09
 63    51.45    77.08   102.70   128.33    57.09     85.54   113.98   142.42   126.23     189.25   252.26      315.28    140.09   210.05   279.99    349.94
 64    55.60    83.30   111.00   138.70    61.69     92.44   123.19   153.94   133.38     199.97   266.56      333.15    148.03   221.94   295.86    369.77
 65    59.75    89.53   119.30   149.08    66.30     99.36   132.40   165.46   140.52     210.68   280.84      351.00    155.96   233.83   311.71    389.59
 66    65.51    98.17   130.82   163.48    72.69    108.95   145.19   181.44   148.51     222.67   296.82      370.98    164.82   247.14   329.45    411.77
 67    71.27   106.81   142.34   177.88    79.09    118.54   157.98   197.42   156.50     234.65   312.80      390.95    173.69   260.44   347.19    433.93
 68    77.03   115.45   153.86   192.28    85.48    128.13   170.76   213.41   164.49     246.64   328.78      410.93    182.56   273.75   364.92    456.11
 69    82.79   124.09   165.38   206.68    91.87    137.72   183.55   229.39   172.48     258.62   344.76      430.90    191.43   287.05   382.66    478.28
 70    88.54   132.71   176.88   221.05    98.26    147.29   196.31   245.34   180.46     270.59   360.72      450.85    200.29   300.33   400.38    500.42
 71   100.44   150.56   200.68   250.80   111.47    167.10   222.73   278.37   193.81     290.62   387.42      484.23    215.11   322.57   430.01    537.47
 72   112.34   168.41   224.48   280.55   124.68    186.91   249.15   311.39   207.16     310.64   414.12      517.60    229.93   344.79   459.65    574.51
 73   124.24   186.26   248.28   310.30   137.88    206.73   275.57   344.41   220.51     330.67   440.82      550.98    244.74   367.02   489.29    611.57
 74   136.14   204.11   272.08   340.05   151.09    226.54   301.99   377.43   233.86     350.69   467.52      584.35    259.56   389.24   518.93    648.61
 75   148.02   221.93   295.84   369.75   164.28    246.32   328.36   410.40   247.23     370.75   494.26      617.78    274.40   411.51   548.61    685.71
 76   168.51   252.67   336.82   420.98   187.02    280.44   373.85   467.27   269.14     403.61   538.08      672.55    298.72   447.99   597.25    746.51
 77   189.00   283.40   377.80   472.20   209.77    314.55   419.34   524.12   291.05     436.48   581.90      727.33    323.04   484.47   645.89    807.31
 78   209.49   314.14   418.78   523.43   232.51    348.67   464.82   580.99   312.96     469.34   625.72      782.10    347.36   520.95   694.53    868.11
 79   229.98   344.87   459.76   574.65   255.26    382.78   510.31   637.84   334.87     502.21   669.54      836.88    371.68   557.43   743.17    928.91
 80   250.48   375.62   500.76   625.90   278.01    416.92   555.82   694.73   356.78     535.07   713.36      891.65    396.00   593.91   791.81    989.71
 81   273.00   409.40   545.80   682.20   303.01    454.41   605.82   757.22   379.27     568.81   758.34      947.88    420.97   631.36   841.74   1,052.12
 82   295.52   443.18   590.84   738.50   328.01    491.91   655.81   819.71   401.76     602.54   803.32     1,004.10   445.93   668.80   891.66   1,114.53
 83   318.04   476.96   635.88   794.80   353.00    529.40   705.80   882.21   424.25     636.28   848.30     1,060.33   470.90   706.25   941.59   1,176.94
 84   340.56   510.74   680.92   851.10   378.00    566.90   755.80   944.70   446.74     670.01   893.28     1,116.55   495.86   743.69   991.52   1,239.35
                                                     Monthly Long Term Care Premium Rates
                                                             For State of New Jersey
                                                             75% Home Health Care
                                                           3 Year Lifetime Maximum
                                                             90 Day Waiting Period


                                                     Basic Plan                               Basic Plan                           Basic Plan
                      Basic                             Plus                                    Plus                        Plus Automatic Inflation
                      Plan                     Shortened Benefit Period                   Automatic Inflation              & Shortened Benefit Period
        Plan 5   Plan 6   Plan 7   Plan 8   Plan 5    Plan 6   Plan 7   Plan 8   Plan 5     Plan 6   Plan 7     Plan 8   Plan 5   Plan 6   Plan 7   Plan 8
Age     $100     $150     $200     $250     $100       $150    $200     $250     $100       $150     $200       $250     $100     $150     $200     $250
18-30    6.87    10.21    13.54    16.88     7.60      11.31   15.01     18.71    32.49      48.64    64.78      80.93    36.04    53.97    71.88    89.81
 31      7.28    10.82    14.36    17.90     8.06      11.99   15.92     19.85    33.76      50.54    67.32      84.10    37.45    56.08    74.70    93.33
 32      7.69    11.44    15.18    18.93     8.51      12.68   16.83     20.99    35.03      52.45    69.86      87.28    38.86    58.20    77.52    96.86
 33      8.10    12.05    16.00    19.95     8.97      13.35   17.74     22.12    36.30      54.35    72.40      90.45    40.27    60.31    80.34   100.38
 34      8.51    12.67    16.82    20.98     9.42      14.04   18.65     23.27    37.57      56.26    74.94      93.63    41.68    62.43    83.16   103.91
 35      8.92    13.28    17.64    22.00     9.88      14.72   19.56     24.40    38.84      58.16    77.48      96.80    43.09    64.54    85.98   107.43
 36      9.33    13.90    18.46    23.03    10.33      15.41   20.47     25.54    40.11      60.07    80.02      99.98    44.50    66.66    88.80   110.96
 37      9.74    14.51    19.28    24.05    10.79      16.08   21.38     26.67    41.38      61.97    82.56     103.15   45.91     68.76    91.62   114.47
 38     10.15    15.13    20.10    25.08    11.24      16.77   22.29     27.82    42.65      63.88    85.10     106.33   47.32     70.88    94.44   118.00
 39     10.56    15.74    20.92    26.10    11.70      17.45   23.20     28.95    43.92      65.78    87.64     109.50   48.73     72.99    97.26   121.52
 40     11.01    16.42    21.82    27.23    12.20      18.20   24.20     30.20    45.21      67.72    90.22     112.73   50.16     75.15   100.12   125.11
 41     11.86    17.69    23.52    29.35    13.14      19.61   26.09     32.56    47.11      70.57    94.02     117.48   52.27     78.31   104.34   130.38
 42     12.71    18.97    25.22    31.48    14.09      21.03   27.97     34.92    49.01      73.42    97.82     122.23   54.38     81.47   108.56   135.65
 43     13.56    20.24    26.92    33.60    15.03      22.44   29.86     37.27    50.91      76.27   101.62     126.98   56.49     84.64   112.78   140.93
 44     14.41    21.52    28.62    35.73    15.97      23.87   31.75     39.64    52.81      79.12   105.42     131.73   58.60     87.80   116.99   146.20
 45     15.26    22.79    30.32    37.85    16.92      25.27   33.63     41.99    54.71      81.97   109.22     136.48   60.71     90.96   121.21   151.47
 46     16.11    24.07    32.02    39.98    17.86      26.70   35.52     44.36    56.61      84.82   113.02     141.23   62.82     94.13   125.43   156.74
 47     16.96    25.34    33.72    42.10    18.80      28.11   37.41     46.71    58.51      87.67   116.82     145.98   64.92     97.29   129.65   162.02
 48     17.81    26.62    35.42    44.23    19.75      29.53   39.29     49.07    60.41      90.52   120.62     150.73   67.03    100.46   133.87   167.29
 49     18.66    27.89    37.12    46.35    20.69      30.94   41.18     51.43    62.31      93.37   124.42     155.48   69.14    103.62   138.08   172.56
 50     19.50    29.15    38.80    48.45    21.62      32.33   43.05     53.76    64.17      96.16   128.14     160.13   71.21    106.72   142.21   177.72
 51     21.70    32.45    43.20    53.95    24.07      36.00   47.93     59.86    68.90     103.25   137.60     171.95   76.46    114.59   152.71   190.84
 52     23.90    35.75    47.60    59.45    26.51      39.66   52.81     65.97    73.63     110.35   147.06     183.78   81.71    122.47   163.21   203.97
 53     26.10    39.05    52.00    64.95    28.95      43.32   57.70     72.07    78.36     117.44   156.52     195.60   86.96    130.34   173.72   217.09
 54     28.30    42.35    56.40    70.45    31.39      46.99   62.58     78.18    83.09     124.54   165.98     207.43   92.21    138.22   184.22   230.23
 55     30.50    45.65    60.80    75.95    33.83      50.65   67.47     84.28    87.82     131.63   175.44     219.25   97.46    146.09   194.72   243.35
 56     32.70    48.95    65.20    81.45    36.28      54.31   72.35     90.39    92.55     138.73   184.90     231.08   102.71   153.97   205.22   256.48
 57     34.90    52.25    69.60    86.95    38.72      57.98   77.23     96.49    97.28     145.82   194.36     242.90   107.96   161.84   215.72   269.60
 58     37.10    55.55    74.00    92.45    41.16      61.64   82.12    102.60   102.01     152.92   203.82     254.73   113.21   169.72   226.22   282.73
 59     39.30    58.85    78.40    97.95    43.60      65.30   87.00    108.70   106.74     160.01   213.28     266.55   118.46   177.59   236.72   295.85
                                                   Monthly Long Term Care Premium Rates
                                                           For State of New Jersey
                                                           75% Home Health Care
                                                         3 Year Lifetime Maximum
                                                           90 Day Waiting Period


                                                   Basic Plan                               Basic Plan                             Basic Plan
                    Basic                             Plus                                    Plus                          Plus Automatic Inflation
                    Plan                     Shortened Benefit Period                   Automatic Inflation                & Shortened Benefit Period
      Plan 5   Plan 6   Plan 7   Plan 8   Plan 5    Plan 6   Plan 7   Plan 8   Plan 5     Plan 6   Plan 7     Plan 8     Plan 5   Plan 6   Plan 7   Plan 8
Age   $100     $150     $200     $250     $100      $150     $200     $250     $100       $150     $200        $250      $100     $150     $200      $250
 60    41.47    62.11    82.74   103.38    46.01     68.92    91.82   114.73   111.45     167.08   222.70      278.33    123.69   185.44   247.18    308.92
 61    45.68    68.42    91.16   113.90    50.68     75.92   101.17   126.41   118.56     177.74   236.92      296.10    131.58   197.27   262.96    328.65
 62    49.89    74.74    99.58   124.43    55.36     82.94   110.51   138.10   125.67     188.41   251.14      313.88    139.47   209.11   278.74    348.38
 63    54.10    81.05   108.00   134.95    60.03     89.94   119.86   149.77   132.78     199.07   265.36      331.65    147.36   220.95   294.53    368.11
 64    58.31    87.37   116.42   145.48    64.70     96.96   129.20   161.46   139.89     209.74   279.58      349.43    155.26   232.79   310.31    387.85
 65    62.50    93.65   124.80   155.95    69.35    103.93   138.51   173.08   147.00     220.40   293.80      367.20    163.15   244.62   326.10    407.57
 66    68.35   102.43   136.50   170.58    75.85    113.68   151.49   189.32   155.01     232.42   309.82      387.23    172.04   257.96   343.88    429.80
 67    74.20   111.20   148.20   185.20    82.34    123.41   164.48   205.55   163.02     244.43   325.84      407.25    180.93   271.30   361.66    452.03
 68    80.05   119.98   159.90   199.83    88.83    133.16   177.47   221.79   171.03     256.45   341.86      427.28    189.82   284.64   379.44    474.26
 69    85.90   128.75   171.60   214.45    95.33    142.89   190.45   238.02   179.04     268.46   357.88      447.30    198.71   297.97   397.22    496.48
 70    91.77   137.56   183.34   229.13   101.84    152.67   203.49   254.31   187.05     280.48   373.90      467.33    207.60   311.31   415.01    518.71
 71   103.77   155.56   207.34   259.13   115.16    172.65   230.13   287.61   200.34     300.41   400.48      500.55    222.36   333.43   444.51    555.59
 72   115.77   173.56   231.34   289.13   128.48    192.63   256.77   320.91   213.63     320.35   427.06      533.78    237.11   355.57   474.01    592.47
 73   127.77   191.56   255.34   319.13   141.80    212.61   283.41   354.21   226.92     340.28   453.64      567.00    251.86   377.69   503.52    629.35
 74   139.77   209.56   279.34   349.13   155.12    232.59   310.05   387.51   240.21     360.22   480.22      600.23    266.61   399.82   533.02    666.23
 75   151.76   227.54   303.32   379.10   168.43    252.55   336.66   420.78   253.48     380.12   506.76      633.40    281.34   421.91   562.48    703.05
 76   171.97   257.86   343.74   429.63   190.86    286.20   381.53   476.87   274.81     412.12   549.42      686.73    305.02   457.43   609.83    762.25
 77   192.18   288.17   384.16   480.15   213.30    319.85   426.40   532.94   296.14     444.11   592.08      740.05    328.69   492.94   657.19    821.43
 78   212.39   318.49   424.58   530.68   235.73    353.50   471.26   589.03   317.47     476.11   634.74      793.38    352.37   528.46   704.54    880.63
 79   232.60   348.80   465.00   581.20   258.16    387.15   516.13   645.11   338.80     508.10   677.40      846.70    376.05   563.97   751.89    939.82
 80   252.82   379.13   505.44   631.75   280.61    420.81   561.02   701.22   360.12     540.08   720.04      900.00    399.71   599.47   799.22    998.98
 81   275.16   412.64   550.12   687.60   305.41    458.01   610.61   763.21   382.31     573.37   764.42      955.48    424.34   636.42   848.48   1,060.56
 82   297.50   446.15   594.80   743.45   330.20    495.20   660.21   825.21   404.50     606.65   808.80     1,010.95   448.97   673.36   897.75   1,122.13
 83   319.84   479.66   639.48   799.30   355.00    532.40   709.80   887.20   426.69     639.94   853.18     1,066.43   473.60   710.31   947.01   1,183.72
 84   342.18   513.17   684.16   855.15   379.80    569.60   759.40   949.19   448.88     673.22   897.56     1,121.90   498.23   747.25   996.27   1,245.29
                                                        Monthly Long Term Care Premium Rates
                                                                For State of New Jersey
                                                                50% Home Health Care
                                                              5 Year Lifetime Maximum
                                                                90 Day Waiting Period


                                                        Basic Plan                                  Basic Plan                            Basic Plan
                      Basic                                Plus                                       Plus                         Plus Automatic Inflation
                      Plan                        Shortened Benefit Period                      Automatic Inflation               & Shortened Benefit Period
        Plan 9   Plan 10   Plan 11   Plan 12   Plan 9    Plan 10   Plan 11   Plan 12   Plan 9     Plan 10   Plan 11   Plan 12   Plan 9   Plan 10   Plan 11   Plan 12
Age     $100     $150      $200      $250      $100       $150     $200      $250      $100       $150      $200      $250      $100     $150      $200      $250
18-30    7.83    11.65     15.46      19.28     8.67      12.91    17.14      21.38     37.11      55.57     74.02     92.48     41.17    61.66     82.14    102.63
 31      8.30    12.35     16.40      20.45     9.19      13.69    18.18      22.68     38.55      57.73     76.90     96.08     42.77    64.06     85.34    106.63
 32      8.77    13.06     17.34      21.63     9.71      14.47    19.23      23.99     39.99      59.89     79.78     99.68     44.37    66.46     88.53    110.62
 33      9.24    13.76     18.28      22.80    10.23      15.25    20.27      25.29     41.43      62.05     82.66    103.28    45.97     68.85     91.73    114.62
 34      9.71    14.47     19.22      23.98    10.76      16.04    21.31      26.60     42.87      64.21     85.54    106.88    47.56     71.25     94.93    118.61
 35     10.18    15.17     20.16     25.15     11.28      16.82    22.36      27.89     44.31      66.37     88.42    110.48    49.16     73.65     98.12    122.61
 36     10.65    15.88     21.10     26.33     11.80      17.60    23.40      29.20     45.75      68.53     91.30    114.08    50.76     76.05    101.32    126.61
 37     11.12    16.58     22.04     27.50     12.32      18.38    24.44      30.50     47.19      70.69     94.18    117.68    52.36     78.44    104.52    130.60
 38     11.59    17.29     22.98     28.68     12.84      19.17    25.49      31.81     48.63      72.85     97.06    121.28    53.96     80.84    107.71    134.60
 39     12.06    17.99     23.92     29.85     13.36      19.95    26.53      33.11     50.07      75.01     99.94    124.88    55.56     83.24    110.91    138.59
 40     12.53    18.70     24.86     31.03     13.89      20.74    27.57      34.42     51.55      77.23    102.90    128.58    57.20     85.70    114.20    142.70
 41     13.49    20.14     26.78     33.43     14.95      22.33    29.70      37.09     53.68      80.42    107.16    133.90    59.56     89.24    118.93    148.61
 42     14.45    21.58     28.70     35.83     16.02      23.93    31.84      39.75     55.81      83.62    111.42    139.23    61.93     92.80    123.65    154.52
 43     15.41    23.02     30.62     38.23     17.08      25.53    33.97      42.41     57.94      86.81    115.68    144.55    64.29     96.34    128.38    160.43
 44     16.37    24.46     32.54     40.63     18.15      27.13    36.10      45.08     60.07      90.01    119.94    149.88    66.66     99.89    133.11    166.34
 45     17.33    25.90     34.46     43.03     19.21      28.73    38.23      47.74     62.20      93.20    124.20    155.20    69.02    103.43    137.84    172.25
 46     18.29    27.34     36.38     45.43     20.28      30.33    40.36      50.41     64.33      96.40    128.46    160.53    71.38    106.98    142.57    178.17
 47     19.25    28.78     38.30     47.83     21.35      31.92    42.49      53.07     66.46      99.59    132.72    165.85    73.75    110.52    147.30    184.07
 48     20.21    30.22     40.22     50.23     22.41      33.52    44.62      55.73     68.59     102.79    136.98    171.18    76.11    114.07    152.03    189.99
 49     21.17    31.66     42.14     52.63     23.48      35.12    46.75      58.40     70.72     105.98    141.24    176.50    78.48    117.62    156.75    195.89
 50     22.10    33.05     44.00     54.95     24.51      36.66    48.82      60.97     72.80     109.10    145.40    181.70    80.79    121.08    161.37    201.67
 51     24.66    36.89     49.12     61.35     27.35      40.93    54.50      68.08     78.33     117.40    156.46    195.53    86.92    130.29    173.65    217.02
 52     27.22    40.73     54.24     67.75     30.19      45.19    60.18      75.18     83.86     125.69    167.52    209.35    93.06    139.49    185.93    232.36
 53     29.78    44.57     59.36     74.15     33.03      49.45    65.87      82.28     89.39     133.99    178.58    223.18    99.20    148.71    198.20    247.71
 54     32.34    48.41     64.48     80.55     35.88      53.71    71.55      89.39     94.92     142.28    189.64    237.00    105.34   157.91    210.48    263.05
 55     34.90    52.25     69.60     86.95     38.72      57.98    77.23      96.49    100.45     150.58    200.70    250.83    111.48   167.12    222.76    278.40
 56     37.46    56.09     74.72     93.35     41.56      62.24    82.92     103.60    105.98     158.87    211.76    264.65    117.62   176.32    235.03    293.74
 57     40.02    59.93     79.84     99.75     44.40      66.50    88.60     110.70    111.51     167.17    222.82    278.48    123.75   185.54    247.31    309.09
 58     42.58    63.77     84.96     106.15    47.24      70.76    94.28     117.80    117.04     175.46    233.88    292.30    129.89   194.74    259.58    324.43
 59     45.14    67.61     90.08     112.55    50.08      75.03    99.97     124.91    122.57     183.76    244.94    306.13    136.03   203.95    271.86    339.78
                                                       Monthly Long Term Care Premium Rates
                                                               For State of New Jersey
                                                               50% Home Health Care
                                                             5 Year Lifetime Maximum
                                                               90 Day Waiting Period


                                                       Basic Plan                                   Basic Plan                              Basic Plan
                    Basic                                 Plus                                        Plus                           Plus Automatic Inflation
                    Plan                         Shortened Benefit Period                       Automatic Inflation                 & Shortened Benefit Period
      Plan 9   Plan 10   Plan 11   Plan 12    Plan 9    Plan 10   Plan 11   Plan 12    Plan 9     Plan 10   Plan 11    Plan 12    Plan 9   Plan 10   Plan 11    Plan 12
Age   $100     $150      $200       $250      $100      $150      $200       $250      $100       $150       $200       $250      $100     $150       $200       $250
 60    47.65    71.38     95.10     118.83     52.87     79.21    105.54     131.88    128.12     192.08     256.04     320.00    142.19   213.19     284.18     355.18
 61    52.73    79.00    105.26     131.53     58.51     87.67    116.82     145.98    136.86     205.19     273.52     341.85    151.89   227.74     303.59     379.43
 62    57.81    86.62    115.42     144.23     64.15     96.13    128.09     160.07    145.60     218.30     291.00     363.70    161.59   242.29     322.99     403.69
 63    62.89    94.24    125.58     156.93     69.79    104.58    139.37     174.17    154.34     231.41     308.48     385.55    171.30   256.84     342.39     427.94
 64    67.97   101.86    135.74     169.63     75.42    113.04    150.65     188.27    163.08     244.52     325.96     407.40    181.00   271.40     361.79     452.19
 65    73.04   109.46    145.88     182.30     81.05    121.48    161.90     202.33    171.84     257.66     343.48     429.30    190.72   285.98     381.24     476.50
 66    80.08   120.02    159.96     199.90     88.87    133.20    177.53     221.87    181.61     272.32     363.02     453.73    201.57   302.25     402.93     503.62
 67    87.12   130.58    174.04     217.50     96.68    144.92    193.16     241.40    191.38     286.97     382.56     478.15    212.41   318.51     424.62     530.72
 68    94.16   141.14    188.12     235.10    104.50    156.64    208.79     260.94    201.15     301.63     402.10     502.58    223.25   334.79     446.31     557.84
 69   101.20   151.70    202.20     252.70    112.31    168.37    224.42     280.48    210.92     316.28     421.64     527.00    234.10   351.05     468.00     584.95
 70   108.25   162.28    216.30     270.33    120.14    180.11    240.07     300.04    220.68     330.92     441.16     551.40    244.93   367.30     489.67     612.03
 71   122.80   184.10    245.40     306.70    136.29    204.33    272.37     340.42    237.02     355.43     473.84     592.25    263.07   394.51     525.94     657.38
 72   137.35   205.93    274.50     343.08    152.44    228.56    304.67     380.80    253.36     379.94     506.52     633.10    281.21   421.71     562.22     702.72
 73   151.90   227.75    303.60     379.45    168.59    252.78    336.97     421.17    269.70     404.45     539.20     673.95    299.35   448.92     598.49     748.06
 74   166.45   249.58    332.70     415.83    184.74    277.01    369.28     461.55    286.04     428.96     571.88     714.80    317.48   476.12     634.76     793.41
 75   181.01   271.42    361.82     452.23    200.90    301.25    401.60     501.95    302.36     453.44     604.52     755.60    335.60   503.30     671.00     838.69
 76   206.08   309.02    411.96     514.90    228.73    342.99    457.25     571.52    329.16     493.64     658.12     822.60    365.35   547.92     730.49     913.06
 77   231.15   346.63    462.10     577.58    256.55    384.74    512.91     641.09    355.96     533.84     711.72     889.60    395.09   592.54     789.99     987.43
 78   256.22   384.23    512.24     640.25    284.38    426.47    568.56     710.66    382.76     574.04     765.32     956.60    424.84   637.16     849.48    1,061.80
 79   281.29   421.84    562.38     702.93    312.21    468.22    624.22     780.23    409.56     614.24     818.92    1,023.60   454.59   681.78     908.98    1,136.17
 80   306.34   459.41    612.48     765.55    340.02    509.92    679.83     849.74    436.37     654.46     872.54    1,090.63   484.35   726.43     968.50    1,210.58
 81   333.89   500.74    667.58     834.43    370.60    555.80    740.99     926.20    463.88     695.72     927.56    1,159.40   514.88   772.23    1,029.57   1,286.91
 82   361.44   542.06    722.68     903.30    401.18    601.66    802.15    1,002.64   491.39     736.99     982.58    1,228.18   545.42   818.04    1,090.64   1,363.26
 83   388.99   583.39    777.78     972.18    431.76    647.54    863.31    1,079.10   518.90     778.25    1,037.60   1,296.95   575.96   863.84    1,151.71   1,439.59
 84   416.54   624.71    832.88    1,041.05   462.34    693.41    924.47    1,155.54   546.41     819.52    1,092.62   1,365.73   606.49   909.65    1,212.79   1,515.94
                                                          Monthly Long Term Care Premium Rates
                                                                  For State of New Jersey
                                                                  75% Home Health Care
                                                                5 Year Lifetime Maximum
                                                                  90 Day Waiting Period


                                                          Basic Plan                                   Basic Plan                            Basic Plan
                       Basic                                 Plus                                        Plus                         Plus Automatic Inflation
                       Plan                         Shortened Benefit Period                       Automatic Inflation               & Shortened Benefit Period
        Plan 13   Plan 14   Plan 15   Plan 16   Plan 13    Plan 14   Plan 15   Plan 16   Plan 13     Plan 14   Plan 15   Plan 16   Plan 13   Plan 14   Plan 15   Plan 16
Age     $100      $150      $200      $250      $100        $150     $200      $250      $100        $150      $200      $250      $100      $150      $200      $250
18-30    8.46     12.59     16.72      20.85     9.37       13.95     18.54     23.12     40.20       60.20     80.20    100.20    44.60      66.80     89.00    111.20
 31      8.97     13.36     17.74      22.13     9.93       14.81     19.67     24.54     41.78       62.57     83.36    104.15    46.35      69.43     92.51    115.58
 32      9.48     14.12     18.76      23.40    10.50       15.65     20.80     25.95     43.36       64.94     86.52    108.10    48.11      72.06     96.02    119.97
 33      9.99     14.89     19.78      24.68    11.07       16.51     21.93     27.37     44.94       67.31     89.68    112.05    49.86      74.69     99.52    124.35
 34     10.50     15.65     20.80     25.95     11.63       17.35     23.07     28.78     46.52       69.68     92.84    116.00    51.62      77.32    103.03    128.74
 35     11.01     16.42     21.82     27.23     12.20       18.20     24.20     30.20     48.10       72.05     96.00    119.95    53.37      79.95    106.54    133.12
 36     11.52     17.18     22.84     28.50     12.77       19.05     25.33     31.61     49.68       74.42     99.16    123.90    55.12      82.58    110.05    137.51
 37     12.03     17.95     23.86     29.78     13.33       19.90     26.46     33.03     51.26       76.79    102.32    127.85    56.88      85.21    113.55    141.89
 38     12.54     18.71     24.88     31.05     13.90       20.75     27.59     34.44     52.84       79.16    105.48    131.80    58.63      87.85    117.06    146.28
 39     13.05     19.48     25.90     32.33     14.46       21.60     28.73     35.86     54.42       81.53    108.64    135.75    60.38      90.48    120.57    150.66
 40     13.59     20.29     26.98     33.68     15.06       22.50     29.93     37.36     55.97       83.86    111.74    139.63    62.10      93.06    124.01    154.97
 41     14.64     21.86     29.08     36.30     16.23       24.24     32.26     40.27     58.32       87.38    116.44    145.50    64.71      96.97    129.23    161.48
 42     15.69     23.44     31.18     38.93     17.39       26.00     34.59     43.19     60.67       90.91    121.14    151.38    67.32     100.89    134.44    168.01
 43     16.74     25.01     33.28     41.55     18.56       27.74     36.92     46.10     63.02       94.43    125.84    157.25    69.93     104.80    139.66    174.53
 44     17.79     26.59     35.38     44.18     19.72       29.49     39.25     49.02     65.37       97.96    130.54    163.13    72.54     108.71    144.88    181.05
 45     18.84     28.16     37.48     46.80     20.89       31.24     41.58     51.93     67.72      101.48    135.24    169.00    75.15     112.62    150.09    187.57
 46     19.89     29.74     39.58     49.43     22.06       32.99     43.91     54.85     70.07      105.01    139.94    174.88    77.76     116.54    155.31    194.09
 47     20.94     31.31     41.68     52.05     23.22       34.73     46.24     57.75     72.42      108.53    144.64    180.75    80.36     120.45    160.53    200.61
 48     21.99     32.89     43.78     54.68     24.39       36.49     48.57     60.67     74.77      112.06    149.34    186.63    82.97     124.36    165.75    207.14
 49     23.04     34.46     45.88     57.30     25.55       38.23     50.90     63.58     77.12      115.58    154.04    192.50    85.58     128.27    170.96    213.65
 50     24.10     36.05     48.00     59.95     26.73       39.99     53.26     66.52     79.44      119.06    158.68    198.30    88.16     132.13    176.11    220.09
 51     26.82     40.13     53.44     66.75     29.75       44.52     59.30     74.07     85.29      127.84    170.38    212.93    94.65     141.88    189.10    236.33
 52     29.54     44.21     58.88     73.55     32.77       49.05     65.33     81.62     91.14      136.61    182.08    227.55    101.14    151.62    202.09    252.56
 53     32.26     48.29     64.32     80.35     35.79       53.58     71.37     89.17     96.99      145.39    193.78    242.18    107.64    161.36    215.07    268.80
 54     34.98     52.37     69.76     87.15     38.81       58.11     77.41     96.71    102.84      154.16    205.48    256.80    114.13    171.10    228.06    285.03
 55     37.70     56.45     75.20     93.95     41.83       62.64     83.45    104.26    108.69      162.94    217.18    271.43    120.62    180.84    241.05    301.27
 56     40.42     60.53     80.64     100.75    44.84       67.17     89.49    111.81    114.54      171.71    228.88    286.05    127.12    190.58    254.03    317.49
 57     43.14     64.61     86.08     107.55    47.86       71.70     95.53    119.36    120.39      180.49    240.58    300.68    133.61    200.32    267.02    333.73
 58     45.86     68.69     91.52     114.35    50.88       76.22    101.57    126.91    126.24      189.26    252.28    315.30    140.10    210.06    280.01    349.96
 59     48.58     72.77     96.96     121.15    53.90       80.75    107.60    134.45    132.09      198.04    263.98    329.93    146.60    219.80    293.00    366.20
                                                         Monthly Long Term Care Premium Rates
                                                                 For State of New Jersey
                                                                 75% Home Health Care
                                                               5 Year Lifetime Maximum
                                                                 90 Day Waiting Period


                                                         Basic Plan                                    Basic Plan                              Basic Plan
                     Basic                                  Plus                                         Plus                           Plus Automatic Inflation
                     Plan                          Shortened Benefit Period                        Automatic Inflation                 & Shortened Benefit Period
      Plan 13   Plan 14   Plan 15   Plan 16    Plan 13    Plan 14   Plan 15   Plan 16    Plan 13     Plan 14   Plan 15    Plan 16    Plan 13   Plan 14   Plan 15    Plan 16
Age   $100      $150      $200       $250      $100       $150      $200       $250      $100        $150       $200       $250      $100      $150       $200       $250
 60    51.28     76.82    102.36     127.90     56.90      85.25    113.60     141.95    137.89      206.74     275.58     344.43    153.04    229.46     305.87     382.30
 61    56.49     84.64    112.78     140.93     62.68      93.93    125.16     156.41    146.69      219.94     293.18     366.43    162.80    244.11     325.41     406.72
 62    61.70     92.45    123.20     153.95     68.47     102.60    136.73     170.86    155.49      233.14     310.78     388.43    172.57    258.76     344.94     431.14
 63    66.91    100.27    133.62     166.98     74.25     111.28    148.30     185.33    164.29      246.34     328.38     410.43    182.34    273.42     364.48     455.56
 64    72.12    108.08    144.04     180.00     80.03     119.95    159.86     199.78    173.09      259.54     345.98     432.43    192.11    288.07     384.02     479.98
 65    77.31    115.87    154.42     192.98     85.79     128.59    171.38     214.19    181.90      272.75     363.60     454.45    201.89    302.73     403.57     504.42
 66    84.56    126.74    168.92     211.10     93.84     140.66    187.48     234.30    191.82      287.63     383.44     479.25    212.90    319.25     425.60     531.95
 67    91.81    137.62    183.42     229.23    101.89     152.74    203.57     254.42    201.74      302.51     403.28     504.05    223.91    335.76     447.62     559.47
 68    99.06    148.49    197.92     247.35    109.93     164.80    219.67     274.54    211.66      317.39     423.12     528.85    234.92    352.28     469.64     587.00
 69   106.31    159.37    212.42     265.48    117.98     176.88    235.76     294.66    221.58      332.27     442.96     553.65    245.93    368.80     491.66     614.53
 70   113.54    170.21    226.88     283.55    126.01     188.91    251.81     314.72    231.48      347.12     462.76     578.40    256.92    385.28     513.64     642.00
 71   128.39    192.49    256.58     320.68    142.49     213.64    284.78     355.93    247.92      371.78     495.64     619.50    275.17    412.65     550.14     687.62
 72   143.24    214.76    286.28     357.80    158.97     238.36    317.75     397.14    264.36      396.44     528.52     660.60    293.42    440.03     586.64     733.24
 73   158.09    237.04    315.98     394.93    175.46     263.09    350.72     438.35    280.80      421.10     561.40     701.70    311.67    467.40     623.13     778.87
 74   172.94    259.31    345.68     432.05    191.94     287.81    383.68     479.55    297.24      445.76     594.28     742.80    329.91    494.77     659.63     824.49
 75   187.80    281.60    375.40     469.20    208.44     312.55    416.67     520.79    313.70      470.45     627.20     783.95    348.19    522.18     696.17     870.16
 76   212.82    319.13    425.44     531.75    236.21     354.21    472.22     590.22    340.10      510.05     680.00     849.95    377.49    566.13     754.78     943.42
 77   237.84    356.66    475.48     594.30    263.98     395.87    527.76     659.65    366.50      549.65     732.80     915.95    406.79    610.09     813.39    1,016.68
 78   262.86    394.19    525.52     656.85    291.75     437.53    583.31     729.08    392.90      589.25     785.60     981.95    436.10    654.05     871.99    1,089.94
 79   287.88    431.72    575.56     719.40    319.52     479.19    638.85     798.51    419.30      628.85     838.40    1,047.95   465.40    698.00     930.60    1,163.20
 80   312.88    469.22    625.56     781.90    347.27     520.81    694.35     867.89    445.69      668.44     891.18    1,113.93   494.69    741.95     989.19    1,236.44
 81   339.79    509.59    679.38     849.18    377.14     565.62    754.09     942.57    472.21      708.22     944.22    1,180.23   524.13    786.10    1,048.06   1,310.03
 82   366.70    549.95    733.20     916.45    407.02     610.42    813.83    1,017.24   498.73      748.00     997.26    1,246.53   553.57    830.26    1,106.94   1,383.63
 83   393.61    590.32    787.02     983.73    436.89     655.23    873.57    1,091.92   525.25      787.78    1,050.30   1,312.83   583.01    874.41    1,165.81   1,457.22
 84   420.52    630.68    840.84    1,051.00   466.76     700.03    933.31    1,166.59   551.77      827.56    1,103.34   1,379.13   612.44    918.57    1,224.69   1,530.81
                            The Prudential Insurance Company of America
                                     Long Term Care Customer Service Center
                                    P. O. Box 8526, Philadelphia, PA 19176-8526
                                         Customer Service: 1-877-582-4865
                                   Prudential Long Term Care CoverageSM
                                        for The State of New Jersey
                                     ENROLLMENT INSTRUCTIONS
                                WHO CAN ENROLL FOR THIS COVERAGE?

         1. State of New Jersey Public Employees, Actively at work*, Full-time, Part-time, and Retirees can
            apply for coverage in The State of New Jersey Long Term Care Insurance Plan by completing the
            enclosed Evidence of Insurability questionnaire and Enrollment Application. Active and retired
            employees of a Local Public Employer are only eligible to apply for the coverage after their Employer,
            or in the case of a retired employee, former Employer, adopts the requisite resolution.
            All sections of the Enrollment Form must be completed.

         2.     *Actively at work, full-time employees and faculty of the Colleges and Universities includes:
                 Full-time and Part-time Employees, Adjunct Faculty, Seasonal Employees,
                Intermittent Employees, Per Diem Employees, and Retired Employees.

              *Actively at Work” means performing the regular duties of the employee’s job at his or her usual
              place of employment or other location where the Employer’s business required the employee to
              travel, without absence for reasons other than cold influenza, or vacation, within the 30 days prior
              to enrollment.

         3. Eligible Family Members of an eligible Actively at Work, Full-time or Part-Time State of New
            Jersey Public Employee:
              The employee’s spouse or domestic partner, parents, step-parents, adult children or the adult child’s
              spouse or domestic partner, adult step-children, grandparents and step-grandparents, of the
              employee, retiree or eligible spouse or domestic partner, and any surviving annuitants of retirees are
              eligible to enroll by completing the Evidence of Insurability form and the Enrollment
              Application. All sections of the Enrollment Form must be completed.

     You must be at least age 18 but less than age 85 when your Enrollment Form is completed. You must be
     residing in the United States or one of its possessions.

     Please read and complete all necessary sections of your Enrollment Form carefully. Please print all information
     except where signatures are required. Use blue or black ink. Return the completed form in the enclosed
     envelope.

     If you have questions, you can call a Long Term Care Customer Service Representative at 1-877-582-4865.




                                                                                 (Control#40285-2006 StateNJ)




GRP 99923                                                   1                                          [D-12/5/2006]
                   Instructions

  STATE OF NEW JERSEY PUBLIC EMPLOYEES,
  COLLEGES AND UNIVERSITIES AND ELIGIBLE
             FAMILY MEMBERS



 (Please refer to the “WHO CAN ENROLL FOR COVERAGE”
                      page included in this kit)




Please complete all sections of the enclosed enrollment
          form and the “Authorization for
    Release of Health-Related Information” form




               USE THIS FORM
                                                                                         The Prudential Insurance Company of America
                                                                                           Long Term Care Customer Service Center
                                                                                          P. O. Box 8526, Philadelphia, PA 19176-8526
                                                                                               Customer Service: 1-877-582-4865

                              IMPORTANT STATE NOTICES ABOUT
                           THIS LONG TERM CARE INSURANCE PLAN
    To Residents of Illinois: THE POLICY IS NOT APPROVED FOR MEDICAID ASSET PROTECTION UNDER THE
    ILLINOIS LONG TERM CARE PARTNERSHIP PROGRAM. HOWEVER, THE POLICY IS AN APPROVED LONG
    TERM CARE POLICY UNDER STATE INSURANCE REGULATIONS. FOR INFORMATION ABOUT POLICIES
    APPROVED UNDER THE ILLINOIS LONG TERM CARE PARTNERSHIP PROGRAM, CALL THE SENIOR
    HELPLINE AT THE ILLINOIS DEPARTMENT ON AGING, AT 1-800-252-8966.

    To Residents of Indiana: THE POLICY DOES NOT QUALIFY FOR MEDICAID ASSET PROTECTION UNDER THE
    INDIANA LONG TERM CARE PROGRAM. HOWEVER, THE POLICY IS AN APPROVED LONG TERM CARE
    POLICY UNDER STATE INSURANCE REGULATIONS. FOR INFORMATION ABOUT POLICIES AND
    CERTIFICATES QUALIFYING UNDER THE INDIANA LONG TERM CARE PROGRAM, CALL THE SENIOR
    HEALTH INSURANCE INFORMATION PROGRAM OF THE INDIANA DEPARTMENT OF INSURANCE AT 1-800-
    452-4800.

    To Residents of Iowa: THE POLICY DOES NOT QUALIFY FOR MEDICAID ASSET PROTECTION UNDER THE
    IOWA LONG TERM CARE ASSET PRESERVATION PROGRAM. HOWEVER, THE POLICY IS AN APPROVED
    LONG TERM CARE POLICY UNDER STATE INSURANCE REGULATIONS. FOR INFORMATION ABOUT
    POLICIES AND CERTIFICATES QUALIFYING UNDER THE IOWA LONG TERM CARE ASSET PRESERVATION
    PROGRAM, CALL THE SENIOR HEALTH INSURANCE INFORMATION PROGRAM OF THE IOWA DIVISION OF
    INSURANCE AT 1-800-281-5705.

    RESIDENTS OF MICHIGAN: For additional information about Long Term Care Coverage, write to the
    MICHIGAN INSURANCE BUREAU, P. O. BOX 30220, LANSING MI 48909, or call the Area Agency on Aging in
    your community.

A. APPLICANT INFORMATION–Please Indicate your eligibility status below:
1. Employee of the State of NJ paid through Centralized Payroll.
   Please list the department of the State of NJ you are employed by: ___________________________________________________
2. Legislative Employee or staff member or State College and University employee.
   Please list the department/College of the State of NJ you are employed by: _____________________________________________
3. Employee of a participating Local employer. Please list your employer name: _________________________________________
4. Qualified Family Members: ❑ Employee's Spouse/Domestic Partner ❑ Retiree ❑ Spouse/Domestic Partner ❑ Parent/Parent-in-law
   ❑ Grandparent/Grandparent-in-law ❑ Adult Child ❑ Adult Child Spouse/Domestic Partner ❑ Surviving Annuitant
❑ Mr. ❑ Mrs. ❑ Ms. ❑ ____
First Name                                         MI.     Last Name

Street Address:                                                                                                            Apt.#

City                                                                                     State    ZIP Code

Social Security Number             Date of Birth                      Marital Status
                                                                        Married                  Unmarried
Daytime Telephone Number                           Evening Telephone Number                            Date of Hire
(            )                                     (              )
E-mail Address: ___________________________________________________________________________________


GRP 99923                                          Page 1 of 3 (Continue to next page)                (STATENJ-01/01/2007 Control #40285 Kit)
                                                                                                     The Prudential Insurance Company of America
                                                                                                       Long Term Care Customer Service Center
                                                                                                      P. O. Box 8526, Philadelphia, PA 19176-8526
                                                                                                           Customer Service: 1-877-582-4865


EMPLOYEE OR RETIREE INFORMATION–If applying as a Qualified Family Member please provide this
information about the eligible Employee or Retiree:
Name                                                                                                                        Date of Hire


Employee Social Security No.             Daytime Telephone Number                                         Evening Telephone Number
                                         (              )                                                 (             )

B. COVERAGE SELECTION–Indicate your benefit choices in this section:
Coverage       Nursing Home &           Home &                Lifetime           Coverage           Nursing Home &         Home &                Lifetime
Amounts        Assisted Living      Community Based          Maximum             Amounts            Assisted Living    Community Based          Maximum
                Facility Daily         Care Daily            Options**                               Facility Daily       Care Daily            Options**
                 Maximum*           Maximum Options              3yr                                  Maximum*         Maximum Options              5yr
                                      50% & 75% *                                                                        50% & 75% *
❑   Plan   1         $100                $50                  $109,500           ❑   Plan   9            $100               $50                 $182,500
❑   Plan   2         $150                $75                  $164,250           ❑   Plan   10           $150               $75                 $273,750
❑   Plan   3         $200                $100                 $219,000           ❑   Plan   11           $200               $100                $365,000
❑   Plan   4         $250                $125                 $273,750           ❑   Plan   12           $250               $125                $456,250
❑   Plan   5         $100                $75                  $109,500           ❑   Plan   13           $100               $75                 $182,500
❑   Plan   6         $150                $113                 $164,250           ❑   Plan   14           $150               $113                $273,750
❑   Plan   7         $200                $150                 $219,000           ❑   Plan   15           $200               $150                $365,000
❑   Plan   8         $250                $188                 $273,750           ❑   Plan   16           $250               $188                $456,250


OPTIONAL BENEFIT RIDERS: I have reviewed the explanation of the Optional Benefits in the Outline of Coverage,
and make the following selection:
Non-forfeiture Benefit/Shortened Benefit Period Option:                        ❑ Yes, include this option ❑ No, do not include this option
Automatic Compound Inflation Increase Option:                                  ❑ Yes, include this option ❑ No, do not include this option
If declining Automatic Compound Inflation Increase Option please sign ______________________________________
If you are interested in additional information or an enrollment form for the Unlimited Lifetime Maximum or Monthly Benefit Rider please call the Prudential
Long Term Care Customer Service Center at 877/LTC-4UNJ (877/582-4865) or visit the website at http://www.state.nj.us/treasury/pensions/ltchomepg.htm.



C. PAYMENT METHOD. Indicate your choice of billing.

Full-time employees MAY elect payroll deduction, direct billing or EFT.
❑ Payroll Deduction. ❑ Bi-weekly ❑ Other. Please check with your employer to confirm if Payroll Deductions are available.
❑ Electronic Funds Transfer (EFT) - Monthly Payment. If EFT, you must complete and return the Electronic Funds
     Transfer Authorization and a sample voided check.
❑ Direct Billing. If Direct Billing, bill will be sent to the Employee.
Billing Address, if different from Section A:


City                                                                                                    State         ZIP Code


How Often:                               ❑ Quarterly 2.2%                            ❑ Semi-Annually 4.5%                        ❑ Annually 6.5%



GRP 99923                                                     Page 2 of 3 (Continue to next page)                        (STATENJ-01/01/2007 Control #40285 Kit)
D. INSURANCE HISTORY: Please provide the requested information about your other insurance coverage.
1. Are you covered by Medicaid or Medi-Cal (not Medicare)?                                            ❑ Yes ❑ No
2. Do you have other long term care or accident and sickness insurance in force (including            ❑ Yes ❑ No
    policies, certificates, health care service contracts, or health maintenance organization contracts)?
3. Do you currently have or during the last 12 months did you have other long term care
    insurance in force?                                                                               ❑ Yes ❑ No
4. Do you intend to replace any of your medical or health insurance with this insurance?              ❑ Yes ❑ No
IF YOU ANSWERED YES TO QUESTIONS 3 or 4 OF THIS SECTION, PLEASE PROVIDE THE FOLLOWING INFORMATION
Group           ❑ Group Type of                                Intend to ❑ Yes   Did Insurance Lapse?             ❑ Yes
or Individual? ❑ Indiv.       Coverage?                        Replace? ❑ No     If Yes, Give Date_______________ ❑ No
Group          ❑ Group Type of                             Intend to ❑ Yes       Did Insurance Lapse?                       ❑ Yes
or Individual? ❑ Indiv.  Coverage?                         Replace? ❑ No         If Yes, Give Date_______________           ❑ No
Full Name and Address of Insurance Company




E. NOTIFICATION OF UNINTENTIONAL LAPSE: You can provide Prudential with the name of a friend or
relative to notify if your coverage lapses because the premium is not paid when due. This designation does not constitute
an acceptance of liability by the person named. Prudential will notify you each year of your right to designate or change the
existing designation for this purpose. Only complete one section: Name a Designee OR Waiver.
❑ CHECK HERE ONLY TO NAME A DESIGNEE, AND PROVIDE THE REQUESTED INFORMATION ABOUT THAT PERSON:
❑ Mr. ❑ Mrs. ❑ Ms. ❑ ____
First Name                                       MI. Last Name

Street Address:                                                                                                     Apt.#

City                                                                             State     ZIP Code

❑ CHECK HERE ONLY FOR WAIVER OF THIS NOTICE OPTION. WAIVER OF NOTIFICATION OPTION: I understand that
   I have the right to name at least one person other than myself to receive notice of lapse or termination of my long term
   care insurance policy for non-payment of premium. I understand that notice will not be given until thirty days after the
   premium is due and not paid. By my signature, I elect NOT to name any person to receive such notice.

 Applicant’s Signature to Waiver:   X   __________________________________________________________________

F. APPLICANT AGREEMENTS:
Caution: If your answers on this Enrollment Form are misstated or untrue, Prudential may have the right to deny
           benefits or rescind your coverage.
To the best of my knowledge and belief, the answers on this Enrollment Form are complete and true. I understand and agree that:
1. The Long Term Care insurance coverage is underwritten by The Prudential Insurance Company of America
     (Prudential), whose Corporate offices are located in Newark, New Jersey.
2. This Enrollment Form will be the basis for the Long Term Care insurance coverage for which I am applying to Prudential
     under a Group Contract.
3. My coverage will NOT take effect unless: Prudential has approved this Enrollment Form and only if the statements and
     answers given in applying for this coverage are without material change until the date this Enrollment Form is approved.
4. If issued, my Long Term Care Insurance coverage will take effect on the Effective Date assigned by Prudential.
5. Prudential has the right to change premium rates in the future but only on a class basis.
6. If Payroll Deduction is indicated in Section C, I authorize the State of New Jersey or my College/University to make
     the payroll deductions needed for premium payment.
7. I have received the Outline of Coverage and A Shopper’s Guide to Long Term Care Insurance.
8. I have received the Notice Concerning Prudential’s Information Practices.
9. I have read, or had read to me the completed Enrollment Form, and I understand that any false statement or
     misrepresentation in my Enrollment Form may result in loss of coverage under the Group Contract.


 Applicant Signature   X_________________________________________________________ Date                     _______________
GRP 99923                                                  Page 3 of 3                         (STATENJ-01/01/2007 Control #40285 Kit)
                                                                                         The Prudential Insurance Company of America
                                                                                           Long Term Care Customer Service Center
                                                                                          P. O. Box 8526, Philadelphia, PA 19176-8526
                                                                                               Customer Service: 1-877-582-4865
                         Prudential Long Term CareSM Insurance Coverage
                                   Your Insurability Profile and Medical History
 PLEASE READ CAREFULLY AND COMPLETE YOUR INSURABILITY PROFILE AND MEDICAL HISTORY. THE
 INFORMATION RELEASE AUTHORIZATION MUST ALSO BE SIGNED. PRINT ALL INFORMATION EXCEPT
 WHERE SIGNATURES ARE REQUIRED. USE BLUE OR BLACK INK. PLACE AN “X” IN THE APPROPRIATE
 BOX WHEN INDICATING “Yes” or “No” RESPONSES. ATTACH THE COMPLETED FORM TO YOUR
 ENROLLMENT FORM AND SEND IN THE ENCLOSED ENVELOPE TO: PRUDENTIAL LONG TERM CARE UNIT
 P. O. BOX 8526, PHILADELPHIA, PA 19176-8526. If you have questions, please call 1-800-732-0416.

     The following does not apply to KS, NJ, or OR Residents. Caution: 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, may commit a fraudulent insurance act, which is a crime that may
 subject such person to criminal and/or civil penalties. With respect to New York Residents, civil penalties not
 to exceed $5,000, plus the stated value of the claim for each violation, can apply.
     Note to Residents of New Jersey: Caution: Any person who includes any false or misleading information
 on an application for coverage under a group policy is subject to criminal and civil penalties.

                               INSURABILITY PROFILE AND MEDICAL HISTORY
APPLICANT’S FULL NAME:
❑ Mr. ❑ Ms. First Name                                              M.I.      Last Name
❑ Mrs. ❑ ___
Applicant’s Phone Number:

Employer:   S t a t e             o f       N e w           J e r s e y
INSURABILITY PROFILE - PART 1. INDICATE "YES" OR "NO."
1. Within the past 7 years or in the time frame otherwise indicated, have you had, do you currently have, or have you
   been diagnosed or treated by a Licensed Health Care Practitioner as having any of the following medical conditions:
   ❑ Yes ❑ No 1a. Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Muscular Dystrophy, or Parkinson’s Disease?
   ❑ Yes ❑ No 1b. Alzheimer’s Disease, Chronic Memory Loss, Frequent or Persistent Forgetfulness, Senility,
                        Dementia or Organic Brain Syndrome?
   ❑ Yes    ❑ No    1c.     Congestive Heart Failure, diagnosed or symptomatic, within the past 12 months?
   ❑ Yes    ❑ No    1d.     Diabetes treated with insulin or Liver Cirrhosis?
   ❑ Yes    ❑ No    1e.     Metastatic Cancer (Cancer that has spread from the original site or location)?
   ❑ Yes    ❑ No    1f.     Stroke or Cerebrovascular Accident?
   ❑ Yes    ❑ No    1g.     Transient Ischemic Attack within the past 5 years; multiple TIA’s; or TIA in combination with
                            Diabetes or any Heart Surgery?
   ❑ Yes ❑ No 2.            Within the past 48 months, have you been diagnosed or treated for Cancer of a major body organ?
   ❑ Yes ❑ No 3.            Do you use a: ❑ Walker? ❑ Wheelchair? ❑ Oxygen? ❑ Respirator? ❑ Kidney Dialysis?
   ❑ Yes ❑ No 4.            Within the past 12 months have you: ❑ needed home health care? ❑ used adult day care?
                            Been medically advised to enter or been confined to: ❑ a nursing home?
                            ❑ an assisted living facility? ❑ other long term care facility?
   ❑ Yes ❑ No 5.            Do you currently need assistance or supervision by another person in performing any of the
                            listed Activities of Daily Living (ADL’s): ❑ Bathing? ❑ Eating? ❑ Toileting?
                            ❑ Bowel or Bladder Control (continence)? ❑ Moving in and out of bed or chair? ❑ Dressing?
                            ❑ Taking your medication?
GRP 99924                                          Page 1 of 5 (Continue to next page)                     (STATENJ-01/01/2007 Control #40285)
INSURABILITY PROFILE - PART 2. INDICATE “YES” OR “NO.”
The following questions relate to the presence of Acquired Immune Deficiency Syndrome (AIDS), AIDS Related
Complex (ARC), and if permitted, HIV (Human Immunodeficiency Virus) testing. Answer only the questions
appropriate to your state of residence.
NOTE TO RESIDENTS OF MINNESOTA: You do NOT need to disclose any HIV (Human Immunodeficiency Virus or AIDS virus)
tests which were given to you as: 1) a criminal offender or crime victim as a result of a crime that was reported to the police; 2)
a patient who received the services of emergency medical services personnel at a hospital or medical care facility; 3) emergency
medical personnel who were tested as a result of performing emergency medical services. “Emergency medical personnel”
includes individuals employed to provide pre-hospital emergency services; licensed police officers, firefighters, paramedics,
emergency medical technicians, licensed nurses, rescue squad personnel and other persons who serve as volunteers of an
ambulance service who provide emergency medical services; crime lab personnel, correctional guards, including security guards
at the Minnesota security hospital who experience a significant exposure to an inmate who is transported to facility for emergency
medical care; and other persons who render emergency care or assistance at the scene of an emergency, or while an injured
person is being transported to receive medical care and who would qualify for immunity under the Good Samaritan law.
FOR RESIDENTS OF ALL STATES OTHER THAN CALIFORNIA, CONNECTICUT, FLORIDA, MAINE, NEW JERSEY,
NEW YORK, NORTH DAKOTA, OREGON, VERMONT OR WISCONSIN:
Have you had, do you currently have, or have you been diagnosed or treated by a Licensed Health Care
Practitioner, as having any of the following medical conditions:
    ❑ Yes ❑ No a. Acquired Immune Deficiency Syndrome (AIDS)?
    ❑ Yes ❑ No b. AIDS Related Complex (ARC)?
    ❑ Yes ❑ No c. Positive HIV test (Human Immunodeficiency Virus)?
FOR RESIDENTS OF CALIFORNIA, CONNECTICUT, NEW YORK, VERMONT, AND WISCONSIN:
Have you had, do you currently have, or have you been diagnosed or treated by a Licensed Health Care
Practitioner, as having any of the following medical conditions:
    ❑ Yes ❑ No a. Acquired Immune Deficiency Syndrome (AIDS)?
    ❑ Yes ❑ No b. AIDS Related Complex (ARC)?
FOR RESIDENTS OF FLORIDA:
    ❑ Yes ❑ No a. Have you tested positive for exposure to the HIV infection or been diagnosed as having ARC or
AIDS caused by the HIV infection or other sickness or condition derived from such infection?
FOR RESIDENTS OF MAINE: You may answer these questions “No” if you have tested positive for HIV (Human
Immunodeficiency Virus) and have not developed symptoms of the disease “AIDS.” Have you had, do you currently have, or
have you been diagnosed or treated by a Licensed Health Care Practitioner, as having any of the following medical conditions:
    ❑ Yes ❑ No a. Acquired Immune Deficiency Syndrome (AIDS)?
    ❑ Yes ❑ No b. AIDS Related Complex (ARC)?
FOR RESIDENTS OF NEW JERSEY AND NORTH DAKOTA: Have you had, do you currently have, or have you been
diagnosed or treated by a Licensed Health Care Practitioner, as having any of the following medical conditions:
    ❑ Yes ❑ No a. Acquired Immune Deficiency Syndrome (AIDS)?
    ❑ Yes ❑ No b. AIDS Related Complex (ARC)?
    ❑ Yes ❑ No c. Any HIV infection (Human Immunodeficiency Virus)?
FOR RESIDENTS OF OREGON: Within the past 10 years, have you had, do you currently have, or have you been
diagnosed or treated by a Licensed Health Care Practitioner, as having any of the following medical conditions:
    ❑ Yes ❑ No a. Acquired Immune Deficiency Syndrome (AIDS)?
    ❑ Yes ❑ No b. AIDS Related Complex (ARC)?
    ❑ Yes ❑ No c. Positive HIV test (Human Immunodeficiency Virus)?
DO NOT SUBMIT THE ENROLLMENT FORM IF YOU ANSWERED “YES” to any question in either Part 1 or Part 2 of
the Insurability Profile. You do not meet our minimum acceptance standards. We regret that we will be unable to offer you
long term care coverage.
If you answered “No” to all questions in each part of the Insurability Profile, please continue to complete the remainder of
this form.

MEDICAL HISTORY - PART 1 - PERSONAL DATA: Please provide the requested information about yourself.
1. Your height: _____ Feet _____ Inches _____. Your weight: _____ Pounds. Your Sex: ❑ Male ❑ Female
2. Please list any activities in which you regularly participate outside your home? (For example, walking, gardening.)
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
3. Have two or more years passed since you received any treatment or examination by ANY health care professional?
   ❑ Yes ❑ No
4. Who is your Primary Physician with most of your medical records?
Name:                                                                                Phone:

Address:

City:                                                                      State:             Zip:

Date Last Seen:                                   Reason Last Seen: ____________________________________________
GRP 99924                                          Page 2 of 5 (Continue to next page)               (STATENJ-01/01/2007 Control #40285)
MEDICAL HISTORY - PART 2 - HEALTH PROFILE: INDICATE “YES” OR “NO” AND CIRCLE
THE CONDITION.
1. Within the past three years, have you:
❑ Yes       ❑ No   Received home health care?
❑ Yes       ❑ No   Used adult day care?
❑ Yes       ❑ No   Been confined to a nursing home, assisted living facility, or long term care facility?
❑ Yes       ❑ No   Been advised by a Licensed Health Care Practitioner to have surgery that has not been performed?

Date Last Treated:                               Details: ____________________________________________________
_________________________________________________________________________________________________

2. Within the past 5 years (7 years for cancer), have you received any advice or treatment from a Licensed Health
   Care Practitioner; taken any medications; or been medically diagnosed for:
     YES    NO      CONDITION (CIRCLE APPLICABLE CONDITION.)
a.   ❑       ❑      Any Heart Conditions, such as Angina, Congestive Heart Failure, Heart Attack, Heart Surgery, or
                    Irregular Heart Beat?
b.   ❑       ❑      Any Circulatory Problems, including Numbness or Mini-Stroke?
c.   ❑       ❑      Cancer of any kind, Hodgkin’s Disease, Leukemia, or Lymphoma?
d.   ❑       ❑      Tumors (non-cancerous) or Skin Ulcers, Amputation or Paralysis?
e.   ❑       ❑      Any Breathing Conditions, such as Asthma, Chronic Bronchitis, Chronic Obstructive Pulmonary
                    Disease, Emphysema, Shortness of Breath, or Tuberculosis?
f.   ❑       ❑      Cirrhosis, Non-Insulin Dependent Diabetes, or Hepatitis?
g.   ❑       ❑      Brain Disorder, Black-outs, Convulsions, Epilepsy, or Seizures?
h.   ❑       ❑      Anxiety, Depression, or other Mental, Emotional or Nervous Disorder?
i.   ❑       ❑      Alcoholism or Chemical Dependency?
j.   ❑       ❑      Bone or spinal disorders such as Osteoarthritis or Rheumatoid Arthritis, Osteoporosis or Joint
                    Replacement?
k.   ❑       ❑      High Blood Pressure, Dizziness, or Balance Problems?
Provide details for any “YES” answers, include the Referance letter (a-k) in the space provided below. If
additional space is required, attach the details on a separate piece of paper, indicating your name and Social
Security Number. You must also sign and date that page.
Condition - ______: Date Last Treated: _____________ ❑ Check here if treated by your Primary Physician only. Give
name, address and phone #, of any other Licensed Health Care Professional who treated your condition:
_________________________________________________________________________________________________
Condition - ______: Date Last Treated: _____________ ❑ Check here if treated by your Primary Physician only. Give
name, address and phone #, of any other Licensed Health Care Professional who treated your condition:
_________________________________________________________________________________________________
Condition - ______: Date Last Treated: _____________ ❑ Check here if treated by your Primary Physician only. Give
name, address and phone #, of any other Licensed Health Care Professional who treated your condition:
_________________________________________________________________________________________________
3. Within the past five years, have you received any advice or treatment from a Licensed Health Practitioner other
   than your Primary Physician for any reason not stated ? (For Residents of California, Connecticut, Florida, Maine,
   New Jersey, New York, North Dakota, Vermont, and Wisconsin, this does not include HIV testing (Human
   Immunodeficiency Virus).
Date Last Treated:                               Details: ____________________________________________________
_________________________________________________________________________________________________
Give name, address and phone # of the Licensed Health Care Practitioner who treated your condition:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

GRP 99924                                        Page 3 of 5 (Continue to next page)          (STATENJ-01/01/2007 Control #40285)
MEDICAL HISTORY - Part 3 MEDICATIONS:
 Please provide the requested information. Are you currently taking any drugs or medications?                   ❑ Yes ❑ No
If Yes, provide the information requested in the space below. Attach additional sheets when needed.
1. Drug or Medication __________ Dosage __________ How long been taking? ________________________________
   ❑ Check here if prescribed by Primary Physician only. Give Name, Address, Phone No. if another Licensed Health
      Care Practitioner: ______________________________________________________________________________
2. Drug or Medication __________ Dosage __________ How long been taking? ________________________________
   ❑ Check here if prescribed by Primary Physician only. Give Name, Address, Phone No. if another Licensed Health
      Care Practitioner: ______________________________________________________________________________
3. Drug or Medication __________ Dosage __________ How long been taking? ________________________________
   ❑ Check here if prescribed by Primary Physician only. Give Name, Address, Phone No. if another Licensed Health
      Care Practitioner: ______________________________________________________________________________
Please list additional medications on the back of this page.

APPLICANT AGREEMENTS:
 Caution: If your answers on this Insurability Profile/Medical History Form are incorrect or untrue, or fail to include
all material medical information requested, Prudential may have the right to deny benefits or rescind your
insurance coverage.
To the best of my knowledge and belief, the answers on this Insurability Profile/Medical History form are complete and true.
I understand and agree:
1. This Insurability Profile/Medical History is the basis for the insurance for which I am applying to THE PRUDENTIAL
    INSURANCE COMPANY OF AMERICA (Prudential).
2. My coverage will NOT take effect unless: Prudential has approved this Enrollment Form and only if the statements and
    answers given in applying for this coverage are without material change until the date this Enrollment Form is approved.
3. I have read, or had read to me the completed Insurability Profile/Medical History, and I understand that any false
    statement or misrepresentation in this Form may result in loss of coverage under the Group Contract.




 Applicant Signature   X_________________________________________________________ Date                     _______________

FOR RESIDENTS OF ALL STATES EXCEPT MAINE, MINNESOTA AND VERMONT —
INFORMATION DISCLOSURE AUTHORIZATION
Print Name:                                                                            S.S. No.

Date of Birth:                            HMO/VA #, if any:

To any Licensed Physician, Medical Practitioner or Case Manager; Clinic, Hospital, or other care facility,
Pharmacy; insurance company, the Medical Information Bureau, Inc., or other medical or insurance organization,
institution or professional:
I authorize you to disclose to The Prudential Insurance Company of America any data or records you may have about
me or my mental or physical health that it may require to evaluate my application for insurance. This authorization is
good for 180 days from the date it is signed. A copy of this authorization will be as valid as the original. I (or my
representative) am entitled to a copy of this authorization.
I authorize The Prudential Insurance Company of America, its affiliates, insurance support organizations, and its
reinsurers to obtain information as to diagnosis, treatment, or prognosis of: my physical or mental condition; drug or
alcohol use history; HIV (Human Immunodeficiency Virus) or AIDS treatment; other insurance coverage; and any other
information needed to evaluate my application for insurance.


 Applicant Signature   X_________________________________________________________ Date                     _______________

GRP 99924                                        Page 4 of 5 (Continue to next page)              (STATENJ-01/01/2007 Control #40285)
FOR RESIDENTS OF MAINE AND VERMONT — INFORMATION DISCLOSURE AUTHORIZATION
This authorization EXCLUDES the release of information about any tests or medical records which show you tested
for the presence of HIV (Human Immunodeficiency Virus) antigens and non-antienic products of HIV, or antibody to
HIV, or what the results of the tests were.

Print Name:                                                                            S.S. No.

Date of Birth:                               HMO/VA #, if any:
To any Licensed Physician, Medical Practitioner or Case Manager; Clinic, Hospital, or other care facility, Pharmacy;
insurance company, the Medical Information Bureau, Inc., or other medical or insurance organization, institution
or professional:
I authorize you to disclose to The Prudential Insurance Company of America any data or records you may have about me
or my mental or physical health that it may require to evaluate my application for insurance.This authorization is good for
180 days from the date it is signed. A copy of this authorization will be as valid as the original. I (or my representative) am
entitled to a copy of this authorization.
I authorize The Prudential Insurance Company of America, its affiliates, insurance support organizations, and its reinsurers
to obtain information as to diagnosis, treatment, or prognosis of: my physical or mental condition; drug or alcohol use
history; AIDS treatment; other insurance coverage; and any other information needed to evaluate my application for
insurance.


 Applicant Signature   X_________________________________________________________ Date                       _______________


FOR RESIDENTS OF MINNESOTA — INFORMATION DISCLOSURE AUTHORIZATION:
You do NOT need to disclose any HIV (Human Immunodeficiency Virus or AIDS virus) tests which were given to you as:
1) a criminal offender or crime victim as a result of a crime that was reported to the police;
2) a patient who received the services of emergency medical services personnel at a hospital or medical care facility;
3) emergency medical personnel who were tested as a result of performing emergency medical services.
“Emergency medical personnel” includes individuals employed to provide pre-hospital emergency services; licensed
police officers, firefighters, paramedics, emergency medical technicians, licensed nurses, rescue squad personnel, and
other persons who serve as volunteers of an ambulance service who provide emergency medical services; crime lab
personnel, correctional guards, including security guards at the Minnesota security hospital who experience a significant
exposure to an inmate who is transported to facility for emergency medical care; and other persons who render emergency
care or assistance at the scene of an emergency, or while an injured person is being transported to receive medical care
and who would qualify for immunity under the Good Samaritan law.

Print Name:                                                                            S.S. No.

Date of Birth:                               HMO/VA #, if any:
To any Licensed Physician, Medical Practitioner or Case Manager; Clinic, Hospital, or other care facility,
Pharmacy; insurance company, the Medical Information Bureau, Inc., or other medical or insurance organization,
institution or professional:
I authorize you to disclose to The Prudential Insurance Company of America any data or records you may have about me
or my mental or physical health that it may require to evaluate my application for insurance.
This authorization is good for 180 days from the date it is signed. A copy of this authorization will be as valid as the original.
I (or my representative) am entitled to a copy of this authorization.
I authorize The Prudential Insurance Company of America, its affiliates, insurance support organizations, and its reinsurers
to obtain information as to diagnosis, treatment, or prognosis of: my physical or mental condition; drug or alcohol use
history; HIV (Human Immunodeficiency Virus) or AIDS treatment; other insurance coverage; and any other information
needed to evaluate my application for insurance.


 Applicant Signature   X_________________________________________________________ Date                       _______________

GRP 99924                                                   Page 5 of 5                             (STATENJ-01/01/2007 Control #40285)
 ALL APPLICANTS MUST SIGN TWO COPIES OF THE
             FOLLOWING FORM:

 ‘Authorization for Release of Health-Related Information’

Retain one copy for your records and include one copy with
        your completed applications to Prudential.

If additional copies are needed this form may be photocopied.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416




Health Insurance Portability
and Accountability Act (HIPAA) Form
 AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION
 This authorization is intended to comply with the HIPAA Privacy Rule.
Please print.

Name of applicant

Date of birth                                   Social Security number


I authorize any health plan, doctor, health care professional, hospital, clinic, laboratory, pharmacy, medical facility,
or other health care provider that has provided treatment or services to me or on my behalf (“My Providers”), and
any other medical or insurance organization, institution or professional, to disclose my entire medical record and
any other health information concerning me, without restriction, to The Prudential Insurance Company of America
and its agents, employees and representatives (“Prudential”). This includes medical records and information on
diagnoses and/or treatment relating to Human Immunodeficiency Virus (HIV) infection or Acquired Immunodeficiency
Syndrome (AIDS), sexually transmitted disease, mental illness, and the use of alcohol, drugs, and tobacco, but
excludes psychotherapy notes.

By my signature below, I terminate any agreements I have made with My Providers to restrict my protected health
information and, for purposes of this authorization, I instruct My Providers to release and disclose my entire medical
record without restriction to Prudential.

This information is to be disclosed under this authorization so that Prudential may do the following, with respect
to long term care insurance I am applying for: underwrite or make rating determinations, evaluate and determine
my eligibility for long term care insurance, or conduct other legally permissible activities related to my application.

This authorization shall remain in force for 24 months following the date of my signature below, unless state law
imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right
to withdraw this authorization in writing, at any time, by sending a written request to: The Prudential Insurance
Company of America, Long Term Care Customer Service Center, P            .O. Box 8519, Philadelphia, PA 19176, ATTN:
Privacy Contact. I understand that a withdrawal is not effective if any of My Providers has relied on this authorization
or to the extent that Prudential has a legal right to contest a claim under an insurance policy or to contest the policy
itself. I understand that any information disclosed pursuant to this authorization may be re-disclosed, to the extent
allowable under federal law and no longer covered by certain federal rules governing privacy and confidentiality
of health information.

I understand that if I refuse to sign this authorization, Prudential may not be able to process my application or, if
coverage has been issued, may not be able to make any benefit payments. I understand that Prudential will provide
me with a copy of this authorization.


X   Signature of applicant
    or personal representative                                                                 Date

    Description of personal representative’s authority or relationship to applicant




GRP 113392                  Detach and mail with your enrollment form.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416




Health Insurance Portability
and Accountability Act (HIPAA) Form
 AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION
 This authorization is intended to comply with the HIPAA Privacy Rule.
Please print.

Name of applicant

Date of birth                                  Social Security number


I authorize any health plan, doctor, health care professional, hospital, clinic, laboratory, pharmacy, medical facility,
or other health care provider that has provided treatment or services to me or on my behalf (“My Providers”), and
any other medical or insurance organization, institution or professional, to disclose my entire medical record and
any other health information concerning me, without restriction, to The Prudential Insurance Company of America
and its agents, employees and representatives (“Prudential”). This includes medical records and information on
diagnoses and/or treatment relating to Human Immunodeficiency Virus (HIV) infection or Acquired Immunodeficiency
Syndrome (AIDS), sexually transmitted disease, mental illness, and the use of alcohol, drugs, and tobacco, but
excludes psychotherapy notes.

By my signature below, I terminate any agreements I have made with My Providers to restrict my protected health
information and, for purposes of this authorization, I instruct My Providers to release and disclose my entire medical
record without restriction to Prudential.

This information is to be disclosed under this authorization so that Prudential may do the following, with respect
to long term care insurance I am applying for: underwrite or make rating determinations, evaluate and determine
my eligibility for long term care insurance, or conduct other legally permissible activities related to my application.

This authorization shall remain in force for 24 months following the date of my signature below, unless state law
imposes a shorter duration. A copy of this authorization is as valid as the original. I understand that I have the right
to withdraw this authorization in writing, at any time, by sending a written request to: The Prudential Insurance
Company of America, Long Term Care Customer Service Center, P            .O. Box 8519, Philadelphia, PA 19176, ATTN:
Privacy Contact. I understand that a withdrawal is not effective if any of My Providers has relied on this authorization
or to the extent that Prudential has a legal right to contest a claim under an insurance policy or to contest the policy
itself. I understand that any information disclosed pursuant to this authorization may be re-disclosed, to the extent
allowable under federal law and no longer covered by certain federal rules governing privacy and confidentiality
of health information.

I understand that if I refuse to sign this authorization, Prudential may not be able to process my application or, if
coverage has been issued, may not be able to make any benefit payments. I understand that Prudential will provide
me with a copy of this authorization.


X   Signature of applicant
    or personal representative                                                                 Date

    Description of personal representative’s authority or relationship to applicant




GRP 113392                           Keep for your records.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .O.
P Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416



Federal HIPAA Notice of Privacy Practices
for Protected Health Information
 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
 HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

“We” refers to The Prudential Insurance Company of          There are also times when federal law permits or
America in its capacity as a provider of Group and          requires us to use or disclose your information without
Individual Long Term Care insurance. “You” or “yours”       your written permission.
refers to any individual covered by a Long Term Care
insurance policy issued by The Prudential Insurance         Additionally, where appropriate, we may disclose
Company of America.                                         protected health information to a group health plan or
                                                            plan sponsor in accordance with federal law.
Federal law—meaning the Health Insurance Portability
and Accountability Act and related privacy rules—           Permitted Disclosures
requires The Prudential Insurance Company of America        We may not make all of the uses and disclosures listed
to keep your health information private. We are not         here, but federal law permits use or disclosure of your
allowed to use or disclose it unless we receive your        information without your permission:
permission or unless permitted by law. Federal law          • When we disclose your information to you.
requires us to give you this Notice of our legal duties
and privacy practices. This Notice is to inform you of      • To third party non-Prudential business associates that
uses and disclosures of your health information that          perform services for us or on our behalf, such as
we may make. It also informs you of your rights and           vendors.
our duties with regard to this health information.          • Where disclosure is required by law.
                                                            • To a public health authority authorized by law to
We must follow the terms of this Notice. We do reserve        collect or receive your information to prevent or
the right to change the terms of this Notice and make         control disease, injury or disability or when reviewing
the new Notice provisions apply to all the health             reports of child abuse or for the conduct of other
information we keep. This includes health information         authorized public health activities and
we had prior to any change in this Notice. We must            responsibilities.
promptly change this Notice when there is a material        • To a governmental authority when we reasonably
change to our uses or disclosures, your rights, our           believe you may be a victim of abuse, neglect or
duties and other related circumstances. We will mail          domestic violence where the governmental authority
you any such revised Notice, unless you have agreed           is allowed by law to have such information.
to receive Notices electronically. To receive such
Notices by E-mail, you should tell the contact listed at    • To a health oversight agency for such activities.
the end of this Notice.                                     • For judicial and administrative proceedings.
                                                            • To a law enforcement official for a law enforcement
Use and Disclosure of Protected Health Information            purpose.
Federal law permits us to use and disclose protected        • To a medical examiner for the purpose of identifying
health information for purposes of treatment, payment         a deceased person, determining the cause of death,
and health care operations as those terms are defined         or other duties authorized by law.
under federal law. As an insurer, we do not provide
treatment, but we may use and disclose protected            • To organ donor organizations in order to aid in such
health information for payment purposes, such as in           donations.
connection with the payment of an insurance claim.          • For certain research purposes authorized by and
We may also use and disclose protected health                 subject to federal law.
information for our health care operations such as          • To avert a serious threat to health or safety.
when we decide to give you insurance or when we
                                                            • To government officials regarding military personnel
renew or replace your insurance. We will also comply
                                                              and certain domestic and foreign government officials
with any state or federal law that is more restrictive as
                                                              for certain functions authorized by federal law.
to our uses and disclosures of protected health
information.                                                • To comply with workers’ compensation and other
                                                              similar programs.
                                                            • To make certain marketing communications and for
                                                              certain fundraising purposes.



GRP 113394
Required Disclosures                                         FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
We are required to disclose your information when            AMEND PROTECTED HEALTH INFORMATION: You have
required by the Secretary of the Department of Health        the right to request that we amend your information
and Human Services to make sure we comply with               kept in our records. We are allowed to deny your
federal law.                                                 request if we did not create the information in the
                                                             record. We will review your request and respond to you
We are also required, with certain exceptions, to            in writing. All requests should be in writing and sent to
provide you with access to inspect and obtain a copy         the contact listed at the end of this Notice. All requests
of your information that we keep. See “Your Right To         should provide needed details, including your name,
Inspect and Copy Protected Health Information” below.        address, insurance policy number, and the reason you
                                                             think your information needs to be changed. If you
Need for Authorization                                       wish additional information, you should write to the
We will not make any uses or disclosures other than          contact listed at the end of this Notice.
those mentioned above without your permission.
You may withdraw such permission in writing. Your            FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
withdrawal will not be effective (1) if we took action       AN ACCOUNTING: You have the right to receive an
relying on your permission before it was withdrawn,          accounting from us of disclosures of your information
or (2) if we obtained your permission as a condition         made for up to the six (6) years prior to your request.
of issuing you insurance, and the law allows us to           This right does not apply to: disclosures made to carry
contest a claim under the policy or to contest the           out treatment, payment, or health care operations;
policy itself. To withdraw your authorization, please        disclosures made with your permission; disclosures
write the contact listed at the end of this Notice. If you   made for police purposes; disclosures allowed by law;
wish additional information, you should write to the         or disclosures made before April 14, 2003. Any request
contact listed at the end of this Notice.                    should be sent to the contact listed at the end of this
                                                             Notice. If you wish additional information, you should
Individual Rights with Respect to Your Protected             write to the contact listed at the end of this Notice.
Health Information
FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO                   FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
REQUEST RESTRICTIONS: You have the right to                  A PAPER COPY OF THIS NOTICE: You have the right,
request that restrictions be placed on certain uses and      even if you have agreed to receive notice by E-mail, to
disclosures of your information. We are not required         get a paper copy of this Notice. All requests should be
to agree. If we do agree, we may not use or disclose         in writing and sent to the contact listed at the end of
any of your information except where you need                this Notice.
emergency treatment. We may end an agreement to
restrict as allowed by federal law. If you wish additional   FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO
information, you should write to the contact listed at       FILE A COMPLAINT. If you believe your privacy rights
the end of this Notice.                                      have been violated, you have the right to complain
                                                             to us by writing to the contact listed at the end of this
FEDERAL LAW PROVIDES YOU WITH THE RIGHT TO                   Notice or to the Secretary of the U.S. Department of
ALTERNATIVE CONFIDENTIAL COMMUNICATION OF                    Health & Human Services, Hubert H. Humphrey Building,
PROTECTED HEALTH INFORMATION: If you choose to               200 Independence Avenue, Washington, DC 20201.
have your information sent to you by a means of your         Federal law prohibits retaliation against you for filing
choice or to an address of your choice, we will do so        such a complaint. The contact listed at the end of this
if the request is reasonable. You must clearly state that    Notice is also available to provide you information
disclosure of all or any part of your information could      regarding questions you have or other information
endanger you if not sent per your choice. Any such           concerning this Notice.
request should be sent in writing to the contact listed
at the end of this Notice. If you wish additional            When you contact us in writing, you should include
information, you should write to the contact listed at       your name, address, and policy number. The contact to
the end of this Notice.                                      whom you should address your complaint is:
FEDERAL LAW PROVIDES YOU WITH THE RIGHT                      The Prudential Insurance Company of America
TO INSPECT AND COPY PROTECTED HEALTH                         Privacy Contact
INFORMATION: You have the right to inspect and copy          Long Term Care Customer Service Center
your information, except for any psychotherapy notes,         .O.
                                                             P Box 8519
certain information relating to civil, criminal, or          Philadelphia, PA 19176
administrative proceedings, and certain information
prohibited by law from disclosure. We are allowed by         Telephone number: 1-800-732-0416
law to deny access in some cases, and subject to
certain procedures. Any request should be sent in            The effective date of this notice is March 1, 2005.
writing to the contact listed at the end of this Notice.
If you wish additional information, you should write
to the contact listed at the end of this Notice.




GRP 113394
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .
P O. Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416


Electronic Funds Transfer Authorization
 INSTRUCTIONS
To enroll in Prudential’s monthly electronic funds transfer (EFT) payment service, please provide us with the
following information. If you wish to use your checking account, enclose your blank, voided check for that
account. If you wish to use your savings account, you must confirm that your financial institution permits
electronic fund withdrawals from savings accounts, and obtain your financial institution’s transit routing
number. Please note that we cannot obtain acceptable banking information from deposit slips. If you have any
questions, please call our Long Term Care Customer Service Center, toll free, at 1-877-582-4865. Please print
except where signatures are required. Use blue or black ink.

 A      APPLICANT/INSURED INFORMATION

Complete information for each applicant for whom this EFT Authorization will be used.                Please indicate the
Full name                                                      Policy/Cert. No. (If known)           bill date you prefer:
                                                                                                         1st*    15th
Full name                                                      Policy/Cert. No. (If known)               8th     22nd

 B      BANKING INFORMATION

Name of financial institution
                                                               Financial institution
Type of account             Checking            Savings        9-digit transit routing number

Account number                                                 Local branch telephone number (       )         -
Full name of account owner
(If other than applicant/insured)                              Relationship to applicant/insured

 C      EFT PAYMENT SERVICE AUTHORIZATION

I hereby request and authorize The Prudential Insurance Company of America (Prudential) to make electronic fund
withdrawals or other forms of pre-authorized withdrawals from my account named above, for payment of the
premium due the policy(ies) or certificate(s) indicated above. My signature below is exactly as it appears in my
financial institution’s records for this account. I agree that withdrawals shall be made approximately 3 to 5 days after
the bill date indicated above. I understand that premium notices will not be mailed. I understand that if a withdrawal
request is not honored by my financial institution, Prudential shall consider that my premium has not been paid. Any
withdrawal returned due to insufficient funds may be re-deposited for collection by Prudential, at its sole discretion.
If this authorization pertains to insurance (or an increase in insurance) for which an application is pending, this
authorization shall take effect on the Effective Date of the insurance applied for. This authorization shall not be
construed as: (a) an approval by Prudential of that application; or (b) a modification of any provisions of any
existing coverage. Otherwise, this authorization shall take effect on the date signed.
Either I or Prudential may cancel this authorization at any time by giving 30 days written notice to the other party.
Any notice hereunder will not be deemed effective until Prudential has had a reasonable time to act. I agree that
Prudential shall not be liable for any loss, liability, cost or expense for acting on this Authorization.

Full name of account owner

             .O.
Address (No P Boxes please)                                                                        Apt.

City                                                                          State                ZIP

X Applicant’s signature that on file with the Financial Institution)
  (Must be the same as
                                                                                                   Date


*If no bill date is selected, the 1st will be the bill date.
GRP 112215                    Detach and mail to insurer.
The Prudential Insurance Company of America
Prudential Long Term Care Customer Service Center
 .
P O. Box 8526, Philadelphia, PA 19176-8526 • 1-800-732-0416


Electronic Funds Transfer Authorization
 INSTRUCTIONS
To enroll in Prudential’s monthly electronic funds transfer (EFT) payment service, please provide us with the
following information. If you wish to use your checking account, enclose your blank, voided check for that
account. If you wish to use your savings account, you must confirm that your financial institution permits
electronic fund withdrawals from savings accounts, and obtain your financial institution’s transit routing
number. Please note that we cannot obtain acceptable banking information from deposit slips. If you have any
questions, please call our Long Term Care Customer Service Center, toll free, at 1-877-582-4865. Please print
except where signatures are required. Use blue or black ink.

 A      APPLICANT/INSURED INFORMATION

Complete information for each applicant for whom this EFT Authorization will be used.                Please indicate the
Full name                                                      Policy/Cert. No. (If known)           bill date you prefer:
                                                                                                         1st*    15th
Full name                                                      Policy/Cert. No. (If known)               8th     22nd

 B      BANKING INFORMATION

Name of financial institution
                                                               Financial institution
Type of account             Checking            Savings        9-digit transit routing number

Account number                                                 Local branch telephone number (       )         -
Full name of account owner
(If other than applicant/insured)                              Relationship to applicant/insured

 C      EFT PAYMENT SERVICE AUTHORIZATION

I hereby request and authorize The Prudential Insurance Company of America (Prudential) to make electronic fund
withdrawals or other forms of pre-authorized withdrawals from my account named above, for payment of the
premium due the policy(ies) or certificate(s) indicated above. My signature below is exactly as it appears in my
financial institution’s records for this account. I agree that withdrawals shall be made approximately 3 to 5 days after
the bill date indicated above. I understand that premium notices will not be mailed. I understand that if a withdrawal
request is not honored by my financial institution, Prudential shall consider that my premium has not been paid. Any
withdrawal returned due to insufficient funds may be re-deposited for collection by Prudential, at its sole discretion.
If this authorization pertains to insurance (or an increase in insurance) for which an application is pending, this
authorization shall take effect on the Effective Date of the insurance applied for. This authorization shall not be
construed as: (a) an approval by Prudential of that application; or (b) a modification of any provisions of any
existing coverage. Otherwise, this authorization shall take effect on the date signed.
Either I or Prudential may cancel this authorization at any time by giving 30 days written notice to the other party.
Any notice hereunder will not be deemed effective until Prudential has had a reasonable time to act. I agree that
Prudential shall not be liable for any loss, liability, cost or expense for acting on this Authorization.

Full name of account owner

             .O.
Address (No P Boxes please)                                                                        Apt.

City                                                                          State                ZIP

X Applicant’s signature that on file with the Financial Institution)
  (Must be the same as
                                                                                                   Date


*If no bill date is selected, the 1st will be the bill date.
GRP 112215                     Keep for your records.
                                                                 The Prudential Insurance Company of
                                                                 America
                                                                 Long Term Care Unit
                                                                 P.O. Box 8526
                                                                 Philadelphia, PA 19176
                                                                 Tel 800 732-0416


                             Long-Term Care Insurance
                                Personal Worksheet
People buy long-term care insurance for many reasons. Some don’t want to use their
own assets to pay for long-term care. Some buy insurance to make sure they can choose
the type of care they get. Others don’t want their family to have to pay for care or don’t
want to go on Medicaid. But, long-term care insurance may be expensive and may not be
right for everyone.
By state law, Prudential must fill out part of the information on this worksheet and ask
you to fill out the rest to help you and Prudential decide if you should buy this Certificate.
Premium Information
Certificate Form Number(s) _____________________________
The premium for the coverage you are considering will be $________________ per year.
Type of Certificate (noncancellable/guaranteed renewable): Guaranteed renewable
The Company’s Right to Increase Premiums: The company has a right to increase
premiums on this Certificate form in the future, provided it raises rates for all certificates
in the same class in this state.
Rate Increase History
The company has sold long-term care insurance since 1986 and has sold this Certificate
since 2002. The company has never raised its rates for any long-term care insurance
certitificate it has sold in this state or any other state.
Questions Related To Your Income
How will you pay each year’s premium? (check one)
    From my Income                 From my Savings/Investments             My Family will Pay
Have you considered whether you could afford to keep this coverage if the premiums
were raised, for example, by 20%?
What is your annual income? (check one)
   Under $10,000                   $10,000-20,000                $20,000-30,000
   $30,000-50,000                  Over $50,000
How do you expect your income to change over the next 10 years? (check one)
    No change           Increase            Decrease




GRP 113704                              Over, please                              NJ 05/2006
If you will be paying premiums with money received only from your own income, a rule
of thumb is that you may not be able to afford this coverage if the premiums will be more
than 7% of your income.

Will you buy inflation protection? (check one)       Yes              No
If not, have you considered how you will pay for the difference between future costs and
your daily benefit amount?

     From my Income              From my Savings/Investments           My Family will Pay

The national average annual cost of care in 2003 was $61,000, but this figure varies
across the country. In ten years, the national average annual cost would be about
$99,363 if costs increase 5% annually.

What elimination period are you considering? Number of days _______
Approximate cost $_____________ for that period of care.

How are you planning to pay for your care during the elimination period? (check one)

    From my Income              From my Savings/Investments            My Family will Pay

Questions Related to Your Savings and Investments

Not counting your home, about how much are all of your assets (your savings and
investments) worth? (check one)

    Under $20,000           $20,000-$30,000         $30,000-$50,000        Over $50,000

How do you expect your assets to change over the next ten years? (check one)
   Stay about the same         Increase                     Decrease

If you are buying this coverage to protect your assets and your assets are less than
$30,000, you may wish to consider other options for financing your long-term care.




GRP 113704                                  2                                  NJ 03/2006
                             DISCLOSURE STATEMENT

If you are an active employee or the spouse of an active employee, no further action
is required. If you are not an active employee or spouse, this must be completed and
signed and returned to Prudential in order for us to process your enrollment form.

Check one.

     The answers to the questions above describe my financial situation.
or
     I choose not to complete this information.

Please check the box.

    I acknowledge that I have reviewed this form including the premium, premium rate
increase history and potential for premium increases in the future. I understand the above
disclosures. I understand that the rates for this coverage may increase in the future.
(This box must be checked).


Signed: ________________________________________                  __________________

                   (Applicant)                                              (Date)

Note: In order for us to process your enrollment form, please return this
signed statement to Prudential along with your enrollment form.
However, if you are an active employee or the employee’s spouse, you do
not need to return this Personal Worksheet in order for Prudential to
process your enrollment form.
                    Prudential may contact you to verify your answers.




GRP 113704                                   3                                NJ 03/2006
       THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE INSURANCE

Long-Term Care Insurance

   •   A long-term care insurance policy may pay most of the costs for your care in a nursing home. Many policies
       also pay for care at home or other community settings. Since policies can vary in coverage, you should read
       this policy and make sure you understand what it covers before you buy it.

   •   You should not buy this insurance policy unless you can afford to pay the premiums every year. Remember
       that Prudential can increase premiums in the future.

   •   The Personal Worksheet includes questions designed to help you and the company determine whether this
       policy is suitable for your needs.

Medicare

   •   Medicare does not pay for most long-term care.

Medicaid

   •   Medicaid will generally pay for long-term care if you have very little income and few assets. You probably
       should not buy this policy if you are now eligible for Medicaid.

   •   Many people become eligible for Medicaid after they have used up their own financial resources by paying
       for long-term care services.

   •   When Medicaid pays your spouse’s nursing home bills, you are allowed to keep your house and furniture, a
       living allowance and some of your joint assets.

   •   Your choice of long-term care services may be limited if you are receiving Medicaid. To learn more about
       Medicaid, contact your local or state Medicaid agency.

Shopper’s Guide

   •   Make sure the insurance company or agent gives you a copy of a book called A Shopper’s Guide to Long-
       Term Care Insurance published by the National Association of Insurance Commissioners. Read it
       carefully. If you have decided to apply for long-term care insurance, you have the right to return the policy
       within 30 days and get back any premium you have paid if you are dissatisfied for any reason or choose not
       to purchase the policy.

Counseling

   •   Free counseling and additional information about long-term care insurance are available through your state’s
       insurance counseling program. Contact your state insurance department or department on aging for more
       information about the senior health insurance counseling program in your state.


GRP 111412
                                                              The Prudential Insurance Company of
                                                              America
                                                              Long Term Care Unit
                                                              P.O. Box 8526
                                                              Philadelphia, PA 19176-8526
                                                              Tel 800 732-0416



                         Long Term Care Insurance
                   Potential Rate Increase Disclosure Form
1. Premium Rate: The premium rate that is applicable to you and that will be in effect
until a request is made and filed for an increase is $ ___________________________
(fill in amount from Rate Sheet based on plan design and options you choose).

2. The premium for this Certificate will be shown on the Confirmation Statement
you will receive together with your Certificate of Insurance.

3. Rate Schedule Adjustments: The company will provide a description of when
premium rate or rate schedule adjustments will be effective (e.g., next anniversary date,
next billing date, etc.) (fill in the blank): No premium rate or rate schedule adjustments
are scheduled for this coverage.

4. Potential Rate Revisions: This Certificate is Guaranteed Renewable. This means
that the rates for this coverage may be increased in the future. Your rates can NOT be
increased due to your increasing age or declining health, but your rates may go up based
on the experience of all insureds with coverage similar to yours.

If you receive a premium rate or premium rate schedule increase in the future, you
will be notified of the new premium amount and you will be able to exercise at least
one of the following options:

   •   Pay the increased premium and continue your coverage in force as is.

   •   Reduce your benefits to a level such that your premiums will not increase.
       (Subject to state law minimum standards.)

   •   Exercise your non- forfeiture option if purchased. (This option may be available
       for purchase for an additional premium.)

   •   Exercise your contingent non-forfeiture rights.* (This option may be available if
       you do not purchase a separate non- forfeiture option.)

*Contingent Non-forfeiture

If the premium rate for your coverage goes up in the future and you didn't buy a non-
forfeiture option, you may be eligible for contingent non forfeiture. Here's how to tell if
you are eligible:

You will keep some long term care insurance coverage, if:


GRP 112407                                  1                                       (1201)
   •   Your premium after the increase exceeds your original premium by the
       percentage shown (or more) in the following table and

   •   You lapse (not pay more premiums) within 120 days of the increase.

The amount of coverage (i.e., new lifetime maximum benefit amount) you will keep will
equal the total amount of premiums you've paid since your coverage was first issued. If
you have already received benefits, so that the remaining maximum benefit amount is
less than the total amount of premiums you've paid, the amount of coverage will be that
remaining amount.

Except for this reduced lifetime maximum benefit amount, all other benefits will remain
at the levels attained at the time of the lapse and will not increase thereafter.

Should you choose this Contingent Non- forfeiture option, your coverage with this
reduced maximum benefit amount will be considered paid up with no further premiums
due.

Example:

You bought the coverage at age 65 and paid the $1,000 annual premium for 10 years, so
you have paid a total of $10,000 in premium.

In the eleventh year, you receive a rate increase of 50%, or $500 for a new annual
premium of $1,500, and you decide to lapse the coverage (not pay any more premiums).

Your paid-up benefits are $10,000 (provided you have at least $10,000 of benefits
remaining.)




GRP 112407                                2                                     (1201)
                                  Contingent Non-forfeiture
                      Cumulative Premium Increase over Initial Premium
                        That qualifies for Contingent Non-forfeiture

(Percentage increase is cumulative from date of original issue. It does NOT represent a one-time increase.)

                     Issue Age                          Percent Increase Over Initial Premium
                    29 and under                                        200%
                       30 – 34                                          190%
                       35 – 39                                          170%
                       40 – 44                                          150%
                       45 – 49                                          130%
                       50 – 54                                          110%
                       55 – 59                                           90%
                         60                                              70%
                         61                                              66%
                         62                                              62%
                         63                                              58%
                         64                                              54%
                         65                                              50%
                         66                                              48%
                         67                                              46%
                         68                                              44%
                         69                                              42%
                         70                                              40%
                         71                                              38%
                         72                                              36%
                         73                                              34%
                         74                                              32%
                         75                                              30%
                         76                                              28%
                         77                                              26%
                         78                                              24%
                         79                                              22%
                         80                                              20%
                         81                                              19%
                         82                                              18%
                         83                                              17%
                         84                                              16%
                         85                                              15%
                         86                                              14%
                         87                                              13%
                         88                                              12%
                         89                                              11%
                     90 and over                                         10%



    GRP 112407                                      3                                          (1201)
                      THE PRUDENTIAL INSURANCE COMPANY OF AMERICA
                                    751 BROAD STREET
                                NEWARK, NEW JERSEY 07102
                                       (800) 732-0416

                                     LONG-TERM CARE INSURANCE
                                       OUTLINE OF COVERAGE

                                     Policy Number: 83500 Contract Series
                                       Group Contract No. LT-40285-NJ

The following applies to applicants who must answer medical questions in order to qualify for the Long Term
Care Insurance.

Caution: The issuance of this long-term care insurance certificate is based upon your responses to the
questions on your enrollment form. . A copy of your enrollment form will be included with your Certificate of
Insurance if you had to provide evidence of insurability. If your answers are incorrect or untrue, the company
has the right to deny benefits or rescind your Certificate. The best time to clear up any questions is now, before
a claim arises! If, for any reason, any of your answers are incorrect, contact the company at this address:
Prudential Long Term Care Customer Service Center, P. O. Box 8526, Philadelphia, PA 19176.

Notice to buyer: This certificate may not cover all of the costs associated with long -term care incurred by
the buyer during the period of coverage. The buyer is advised to review carefully all plan limitations.

1. This policy is a group policy which was issued in the State of New Jersey.

2. PURPOSE OF OUTLINE OF COVERAGE. This outline of coverage provides a very brief description of
   the important features of the Coverage. You should compare this outline of coverage to outlines of
   coverage for other policies available to you. This is not an insurance contract, but only a summary of
   coverage. Only the group policy contains governing contractual provisions. This means that the group
   policy sets forth in detail the rights and obligations of both you and the insurance company. Therefore, if
   you purchase this coverage, or any other coverage, it is important that you READ YOUR CERTIFICATE
   CAREFULLY!

3. FEDERAL TAX CONSEQUENCES. This Certificate is intended to be a federally tax-qualified long
   term care insurance contract under Section 7702B(b) of the Internal Revenue Code of 1986, as
   amended.

4. TERMS UNDER WHICH THE CERTIFICATE MAY BE CONTINUED IN FORCE OR
   DISCONTINUED. RENEWABILITY: THIS CERTIFICATE IS GUARANTEED RENEWABLE.
   This means you have the right, subject to the terms of your certificate to continue this certificate as long as
   you pay your premiums on time. Prudential cannot change any of the terms of your certificate on its own,
   except that, in the future, IT MAY INCREASE THE PREMIUM YOU PAY. This coverage may be
   continued if your coverage ends for any reason other than nonpayment of premiums or exhaustion of the
   Lifetime Maximum. You may elect to continue the Coverage by paying the applicable premium for it. This
   Certificate contains a Waiver of Premium provision. After you meet the Benefit Eligibility Criteria and
   satisfy the required Benefit Waiting/Elimination Period, the premiums for your Coverage will be waived.
   These features are described in full detail in the Certificate.



GRP 99988                                                            (40285-NJ-7/1/2002)
5. TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS. PRUDENTIAL
   RESERVES THE RIGHT TO CHANGE THE PREMIUM YOU PAY. ANY
   CHANGE WILL APPLY ON A CLASS BASIS TO ALL INSUREDS.

6. TERMS UNDER WHICH THE CERTIFICATE MAY BE RETURNED AND PREMIUM REFUNDED.
   If you decide you do not want this Long Term Care Coverage, you may return the Certificate, along with a
   written request to cancel the coverage within 30 days of receipt. Your coverage will be canceled as of the
   Effective Date and any premium paid will be returned to you within 10 days of receiving your cancellatio n
   request. Upon proper notification of the your death or cancellation of this coverage at a time occurring after
   the 30 day free look period, Prudential will refund on a pro-rata basis any part of the periodic premium
   contribution for you which applies to the period after cancellation. The Certificate does contain provisions
   which provide for a refund or partial refund upon the death of the insured. Please refer to the section
   entitled “Additional Features” which describes the Death Benefit.

7. THIS IS NOT MEDICARE SUPPLEMENT COVERAGE. If you are eligible for Medicare, review the
   Guide to Health Insurance for People with Medicare available from Prudential by calling 1-800-732-0416.
   Prudential is not representing Medicare, the federal government or any state government.

8. LONG-TERM CARE COVERAGE. Policies of this category are designed to provide coverage for one or
   more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or
   personal care services, provided in a setting other than an acute care unit of a hospital, such as in a nursing
   home, in the community or in the home. This Certificate provides coverage in the form of reimbursement
   benefits, according to the Plan you choose, for covered long term care expenses, subject to Benefit Waiting/
   Elimination Period and Daily Maximum, Calendar Year and Lifetime Maximum benefits.

9. BENEFITS PROVIDED BY THIS CERTIFICATE. This Certificate pays benefits for Eligible Charges
   incurred by you for Institutional Care which inc ludes Nursing Home Care, Assisted Living Facility Care,
   and Bed Reservation; Home and Community- Based Care, which includes Home Health Care and Adult Day
   Care; and Additional Benefits which includes Hospice Care, Respite Care, Independence Support, Caregiver
   Training, Information and Referral Services, Private Care Management and Alternate Plan of Care.
   Benefits paid for Eligible Charges count towards fulfillment of your Lifetime Maximum, unless otherwise
   stated. The actual amount paid depends on the Plan you have chosen. You may choose one of the
   following Plans:




GRP 99988                                               2             (40285-NJ-7/1/2002)
                                       STATE OF NEW JERSEY
                             LONG TERM CARE PLAN SCHEDULE OF BENEFITS

Benefit Elimination/Waiting Period                                   90 Days

INSTITUTIONAL CARE BENEFITS                                Plan 1           Plan 2           Plan 3     Plan 4
NURSING HOME CARE
   Up to the Daily Maximum for Nursing Home Care           $ 100            $ 150            $200       $ 250

ASSISTED LIVING FACILITY CARE
   Up to the Daily Maximum for                             $ 100            $ 150            $200       $ 250
   Assisted Living Facility Care

BED RESERVATION
  Up to the Daily Maximum for Bed Reservation              $ 100            $ 150            $ 200      $ 250
  21 Day Benefit Limit per Hospital Stay                   $ 2,100          $3,150           $4,200     $5,250

HOME & COMMUNITY-BASED CARE BENEFITS*
HOME HEALTH CARE
  Up to the Daily Maximum for Home Health Care        $        50           $ 75             $ 100      $ 125
  Calendar Year Benefit Limit for Informal Caregivers $        750          $1,125           $1,500     $1,875

ADULT DAY CARE
  Up to the Daily Maximum for Adult Day Care               $   50           $     75         $ 100      $ 125

ADDITIONAL BENEFITS
HOSPICE CARE
  Up to the Daily Maximum for Hospice Care                 $ 100            $ 150            $ 200      $ 250

RESPITE CARE
  Up to the Daily Maximum for Respite Care                 $ 100            $ 150            $ 200      $ 250
  21 Day Calendar Year Benefit Limit                       $ 2,100          $ 3,150          $4,200     $5,250

INDEPENDENCE SUPPORT
Independence Support Lifetime Benefit Limit                $   500          $     750        $1,000     $1,250

CAREGIVER TRAINING
Caregiver Training Lifetime Benefit Limit                  $   500          $     500        $ 500      $ 500

INFORMATION AND REFERRAL SERVICES
Information and Referral by Prudential                     No limit         No limit         No limit   No limit

PRIVATE CARE MANAGER
Private care Manager Calendar Year Benefit Limit           $   600          $ 900            $1,200     $1,500

ALTERNATE PLAN OF CARE                                     Paid at the discretion of Prudential.

LIFETIME MAXIMUM**
   For all Long Term Care During Your Lifetime             $182,500         $273,750         $365,000   $456,250

*  The benefits paid for all covered Home & Community-Based Care services received on any given day will not
   exceed the Daily Maximum benefit for Home Health Care.
** The Lifetime Maximum is equal to the Daily Maximum for Nursing Home Care you choose times 365 days times
   5 years. For example, electing the $100 Daily Maximum for Nursing Home Care provides for a Lifetime
   Maximum of $182,500 ($100 x 365 x 5).




    GRP 99988                                          3                        (40285-NJ-7/1/2002)
  Benefit Waiting/Elimination Period: A Benefit Waiting/Elimination Period must be met
  once during your lifetime before benefits are payable. This Certificate has one combined
  Benefit Waiting/ Elimination Period for all covered services, except Hospice Care,
  Independence Support, Caregiver Training, Information & Referral and Private Care
  Management. This is a period, counted in calendar days, which begins on the date you are
  assessed, if that assessment results in eligibility for benefits, and continues as long as you
  have a Chronic Illness. You do not need to incur charges to satisfy the Benefit
  Waiting/Elimination Period. The Benefit Waiting/Elimination Period can be satisfied over
  multiple periods of Chronic Illness. The Benefit Waiting/ Elimination Period is shown in
  the Schedule of Benefits above.

  Eligibility for Payment of Benefits: In order to receive benefits you must be assessed by an
  Assessor and be confirmed as having a Chronic Illness. A Chronic Illness is one in which
  there is:
  1) A loss of the ability to perform, without Substantial Assistance, at least two Activities of
      Daily Living. This loss must be expected to continue for 90 days. Activities of Daily
      Living are: Bathing, Continence, Dressing, Eating, Toileting, and Transferring; or
  2) A severe Cognitive Impairment which requires Substantial Supervision to protect you
      from threats to health or safety.

  Activities of Daily Living are defined as follows:
  Bathing - Washing oneself by sponge bath, or in either a tub or shower, including the task of
  getting into or out of the tub or shower; Continence - The ability to maintain control of bowel
  and bladder function, or, when unable to maintain control of bowel or bladder function, the
  ability to perform associated personal hygiene (including caring for catheter or colostomy
  bag); Dressing - Putting on and taking off all items of clothing and any necessary braces,
  fasteners or artificial limbs; Eating - Feeding oneself by getting food into the body from a
  receptacle (such as a plate, cup or table) or by feeding tube or intravenously; Toileting -
  Getting to and from the toilet, getting on and off the toilet, and performing associated
  personal hygiene; Transferring - Sufficient mobility to move into or out of a bed, chair or
  wheelchair or to move from place to place, either by walking, using a wheelchair or by other
  means.

  Cognitive Impairment is defined as follows: A loss or deterioration in intellectual capacity
  that is: comparable to and includes Alzheimer’s disease and similar forms of irreversible
  dementia; and measured by clinical evidence and standardized tests that reliably measure
  impairment in the individual’s short-term or long term memory; orientation as to people,
  places, or time; and deductive or abstract reasoning.

  Prudential will arrange for a trained Assessor to assess you or you may select your own
  Assessor. The assessment will be based on objective standards of measurement. Based on
  the information obtained during the assessment, your eligibility will be confirmed or denied
  based on Prudential’s use of objective standards of measurement. If you are eligible, you
  will need a Plan of Care. Your Plan of Care will be used to determine benefits based on the
  Plan you have chosen.




GRP 99988                                      4                     (40285-NJ-7/1/2002)
10. LIMITATIONS AND EXCLUSIONS. Charges Not Covered:
    a) Work-connected Conditions Charge: A charge covered by a workers’ compensation
       law, occupational disease law or similar law.

   b) Government Plan Charge: A charge for a service or supply: (A) furnished by or for the
      United States government or any other government, unless payment of the charge is
      required by law; or (B) to the extent that the service or supply, or any benefit for the
      charge, is provided by any law or governmental plan under which the patient is or could
      be covered. This (B) does not apply to a state plan under Medicaid or to any law or plan
      when, by law, its benefits are excess to those of any private insurance program or other
      non-governmental program. When this (B) applies to Medicare, the benefits provided
      by Medicare will be deemed to include any amount that would have been payable by
      Medicare in the absence of a deductible or coinsurance requirement under that program.

   c) War, Felony, Riot or Insurrection: Charges for a condition due to war or any act of war
      while you are insured or due to your participation in an act of felony, riot or insurrection.
      "War" means declared or undeclared war and includes resistance to armed aggression.
      “Riot” means a wild, violent, public disturbance of the peace.

   d) Self- inflicted Injury or Suicide: Charges arising from intentionally self- inflicted injury
      or attempted suicide, while sane or suffering from inorganic based insanity.

   e) Services and Supplies Outside the United States: Charges for services or supplies
      outside of the United States and its possessions.

   f) Treatment for Chronic Alcoholism or Chemical Dependency: Charges in connection
      with the treatment of chronic alcoholism or chemical dependency.

   Pre-existing Conditions Exclusion: Within a limited period, benefits will not be paid for
   charges made in connection with your Pre-existing Conditions. This is a condition for which
   a health care Provider gave you medical advice, treated you, or recommended treatment
   within six months before the date you became insured. This limited period extends for six
   months after your Effective Date. If you purchase this Long Term Care Coverage to replace
   another Long Term Care policy or certificate, Prudential will waive this limitation to the
   extent that a similar pre-existing conditions exclusion has been satisfied under your previous
   Long Term Care policy or certificate. If you were required to answer questions about your
   health when you applied for this Long Term Care Coverage, the Pre-existing Condition
   exclusion described in the previous paragraph does not apply to you.

     THIS POLICY MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH
                     YOUR LONG-TERM CARE NEEDS.




GRP 99988                                        5                     (40285-NJ-7/1/2002)
  11. RELATIONSHIP OF COST OF CARE AND BENEFITS. Because the costs of long
  term care services will likely increase over time, you should consider whether and how the
  benefits of this plan may be adjusted. Benefit levels may increase over time in accordance
  with the inflation protection provision you choose.

  a) Periodic Offers for Inflation Increase Protection: Every three years you will be
  offered the opportunity to increase your benefits to keep up with inflation. If you accept the
  offer, the amount of the additional benefit shall be the difference between your existing
  benefits and those benefits compounded annually at a rate of five percent for the period
  beginning with the purchase of your existing benefits and extending until the year in which
  the offer is made. Benefits will be rounded to nearest dollar. Your Lifetime Maximum will
  also increase accordingly. Your age on the Effective Date of the increase will be used to
  determine the additional separate premium for the increased Coverage. Therefore, your
  premium will increase each time you accept an inflation protection offer. You do not have to
  provide evidence of insurability to take inflation increases. However, if you decline the
  previous two offerings made to you, and then want to increase Coverage, you will be
  required to submit satisfactory evidence of insurability the next time you accept an offer.

  b) Automatic Compound Inflation Increase Option- : Your benefits will automatically
  increase on the anniversary of the Effective Date of your Coverage. These increases will
  occur even if you are receiving benefits. Each year, all benefits increase by 5% compounded
  annually, rounded to the nearest dollar. Your Lifetime Maximum will also increase
  accordingly. You do not have to provide evidence of insurability. No additional premium
  charge will be imposed.




GRP 99988                                     6                    (40285-NJ-7/1/2002)
                                                              LTC Benefit Comparison
                                                      Periodic Inflation vs. Automatic Inflation
                           450

                           400

    Daily Benefit Amount   350                                                                                     Periodic Inflation
                                                                                                                   (w/ increases)
                           300

                           250                                                                                     Automatic
                                                                                                                   Compound
                           200
                                                                                                                   Inflation
                           150
                                                                                                                   Periodic Inflation
                           100                                                                                     (no increases)

                            50

                             0
                                         45    48    51     54    57    60    63       66    69    72    75
                                                                  Attained Age


                                                             LTC Premium Comparison
                                                      Periodic Inflation vs. Automatic Inflation
                           4,500

                           4,000
                                                                                                                   Periodic
                           3,500                                                                                   Inflation (w/
    Annual Premium




                                                                                                                   increases)
                           3,000

                           2,500                                                                                   Automatic
                                                                                                                   Compound
                           2,000                                                                                   Inflation
                           1,500
                                                                                                                   Periodic
                           1,000                                                                                   Inflation (no
                                                                                                                   increases)
                            500

                                 0
                                          45    48    51     54    57    60   63       66    69    72    75
                                                                   Attained Age


                                                           Comparison of Cumulative Premiums

                           40,000

                           35,000
                                                                                                                        Periodic
                           30,000                                                                                       Inflation
    Cumulative Premium




                                                                                                                        (with
                           25,000                                                                                       increases)
                                                                                                                        Automatic
                           20,000
                                                                                                                        Compound
                           15,000                                                                                       Inflation

                           10,000                                                                                       Periodic
                                                                                                                        Inflation
                            5,000                                                                                       (no
                                                                                                                        increases)
                                     0
                                         45    48    51      54   57     60      63     66    69    72        75
                                                                        Age



GRP 99988                                                                          7                          (40285-NJ-7/1/2002)
12. ALZHEIMER'S DISEASE AND OTHER ORGANIC BRAIN DISORDERS. The certificate
    provides coverage for insureds clinically diagnosed as having Alzheimer's disease or related
    degenerative and dementing illnesses.

13. PREMIUM. Premiums vary according to the Plan you choose. The initial premium for your
    Coverage will be determined from the premium rate schedules contained in your enrollment
    material based on the Plan selected and your age as of the date you enroll.

14. ADDITIONAL FEATURES.

   Medical Underwriting: Medical underwriting is used to determine eligibility for Coverage.
   To enroll for Coverage under this plan, you must complete an Enrollment Form.
   Satisfactory evidence of good health is required, except for newly hired and newly eligible
   employees who apply within 90 days of becoming eligible. Newly hired and newly eligible
   employees who apply more than 90 days after their initial period of eligibility must also
   provide satisfactory evidence of good health. Individuals aged 85 and over are not eligible.

   Third Party Lapse Designee: Unless you decline to do so in your Enrollment Form, you
   have the right to name a third party as your authorized designee to be notified when the lapse
   of your coverage is imminent. It is our responsibility to notify you and this designee prior to
   canceling your Coverage due to lack of premium payment. Notice will no t be given until 30
   days after a premium is due and unpaid. You may change your designee at any time by
   notifying Prudential in writing.

   Reinstating Coverage: If you fail to pay your premium and your Coverage ends for this
   reason, you may be eligible to reinstate your Coverage. You may make a request for
   reinstatement within 60 days of the date premiums were due. If, due to your Chronic Illness,
   you fail to pay your premium and your Coverage ends for this reason, you may be eligible to
   reinstate your Coverage. You or your representative may request reinstatement within five
   months of the date premiums were due.

15. OPTIONAL BENEFITS THAT ARE AVAILABLE TO YOU FOR ADDITIONAL PREMIUM

   In addition to the Automatic Compound Inflation Increase Option described above, the
   following options are available:

   Monthly Benefit Rider: The Long Term Care Coverage provides benefits for Home and
   Community-Based Care subject to a Daily Maximum. Under this Rider, benefits for Eligible
   Charges will be paid up to a Monthly Maximum for all Home and Community- Based Care
   combined. The Monthly Maximum equals the Daily Maximum benefit for Home Health Care you
   selected, times the number of days in the month. These benefits are subject to your Lifetime
   Maximum.




GRP 99988                                       8                    (40285-NJ-7/1/2002)
    Non-Forfeiture Benefit - Shortened Benefit Period Rider: This rider provides a non-
    forfeiture benefit in the form of a shortened benefit period. This rider will pay benefits
    according to the conditions in effect at the time insurance ended, up to the benefit limits you
    have chosen. However, you will have a reduced Lifetime Maximum. If your insurance
    ended due to non-payment of premium on or after the third anniversary of your Effective
    Date, you may be entitled to receive benefits under this provision. If you are entitled to a
    benefit, this benefit will be equal to the greater of: 30 times the Daily Maximum for
    Nursing Home Care at the time of lapse, up to your remaining Lifetime Maximum; or the
    total amount of premiums paid for your Coverage, less the sum of all benefits paid on your
    behalf while you were covered by this insurance. This benefit can be used at any time
    during your lifetime. To use it, you must request benefits and Prudential must determine
    your eligibility. Your benefits will be based on the benefit limits in effect at the time your
    insurance ended.
16. CONTACT THE STATE SENIOR HEALTH INSURANCE ASSISTANCE PROGRAM IF
    YOU HAVE GENERAL QUESTIONS REGARDING LONG TERM CARE INSURANCE.
    CONTACT THE INSURANCE COMPANY IF YOU HAVE SPECIFIC QUESTIONS
    REGARDING YOUR LONG TERM CARE INSURANCE CERTIFICATE.

17. SENIOR COUNSELING PROGRAMS. Please refer to A Shopper’s Guide To Long Term
    Care Insurance contained in your enrollment material for the telephone number of the Senior
    Counseling Program in your state.




GRP 99988                                        9                    (40285-NJ-7/1/2002)

				
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