HomeMy WebLinkAbout99-00142
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KIRKPATRICK & LOCKHART LLP
ATTORNEYS AT L-\W
HO NORTH THIRO STREET
HARRISBURG. PENNSYLVANIA 17101-1507
TElEPHONE, (717) 2]1..04500
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ROBERT E. HECK,
Plaintiff,
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IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY,
PENNSYLVANIA
Civil Action
v.
NO. 99-142 Civil Term
THE DEFENDANT INSURANCE
COMPANY OF AMERICA,
Defendant.
Jury Trial Demanded
NOTICE TO PLEAD
TO: ROBERT E. HECK:
You are hereby notified to file a written response to the enclosed NEW MATTER within
twenty (20) days from service hereof or a judgment may be entered against you.
D,", j.~ B, ICfl'J
. KIRKPATRICK & LOCKHART LLP
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Andrew H. Cline
Pa. Supreme Ct. No. 29020
Lisa A. Balestrini
Pa. Supreme Ct. No. 78479
240 North Third Street
Harrisburg, Pennsylvania 17101
(717) 231-4500
(717) 231-4501 (facsimile)
Counselfor The Defendant Insurance
Company of America
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ROBERT E. HECK,
Plaintiff,
v.
THE DEFENDANT INSURANCE
COMPANY OF AMERICA,
Defendant.
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IN THE COURT OF COMMON PLEAS
OFCUMBERLANDCOUNT~
PENNSYL VANIA
CIVIL ACTION
NO. 99-142 CIVIL TERM
JURY TRIAL DEMANDED
ANSWER
I. Admitted upon information and belief.
2. Denied. By way of further answer, Defendant's corporate headquarters is located
at 751 Broad Street, Newark, New Jersey 07102.
3. Admitted upon information and belief.
4. Admitted in part; denied in part. It is admitted that a ten thousand dollar
($10,000.00) life insurance policy, Policy No. 63 483 092, was issued to the insured, Gloria J.
Heck ("Heck"), on December II, 1997. It is denied, however, that at the time of her dea!b
Heck's life was insured by an insurance policy issued by Defendant because the policy was
rescinded due to Heck's material misrepresentations on the Application For Life Insurance.
1998, is attached hereto as "Exhibit A".
Defendant's letter, in which it specifies several ofthe reasons for nonpayment, dated October 9,
5. Denied. By way offurther answer, all premiums paid on Policy No. 63 483 092
have been returned to Plaintiff. It is denied that Heck had taken "all actions necessary to validly
obtain, to maintain, and to keep in full force and effect, the said policy of insurance." See
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Complaint, para. 5. Due to Heck's material misrepresentations on her Application For Life
Insurance, the policy was rescinded, and therefore not validly obtained, maintained, or held in
full force and effect at any time. See "Exhibit A".
6. Denied. By way of further answer, it is denied that Plaintiff currently holds
beneficiary status, since !be life insurance policy sold to Heck was not a valid contract due to her
material misrepresentations on the Application For Life Insurance.
7. Denied. By way offurther answer, it is denied !bat any benefit is due Plaintiff
since the life insurance policy sold to Heck was not a valid contract because of her material
misrepresentations on the Application For Life Insurance.
8. Denied. By way of further answer, it is denied that Defendant is obligated to
make payment to Plaintiff because the policy was rescinded due to !be material
misrepresentations made by Heck.
9. Denied. By way offurtber answer, it is denied !bat Defendant has breached the
life insurance contract, because the policy was rescinded due to the material misrepresentations
made by Heck. Furtber, it is denied that Defendant has injured Plaintiff because Plaintiff does
not hold beneficiary status under !be Heck policy, since the life insurance policy was rescinded
and never a valid contract due to Heck's material misrepresentations.
NEW MATTER
I. Plaintiff has failed to state a claim upon which relief may be granted.
2. The claim must be dismissed because it is based upon an act of fraud.
3. The claim must be dismissed because the contract was rescinded.
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WHEREFORE, Defendant requests judgment in its favor against Plaintiff, its costs and
attorneys' fees, and such other and further relief as the Court deems just and proper.
Respectfully submitted,
KIRKPATRICK & LOCKHART LLP
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Andrew H. Cline
Pa. Supreme Ct. No. 29020
Lisa A. Balestrini
Pa. Supreme Cl. No. 78479
240 North Third Street
Harrisburg, Pennsylvania 17101
(717) 231-4500
(717) 231-4501 (facsimile)
COllllsc/for The Defendant Insurance
Company of America
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VERIFICATION
I, Brenda Tate, hereby certify that I am a Senior Claims Examiner with the Defendant,
Prudential Insurance Company of America, and as such, I am authorized to make this
Verification on its behalf. I hereby verify that the foregoing facts are true and correct to
the best of my knowledge or information and belief. I understand that tIris verification
is made subject to the penalties of 18 Pa. C.S. ~4904 (relating to unsworn falsifications
to authorities).
Date: ~ / sf 91
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The Prudential Insurance Corrpany of America
Customer Service Office
P. 0, Box 7390
Philadelphia. PA 19101
Carol Hartman
Senior Claim Examiner
October 9, 1998
ROBERT E HECK
6023 HUMMINGBIRD
MECHANICSBURG PA
DRIVE
17055
Insured:
Gloria J. Heck
Policy H: 63 483 092
Dear Mr. Heck:
Thank you for your continued patience during these difficult days, and for
your assistance in providing the information we requested. As you may
recall, we have been reviewing information that your wife provided when she
applied for this insurance. This is a routine procedure whenever an insured
dies within the first two years of coverage.
During our review of Dr. Harhigh's records, we learned that your wife had
stress tests on January 29, 1993 and March 8, 1993. The January 93 test
showed mild ischemia. The March 1993 test showed a complete left bundle
block and resting EKG abnormalities. In addition, while she told us she was
taking Haldol, she didn't tell us she was taking Cogentin as well.
If all the facts concerning her medical history had been included on the
application for insurance, we would not have issued this policy. As a
result, no benefit is payable. Prudential assumed that all statements in the
application were made to the best knowledge and belief of the person who made
them. The company relied on those statements when issuing the policy, and
coverage can be invalidated if any of the information was materially
misrepresented.
Although we cannot pay a death benefit, I am enclosing a check in the amount
of 456.]8, which is the total premium payments for the policy plus interest
of $14.38. For your information, I have also enclosed a copy of your wife's
signed application.
Corporate Olliee: 751 Broad Street, Newark., NJ 07102-3777
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Please don't hesitate to call me collect at 215-784-3625 if you have any
questions regarding our findings.
Sincerely,
Carol Hartman
Senior Claim Examiner
cc: fi Ie
Enclosure
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I hereby certify that on this 8th day of February, 1999, I have served a copy of the
foregoing by hand delivery:
CERTIFICATE OF SERVICE
Samuel L. Andes, Esquire
525 North 12th Street
Lemoyne, P A 17043
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Lisa A. Bales mi
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IN THE COURT OF COMMON
PLEAS OF CUMBERLAND
COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. qq - \ '-td. Lv,',\) ,en"\
ROBERT E. HECK,
Plaintiff
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA,
Defendant
JURY TRIAL DEMANDED
NOTICE
TO DEFENDANTS NAMED HEREIN:
YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE
CLAIMS SET FORTH IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN
TWENTY (20) DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED, BY
ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILING IN
WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET
FORTH AGAINST YOU. YOU ARE WARNED THAT IF YOU FAIL TO DO SO, THE CASE
MAY PROCEED WITHOUT YOU, AND A JUDGMENT MAY BE ENTERED AGAINST YOU
BY THE COURT WITHOUT FURTHER NOTICE FOR ANY MONEY CLAIMED IN THE
COMPLAINT OR FOR ANY OTHER CLAIM OR RELIEF REQUESTED BY THE PLAINTIFF.
YOU MAY LOSE MONEY OR PROPERTY OR OTHER RIGHTS IMPORTANT TO YOU.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET
FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PENNSYLVANIA 17013
TELEPHONE: (717) 249-3166
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vs.
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IN THE COURT OF COMMON
PLEAS OF CUMBERLAND
COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
ROBERT E. HECK,
Plaintiff
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA,
Defendant
NO. qq - l-+d-. ~ \€.fiYI
JURY TRIAL DEMANDED
COMPLAINT
AND NOW comes the above-named Plaintiff, Robert E. Heck, by his attorney,
Samuel L. Andes, and makes the following Complaint in this matter:
1. The Plaintiff is Robert E. Heck an adult individual who resides at 6023
Hummingbird Drive in Mechanicsburg, Cumberland County, Pennsylvania. '
2. The Defendant is the Prudential Insurance Company of America" which
maintains offices in Philadelphia, Pennsylvania, and whose address is P.O. Box
7390, Philadelphia, PA 19101.
3. Plaintiff is the widower of Gloria J. Heck, who died on 5 August 1998.
4. At the time of her death, Gloria Heck's life was insured by a policy of
insurance issued by the Defendant, which provided death benefits in the amount of
$10,000.00, which was dated 11 December 1997, and which was identified as Policy
No. 63 483 092. A copy of said policy is attached hereto and marked as Exhibit A.
5. Prior to the time of her death, Gloria Heck, or persons on her behalf, have
paid all premiums and taken all actions necessary to validly obtain, to maintain, and
to keep in full force and effect, the said policy of insurance.
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6. Following the death of Gloria Heck, Plaintiff has taken all steps requested
by Defendant to make proper application for payment of the death benefits due
under the policy.
7. To date, Defendant has not paid the death benefit due under the said
policy to Plaintiff, or to any other person or entity to Plaintiff's knowledge.
8. Defendant is obligated to make payment of the death benefit to Plaintiff
under the terms of the said policy. Defendant's failure and refusal to make such
payment is a violation of the contract of insurance which that policy represents.
9. Defendant has breached its own contract, or policy of insurance and, by
doing so, has injured Plaintiff in the amount of $10,000.00, plus interest from and
after the date of the death of Gloria Heck.
WHEREFORE, Plaintiff demands judgment against Defendant in the amount
of $10,000.00, plus interest from and after the date of death of Gloria Heck, plus
Plaintiff's costs in this action.
&L.~
Attorney for Plaintiff
Supreme Court ID # 17225
525 N. 12th Street
Lemoyne, PA 17043
(717) 761-5361
COMMONWEALTH OF PENNSYLVANIA
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COUNTY OF CUMBERLAND
ROBERT E. HECK, being duly sworn according to law, deposes and says that
the facts set forth in the foregoing COMPLAINT are true and correct to the best of
his knowledge, information, and belief.
d/~L
-ROBERT E. HECK
Sworn to and subscri.bg,q
bef~^r:P.e thi,s_.jOUG day
of "'JL<LQ.I71t.:.JU , 1998.
a~ lm. lk2ku/ -t
Notary ,ubllc.
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NOTARLIL f8L
ROSBll. ~l>l.-.y Pa.'ic
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TheP~udentlal ~
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The Prudential Insurance Company of America
a .mutual~life insurance company
Prudential Plaza, Newark, New Jersey 07102
Insured GLOR I A J HECK
63 483 092
DEC 11, 1991-
Policy Number
Contract Date
Agency 4-w SH-G-168
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Whole Life Policy. Life insurance payable upon death. Premiums payable during Insured's lifetime. Eligible for
annual dividends as stated under Dividends.
We will pay the beneficiary the death benefit described in this contract promptly if we receive due proof that the Insured died,
We make this promise subject to all the provisions of this contract.
If there is ever a question about this contract. just see a Prudential representative or contact one of our offices.
10-Day Right to Cancel Contra ct.-If you return this contract to us no later than 10 days after you receive it, we will refund
your money promptly. The contract will be canceled from the start. All you have to do is take it or mail it toone of our offices
or to the representative who sold it to you.
Signed for Prudential.
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Secretary
President
PLEASE READ YOUR POLICY CAREFULLY; it is a legal contract between you and Prudential,
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WL-98
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GUIDE TO CONTENTS
Page
Contract Data . . . , ... . . . . . . . . . . . . . . . . . , , . . . . . , . . . ''- .
Basic Contract Information About Insurance Coverage and Premiums Payable Under the Contract
, , 3
Table of Velues , . . , . . . . . , . . . . . , . . . , , . . . . , . , , . . . . . . . . . . . . . . . . . . . . , . . . 4
A table showing Cash and Loan Values, amounts of Reduced Paid-Up Insurance. and Extended Insurance. if any
Definitions
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The Contract 5
Entire Contract; Contract Modifications: Incontestability
Ownership. , . 5
Deeth Benefits 6
Premium-Paying Basis: Extended Insurance; Reduced Paid-Up Insurance; Optional Benefit; Computations;
Unearned Premium: Interest on Death Benefit; Suicide Exclusion; Method of Payment
Beneficiery 8
Dividends . 8
Dividend Options; Dividend Credits Described
Loens .. . . . . . . . . . , , . . . . . , . . . . . . . . . . . . . . . .. ... . . . . . . . . . . . . . . . . . 9
Loan Requirements; Interest Charge; Amount You May Borrow; Loan Value; Contract Debt: Repayment; Excess
Contract Debt; Postponement of Loans
Premium Payment . . . . . . . . . . . . . . . . . . . . .
Payment of Premiums; Change of Frequency; Grace Period
11
Cash Velue Option Upon Surrender t 1
Reinstatement. . . 1 2
General Provisions t 2
Currency; Misstatement of Age or Sex; Assignment; Change in Plan or Basic Amount of Insurance: Voting Rights
Basis of Computation , , . , , . , , , . , . , . . . . . , . . . . . . . . . .
Monality Basis and Interest Rate; Exclusions; Values; Minimum Legal Values
13
Senlement Options . . . . . . . .
Options Described; Interest Rate
. . . . . . . . . . . . . . . . , .. 14
Senlement Options Tebles . . . .
15
A copy of the application and any riders or endorsements can be found at the end of the contract.
(WL-98)
Page 2
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CONTRACT DATA
Insured
GLORIA J HECK
Female, Issue Age 57
Rating Class
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Gib Standard R, No Extended Insurance
Basic Contract Information
Po I icy Number
Contract Date
Premium Period
Initial Dividend
63 483 092
December 11, 1997
Li fe
We do not expect to credit a dividend before the third
anniversary (see Dividends).
See Beneficiary Provision attached.
Beneficiary
Life Insurance on the Insured
Basic Amount
$10,000.00
Other Beneflt(s) on the Insured (see appropriate form for details)
Rider MSB 220 - Insured's Accidental Death and Dismemberment Benefit.
Amount varies. Refer to the form for details on the amount payable.
CONTRACT DATA CONTINUED ON NEXT PAGE
Page 3 (95)
ThePrudentlal ~
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Schedule of Premiums
POLICY NO. 63 483 092
CONTRACT DATA CDNTINUED
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Contract premiums are due on the contract date and at intervals of 1 month
after that date. They start at $55.30 and change as shown below.
Premium Chanqe Date(s)
DEC 11, 2017
Contract Premiums
$ 39'. '10
Each contract premium consists of the premium for the basic amount and
the premium(s) for the benefit(s) shown in the section that follows.
Prem I um (s) for Benef I t (s)
Premium for Benefit'MSB 220 (accidental death and dismemberment benefit):
$3.00
Starting on the Contract Date
Page 3A (95)
END OF CONTRACT DATA
ThePrudentlal ~
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POLICY NO. 63 483 092
TABLE OF GUARANTEED VALUES
These are the values for the basic amount if all due premiums have been paid,
there is no contract debt, and there are no dividend credits. ~These values
are determined as provided in the Basis of Computation provision.
Guaranteed
End of Guaranteed Reduced Paid-Up
Contract Year Cash Insurance
1 $0.00 , $0.00
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2 $0.10 $1.00
3 $239.40 $510.00
4 $484.90 $1,003.00
5 $735.80 $1,479.00
6 $999.60 $1.954.00
7 $1,266.70 $2,410.00
8 $1,537.10 $2.846.00
9 $1,810.30 $3,264.00
10 $2,087.30 $3,667.00
11 $2,368.80 $4,055.00
12 $2,656.00 $4,432.00
13 $2,948.30 $4,797.00
14 $3.245.30 $5,150.00
15 $3.545.30 $5,489.00
16 $3,846.40 $5,815.00
17 $4,146.60 $6.125.00
18 $4,445.30 $6.421.00
19 $4,741.80 $6,704.00
20 $5.037 .00 $6,976.00
Age 60 $239.40 $510.00
Age 62 $735.80 $1,479.00
Age 65 $1,537.10 $2,846.00
If we need to compute these values during a contract year. we will take
into account the time since the start of the year and any premiums paid for
the year. If you ask us. we will tell you the values for durations other
than those shown in this table.
Nonforfeiture Factor
Factor (per $1,000 of Basic Amount): 28.77238
Contract Years: 21 and later
This Nonforfeiture Factor is applicab!e during the premium period.
END OF TABLE (5)
Page 4 (95)
ThePrudentlal ~
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DEFINITIONS
We, our and uS.-Prudential.
You and Vour.-The owner of the contract.
Insured.-The person named as the Insured on the first page. He orshe need not be the owner.
Issue date.-Same as the contract date.
Anniversary or contract anniversary.- The same day and month as the contract date in each
later year. /
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Contract year.-A year that starts on the contract date or on an anniversary.
Attained age.-The Insured's issue age plus the length of time since the contract date. You will
find the Insured's issue age near the top of page 3. '
THE CONTRACT
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Entire Contract This policy and any attached copy of an application, including an application requesting a
change, form the entire contract. We assume that all statements in an application are made to
the best of the knowledge and belief of the person(s) who make them; in the absence of fraud,
they are deemed to be representations and not warranties. We rely on those statements when
we issue the contract and when we change it. We will not use any statement. unless made in an
application, to try to void the contract, to contest a change, or to deny a claim.
Contract Modifications Onlya Prudential officer with the rank or title of vice president may agree to modify this contract,
and then only in writing.
Incontestability Except for non.payment of premium, we will not contest this contract after it has been in force
during the Insured's lifetime for two years from the issue date.
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OWNERSHIP
On the contract date, the Insured is the owner of the contract. unless a different owner is named
in the application. If a different owner is named, we will show that owner in a provision we
endorse in the contract. The ownership arrangement in effect on the contract date will remain in
effect unless you ask us to change it,
If you wish to change the ownership of the contract, your request must be in a form that meets
our needs. The change will take effect only when we file the request: this will be alter you send
us the contract, if we require it to issue an endorsement. Then any previous owner's interest will
end as of the date of the request, even if the Insured is not living when we file the request.
While the Insured is living, the owner alone is entitled to any contract benefit and value, and to
the exercise of any right and privilege granted by the contract or by us.
(WL-98)
Page 5
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DEATH BENEFITS
We will pay a benefit at the Insured's death (except as we state in the Suicide Exclusion) if this
contract is in force at the time of ddath, that is, the initial premium has been paid and the
contract has not been surrendered or expired without value. It may be in force on a premium..
paying basis. as extended insurance. or as reduced paid.up insurance.
Premium-Paying Basis The contract will be in force on a premium-paying basis if no premium is past due beyond the 31-
day grace period we describe under Premium Payment.
The benefit payable at the Insured's death will be equal to the Life Insurance on the Insured as
described on page 3, plus any dividend credits, plus a returri~f any unearned premium less any
contract debt and less any past due premium.
This contract may provide benefits on the death of other insureds. If it does, each benefit will be
listed on a contract data page, and a form describing the benefit and the conditions under which
it is payable will be included in this contract, Any such benefit will be payable only if the contract
is in force on a premium,paying basis, unless the form that describes the benefit states
otherwise.
Extended Insurance Unless the contract continues as reduced paid.up insurance as described below, the contract will
be in force as extended insurance if a premium is past due beyond the 31-day grace period and
you have not surrendered the contract for its net cash value.
Extended insurance is term insurance that pays a death benefit only if the Insured dies within the
term period. The term period starts on the due date of the past due premium, The duration of the
term period will be what is provided when we use the net cash value at the net single premium
rate. This rate depends on the Insured's issue age and sex and on the length of time since the
contract date. The amount of term insurance will be the basic amount shown on page 3, plus any
dividend credits, less any contract debt. At the end of the term period, the extended insurance
expires without value. The guaranteed durations of extended insurance provided by the contract
are shown in the table on page 4.
We will grant extra days of term insurance if the due date of the past due premium is before the
date that the duration of the guaranteed extended term insurance (see page 4) first equals or
exceeds gO days or the number of days for which premiums have been paid, if less. The number
of extra days will be gO or the number of days for which premiums have been paid, if less, minus
the number of days of any extended insurance. Extra days start on the day after the last day of
term insurance provided by any net cash value. If there is no such term insurance~ they start on
the due date of the past due premium, There will be no extra days if you replace the extended
insurance with reduced paid-up insurance or you surrender the contract before the extra days
start.
The contract will be in force as reduced paid-up insurance if a premium is past due beyond the
31-day grace period, you have not surrendered the contract for its net cash value, and the
statement No Extended Insurance is shown with the Rating Class heading on page 3. It will also
be in force as reduced paid.up insurance if the amount of that insurance equals or exceeds the
amount of extended insurance. The guaranteed amounts of reduced paid-up insurance provided
by the contract are shown in the table on page 4.
Reduced Paid-up
Insurance
If the contract is in force as reduced paid-up insurance, the benefit payable at the time of the
Insured's death is the amount of reduced paid-up insurance, plus any'dividend credits, minus
any contract debt. The amount of this insurance will be what is provided when we use the net
cash value at the net single premium rate. This rate depends on the Insured's issue age and sex
and on the length of time since the contract date.
(WL-98)
Page 6
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Optional Benefit Within three months after the due date of a past due premium. you may replace any extended
insurance that has a cash value with'reduced paideup insurance. You must tell us in a form that
meets our needs, and we may require you to send us the contract to be endorsed.
Computations
Unearned Premium
Interest on Death
Benefit
Suicide Exclusion
Method of Payment
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(WL-98)
We will make all computations for either extended insurance or reduced paid-up insurance as of
the due date of the past due,premium, But we will consider any dividend credits you surrender
and any loan you take out or pay back in the grace period of that premium.
When we pay a death benefit on any insured. we will return that part of the last premium paid for
that benefit that covers the period after the date of death,
Any death benefit described above will be credited with interest from the date of death accordin9
to the laws of the jurisdiction where this contract is delivered.
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If the Insured, whether sane or insane, dies by suicide within two years from the issue date. this
contract will end and we will return the premiums paid, The contract will provide no further
benefit,
You may choose to have any death benefit paid in a single sum or under an optional mode of
settlement (see Settlement Options),
Page 7
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BENEFICIARY
You may designate or change a beneficiary. Your request for a change must be in a form that
meets our needs, The change will take effect only when we file the request; this will be after you
send us the contract, if we require it to issue an endorsement. Then any-previous beneficiary's
interest will end as of the date of the request. even if the Insured is not living when we file the
request. Any beneficiary's interest is subject to the rights of any assignee we know of,
When a beneficiary is designated, any relationship shown is to the Insured, unless otherwise
stated. To show priority, we will use numbered classes, so that the class with first priority is
called class 1. the class with next priority is called class 2, Jlnd so on, When we use numbered
classes, these statements apply to beneficiaries unless the form states otherwise:
1. One who survives the Insured will have the right to be paid only if no one in a prior class
survives the Insured. .
2. One who has the right to be paid will be the only one paid if no one else in the same class
survives the Insured.
3. Two or more in the same class who have the right to be paid will be paid in equal shares.
4. If none survives the Insured, we will pay in one sum to the Insured's estate.
Before we make a payment, we have the right to decide what proof we need of the identity, age
or any other facts about any persons designated as beneficiaries. If beneficiaries are not
designated by name and we make payment(s) based on that proof, we will not have to make the
payment(s) again.
DIVIDENDS
We will decide each year what part, if any, of our surplus to credit to this contract as a dividend.
We will credit any dividend on an anniversary if the contract is then in force as other than
extended insurance. But we do not expect to credit one before the anniversary shown under
Initial Dividend in the Contract Data pages.
If the contract is in force as extended insurance, it is not eligible for a dividend.
Dividend Options If the contract is in force on a premium-paying basis and if you ask us in a form that meets our
needs, you may choose any of these uses for any dividend:
1, Cash,-We will pay it to you in cash.
2. Premium Reduction.-We will use it to reduce any premium then due.
3, Paid-Up Life Insurance Addition.-We will use it at the net single premium rate as of the
anniversary to provide a paid-up life insurance addition. We will pay the amount of this
insurance at the Insured's death.
4. Accumulation ,-We will hold it at interest. The rate will be at least 3% a year.
(WL-98)
Page 8
Dividend Credits
Described
If you have not made another choice by 31 days after the anniversary, we will use the dividena
as we state under dividend option 3. If a past due premium remains unpaid at the end of the
grace period, we will use the dividend as we state under Cash Value Option Upon Surrender,
You may surrender paid-up life insurance additions or withdraw accumulations if: (1) we have
not included them in the net cash value used to provide extended or reduced paid.up insurance;
(2) we do not need them assecurity'for contract debt; and (3) we have your request in a form
that meets our needs. The surrender value of those additions wilrnot be less than the dividends
we used to provide them.
If the contract is in force as reduced paid.up insurance, we will credit any dividend as a paid.up
life insurance addition.
When we describe the amount of any death benefit"the phrase "dividend credits" means the
total of: . /
1. The amount of any paid-up life insurance additions;
2, Any dividends and interest we hold under dividend option 4; and,
3. Any other dividends we have credited to the contract but have not yet used or paid,
When we describe loan values and net cash values, the phrase "dividend credits" means the
total of:
1. The net value of any paid-up life insurance additions;
2. Any dividends and interest we hold under dividend option 4; and,
3. Any other dividends we have credited to the contract but have not yet used or paid.
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LOANS
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Loan. Requirements You may borrow from us on the contract if it has a loan value, We describe loan value below, The
contract must be in force as other than extended insurance; the Insured must be living; and as
sole security for the loan you must assign the contract to us in a form that meets our needs.
If there is already contract debt when you borrow from us, we will add the new amount you
borrow to that debt.
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Interest Charge We will charge interest daily on any loan. Interest is due on each contract anniversary, or when
the loan is paid back if that comes first. If interest is not paid when due, it will become part of the
loan. Then we will start to charge interest on it, too.
The loan interest rate is the annual rate we set from time to time. The rate will never be greater
than is permitted by law.
(WL-98)
Page 9
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Amount You May
Borrow
Loan Value
Contract Debt
Repayment
Excess Contract Debt
Postponement of
Loans
(WL-98)
Before the start of each contract year, we will determine the loan interest rate we can charge for
that contract year. To do this. we will first find the rate that is the greater of: (1' The Pl:lblished
Monthly Average (which we describe below) for the calendar month ending two months before
the calendar month of the contract anniversary; and (2) the fate we use to compute the cash
value described on page 4 for the same contract year, plus 1 %.
, .
If that greater rate is at least ~ % more than the loan interest rate we had set for the current
contract year. we have the right to increase the loan interest rate by at least 1;2 %. up to that
greater rate. If it is at least 1;2 % less, we will decrease the loan interest rate to be no more than
the greater rate, We will not change the loan interest rate by less than * %.
When you make a loan we will tell you the initial interest rate for the loan, We will send you a
notice if there is to be an increase in the rate. /
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The Published Monthly Average means:
1. Moody's Corporate Bond Yield Average-Monthly Average Corporates, as published by
Moody's Investors Service, Inc. or any successor to that service; or
2. If that average is no longer published, a substantially similar average established by the
insurance regulator where this contract is delivered.
You may borrow any amount up to the difference between the loan value and any existing
contract debt, both of which we describe below.
If the contract is in force on a premium~paying basis, the loan value on a premium due date is the
guaranteed cash value shown in the Table of Guaranteed Values on page 4 plus the value of any
dividend credits. In the grace period of a past due premium, the loan value is what it was on the
due date of that premium. We will subtract the value of any dividend credits you surrender in the
grace period, At any other time, the loan value is the amount that would grow at the loan
interest rate to equal the loan value on the next premium due date.
If the contract is in force as reduced paid-up insurance or has become paid.up, the loan value is
the net value we describe in the Basis of Computation. On a contract anniversary, the loan value
is determined as of that date. At any other time, the loan value is the amount that would grow at
the loan interest rate to equal the loan value on the next contract anniversary.
Contract debt at any time means the loan on the contract, plus any interest we have charged that
is not yet due and that we have not yet added to the loan.
All or part of any contract debt may be paid back at any time while the Insured is living, But if
there is contract debt at the end of the grace period of a past due premium,. it may be paid back
only if the contract is reinstated. When we settle the contract, any contract debt is due us. We
will make an adjustment so that the proceeds will not include the amount of that debt.
If contract debt ever grows to be equal to or more than the loan value, the contract will expire
without value 31 days after we mail a notice to you and any assignee we know of. We will also
send a notice to the Insured's last known address, In the notice we will state the amount that, if
paid to us, will reduce the contract debt enough to keep the contract's benefits from ending for a
limited time.
We will usually make a loan promptly, Butwe have the right to postpone making a loan for up to
six months unless it will be used to pay premiums on this or other contracts with us.
Page 10
PREMIUM PAYMENT
Payment of Premiums Premiums are due under this contract while the Insured is living. The Schedule of Premiums
shows the amounts of the premiums and when they are due. The premium period, which we
show on a contract data page, starts on the contract date. Premiums may be paid to us or to any
of our authorized representatives. We will give a receipt upon request.
Change of Frequency If you ask us and we agree, you may change the frequency of premium payments. The more
often premiums are due, the larger the total amount that will have to be paid for a contract year.
Grace Period We grant a 31-day grace period for paying each prenyum except the first one. If a premium has
not been paid by its due date, the contract will st.V In force on a premium,paying basis during
the grace period. If a premium has not been paid when the grace period is over, the contract will
end and have no value, except as we state under Cash Value Option Upon Surrender and under
Death Benefits. '
CASH VALUE OPTION UPON SURRENDER
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You may surrender this contract at any time for its net cash value. To doso, you must ask us in a
form that meets our needs. We may require you to send us the contract. Here is how we will
compute the net cash value:
1. If no premium is past due, the net cash value as of any date will be the guaranteed cash
value computed as described on page 4, plus any dividend credits, minus any contract debt.
2. If premium payment is past due three months or less, we will compute the net cash value as
of the due date of the first unpaid premium. But we will adjust this value for any dividend
credits you surrender and any loan you take out or pay back in the grace period of that
premium.
3, If premium payment is past due more than three months, the net cash value as of any date
will be the net value on that date of any extended insurance benefit then in force, excluding
the net value of any extra days described under Death Benefits. Or it will be the net value on
that date of any reduced paid-up insurance benefit then in force, including any dividend
credits, less any contract debt.
However, within 30 days after an anniversary, the net cash value under 2 and 3 will not be less
than the net cash value on that anniversary, adjusted for any dividend credits you surrender and
any loan you take out or pay back in those 30 days,
We will usually pay any net cash value promptly, Butwe have the right to postpone paying it for
up to six months. If we doso for more than 30 days, we will pay interest at the rate of 3% a year,
You may choose to have any net cash value paid in a single sum or under an optional mode of
settlement (see Settlement Options).
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(WL-98)
Page 11
REINSTATEMENT
You may reinstate this contract after the grace period of a past due premium if:
1. The premium payment is not past due more than five years:
2. The contract has not been surrendered for its net cash value; and,
3. You prove to us that the Insured is insurable for the contract.
You must pay us all premiums in arrears with compound interest; the rate will not exceed 6% a
year. Any contract debt must be restored or paid back with i~terest to date at the loan interest
rate. If that debt with interest would exceed the loan value 6f the reinstated contract, the excess
must be paid to us before reinstatement.
Currency
Misstatement of
Age or Sex
Assignment
Change in Plan or
Basic Amount of
Insurance
Voting Rights
(WL-98)
GENERAL PROVISIONS
Any money we pay, or that is paid to us, must be in United States currency.
If the Insured's stated age or sex or both are not correct, we will change each benefit and any
amount to be paid to what the premium would have bought for the correct age and sex.
The Schedule of Premiums may show that premiums change or stop on a certain date. We may
have used that date because the Insured would attain a certain age on that date, If we find that
the issue age was wrong, we will correct that date.
We will not be deemed to know of an assignment unless we receive it, or a copy of it. We are not
obliged to see that an assignment is valid or sufficient. This contract may not be assigned to any
employee benefit plan without our consent. This contract may not be assigned if such
assignment would violate any federal, state, or local law or regulation prohibiting sex distinct
rates for insurance.
You may be able to have this contract changed to another plan of life insurance or you may be
able to reduce the Basic Amount of insurance. Any change will be made only if we consent, and
any change or reduction in the Basic Amount of insurance will be subject to conditions rules, and
monetary adjustments that are then applicable.
We are a mutual life insurance company. Our principal office is in Newark, New Jersey, and we
are incorporated in that State. By law, we have 24 directors. This includes 16 elected by our
policyholders (four each year for four year terms), two of our officers, and six public directors
named by New Jersey's Chief Justice,
The election is held on the first Tuesday in April from 10:00 A.M. to 2:00 P,M, in our office at
Prudential Plaza, Newark, N.J. After this contract has been in force for one year, you may vote
either in person or by mail. We will send you a ballot if you ask for one. Just write to the
Secretary at Prudential Plaza, Newark, New Jersey 071 02, at least 60 days before the election
date. By law, your request must sh,ow your name, address, policy number and date of birth. Only
individuals at least 18 years old may vote.
Page 12
ENDORSEMENTS
(Only we can endorse this contract,)
BASIS OF COMPUTATION
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Mortality Basis and
Interest Rate
We compute all net single premiums, net values, and the guaranteed cash, and reduced paid~up
insurance values shown on page 4 using:
1. the Commissioners 1980 Standard Ordinary Mortality Table (for extended insurance we use
the Commissioners 1980 Extended Term Insurance Table) based on age last birthday;
2. the Insured's issue age and sex and the length of time since the contract date; and
3. an effective interest rate of 4% a year.
Exclusions When we compute net values and the values shown on page 4, we exclude the value of any
supplementary benefits and any other additional benefits added by rider to this contract.
Values Values for durations not shown on page 4 will in accordance with the Standard Nonforfeiture
Value Method. We show any applicable nonforfeiture factor(s) for such values at the end of the
Table of Values.
When we use the words "net value" in connection with extended insurance. reduced paid.up
insurance and paid-up insurance provided by dividends we mean the present value of future
benefits,
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Minimum Legal Values The cash, loan and other values in this contract are at least as large as those set by law where it is
delivered. Where required, we have given the insurance regulator a detailed statement of how
we compute values and benefits.
The Prudential Insurance Company of America,
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ORD 971 64-98
(WL-98)
Page t 3
Options Described"
Option 1 (Installments
for a Fixed Period)
Option 2 (Life Income)
Option 3 (Interest
Payment)
Option 4 (Installments
of e Fixed Amount)
Option 5 (Non-
Participating Income)
Interest Rate
(WL-98)
SETTLEMENT OPTIONS
You may choose to have the proceeds (that is, any death benefit or any amount payable upon
surrender of the contract) paid in a single sum or under one of the optional modes of settlement
described below.
If the person who is to receive the proceeds of this contract wishes to take advantage of one of
these optional modes, we will be glad to furnish, on request, details of the options we describe
below or any others we may have available at the time the proceeds become payable.
We will make equal payments for up to 25 years. The Option 1 Table shows the minimum
amounts we will pay. . A /'
We will make equal monthly payments for as long as the person on whose life the settlement is
based lives, with payments certain for 120 months or until the sum of the payments equals the
amount put under this option. The Option 2 Table shows the minimum amounts we will pay.
But, we must have proof of the date of birth of the person on whose life the settlement is based.
The settlement will share in our surplus to the extent and in the way we decide.
We will hold an amount at interest. We will pay the interest annually, semi-annually, quarterly,
or monthly.
We will make equal annual, semi-annual, quarterly, or monthly payments for as long as the
available proceeds provide.
We will make payments like those of any annuity we then regularly issue that: (1) is based on
United States currency: (2) is bought by a single sum: (3) does not provide for dividends; and
(4) does not normally provide for deferral of the first payment, Each payment will be at least
equal to what we would pay under that kind of annuity with its first payment due on its contract
date. If a life income is chosen, we must have proof of the date of birth of any person on whose
life the option is based, Option 5 cannot be chosen more than 30 days before the due date of the
first payment.
Payments under Options 1 and 4 will be calculated assuming an effective interest rate of at least
314 % a year, Under Option 3 it will be at an effective rate of at least 3% a year. We may include
more interest.
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SWL12
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RIDER FOR INSUR'ED'S'ACCIDENTAL DEATH AND
DISMEMBERMENT BENEFIT
This benefit is a part of this contract only if it is listed on a contract date page.
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Benefits Subject to all the provisions of this benefit and of the rest of this contract, we will pay the
amount(s) we show below for any of the listed losses.
For the Insured's
Accidental Loss of:
Life.
Both hands;
Both feet:
Sight of both eyes:
One hand and one foot: The basic amount
One hand and sight of one eye;
One foot and sight of one eye.
Payment:
Twice the basic. arrl6unt
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One hand; ]
One 'foot; One-half the basic amount
Sight of one eye.
As used here, loss of a hand means physical severance at or above the wrist. Loss of a foot
means physical severance at or above the ankle. Loss of sight means permanent and complete
blindness,
Amount Limitation We will not pay a total of more than twice the basic amount for all losses caused by the same
accident.
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Payment of Benefit We will include in the death benefit of this contract any payment under this benefit for loss of
life. For any other loss, we will make payment to whoever is the owner as of the date of loss. If a
payment is due the Insured under this benefit and he or she is not living when we pay, we have
the choice of paying the beneficiary for insurance payable upon the death of the Insured or the
Insured's estate.
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Conditions Both of these conditions must be met: (1) We must receive due proof that the Insured's loss was
the direct result, independent of all other causes, of accidental bodily injury that occurred on or
after the contract date. (2) The loss must occur (a) while the contract is in force on a premium-
paying basis: and (b) before the end of the contract's term or endowment period, if any.
Exclusions We will not pay a benefit under this rider for any loss caused or contributed to by: (1) suicide or
attempted suicide while sane or insane; or (2) infirmity or disease of mind or body or treatment
for it; or (3) any infection other than one caused by an accidental cut or wound,
Even if a loss is caused by accidental bodily injury, we will not pay a benefit for it under this rider
if it is caused or contributed to by: (1) service in the armed forces of any country at war; or
(2) war or any act of war: or (3) travel by, or descent from, any aircraft if the Insured had any
duties or acted in any capacity other than as a passenger at any time during the flight. But we
will ignore (3) if all these statements are true of the aircraft: (a) It has fixed wings and a
permitted gross takeoff weight of at least 75,000 pounds. (b) It is operated by an air carrier that
is certificated under the laws of the United States or Canada to carry passengers to or from
places in those countries. (c) It is not being operated for any armed forces for training or other
purposes, As used here, the word "aircraft" includes rocket craft or any other vehicle for flight
in or beyond the earth's atmosphere. The word "war" means declared or undeclared war and
includes resistance to armed aggression.
MSB 220-95 CP
Benefit Premiums We show the premiums for this benefit on a contract data page.
Termination This benefit will end on the earliest of:
1, the end of the last day of the grace period of a past due premium; it will not continue if either
extended or reduced paid.up insurance takes effect;
2. the date the contract is surrendered under its Cash Value Option Upon Surrender, if it has
one; and
3, the date the contract ends for any other reason.
If you ask us in a form that meets our needs in the premium period, we will cancel this benefit as
of the date to which premiums are paid, Contract premiums due then and later will be reduced
accordingly. . / I
This Supplementary Benefit rider attached to this contract on the Contract Date
The Prudential Insurance Company of America,
By
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Secretary
MSB 220-95
ThePrudentlal~The Prudential
. ~ Insurance Comparyy
of America
GLORIA J HECK
Policy No.
6}:::483-092
Insured
Settlement of the proceeds of this contract will be made in accord with the following Beneficiary Provision. The
texts on the reverse headed Beneficiaries for Other Proceeds and Special Conditions are a part of this Beneficiary
Provision in any case to which they apply.
Beneficiary Provision
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The proceeds that arise from the Insured's death will be settled in one sum with the beneficiary(ies) shown below,
If a contract provides, by rider or otherwise, for income payments to begin upon the Insured's death, the word
proceeds includes the one sum value of those payments that arise from his or her death,
Beneficiary Schedule
Beneficiaries in Order of Priority:
CLASS 1 ROBERT E HECK, HUSBAND.
CLASS 2 ROBERT C HECK, TERRANCE E HECK AND TODD M HECK, SONS.
CLASS 3 NONE
CLASS 4 NONE
CLASS 5 NONE
These statements apply to the beneficiaries: (1) One who survives the Insured will have the right to be paid only
if no one in a prior class survives the Insured: (2) One who has the right to be paid will be the only one paid if
no one else in the same class survives the Insured: (3) Two or more in the same class who have the right to be
paid will be paid in equal shares, but if children by representation are included in that class they will only
have the right, as we state under Special Conditions on the reverse, to the share to which their deceased parent
would have been entitled if that parent were then living; and (4) If none survives the Insured, unless we state
otherwise below, we will pay in one sum to the Insured's estate.
This contract might have an Automatic Mode of Settlement provision. If so, beneficiaries who do not have a
right to be paid at the Insured's death may still have a right to be paid under that provision.
lORD 85046
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(Continued on Reverse)
Beneficiaries for Other Proceeds
This section applies only to a contract that provides for insurance on the lives of the Insured, the insured
spouse and dependent children:
the beneficiary for insurance payable upon the death of the insured spouse will be the Insured if living,
otherwise the estate of the insured spouse.
The beneficiary for insurance payable upon the death of a dependent child will be the Insured if living,
otherwise the insured spouse if living, otherwise the estate of the later to die of the Insured and the
insured spouse.
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This section applies only to a contract that provides for insurance on the lives of the Insured and depen-
dent children:
The beneficiary for insurance payable upon the death of a dependent child will be the Insured if living,
otherwise the beneficiary(ies) in the order of priority and in accord with the distribution shown in this
beneficiary provision, otherwise the estate of the later to die of the Insured and the beneficiary(ies).
This section applies only to a contract that provides for insurance on the lives of the Insured and the insured
spouse (other than a joint whole life contract):
The beneficiary for insurance payable upon the death of the insured spouse will be the Insured if
living, otherwise the estate of the insured spouse.
Special Conditions
The phrase their children by representation might be included in a designation of a class of beneficiaries who
are to receive settlement of the proceeds. If so, here is what that means, If a beneficiary (other than a child
by representation) in that class is not living at a time when he or she would otherwise have been entitled to
settlement, and if any child of his or hers is then living (his or her child by representation), we will pay the
amount to which that beneficiary would have been entitled in one sum to such child or, if there is more than
one such child, in equal shares to such children,
In the case of a variable annuity or a retirement annuity: (a) the word policy means contract; (b) the word
Insured means Annuitant; and (c) the word proceeds means any amount that may arise from the Annuitant's
death before the annuity date,
Unless otherwise stated, the relationship of any beneficiary shown in this form is to the Insured,
In this form, the words child and children mean only sons and daughters, They do not mean grandchildren or
other descendants.
Before we make a payment, we have the right to decide what proof we need of the identity, age or any other
facts about any persons designated as beneficiaries. If beneficiaries are not designated by name and we make
payment(s) based on that proof, we will not have to make the payment(s) again.
Endorsed by attachment on Contract Date for the Company
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APPLICATION FOR LIFE INSURANCE
OR POLlCY'CHANGE
Iill The Prudential Insurance Company of America
o Pruco Ufe Insurance Company
A Subsic;liary of The Prudential Insurance Company of America
Corporate Offices, Newark, New JersQY
Policy No. 63483092 N
o Check here if policy change.
GLORIA J HECK
Name of primary proposed Insured (or current Insured, if policy change) (first, initial, last)
PART 1
A. PERSONAL INFORMATION (Primary Proposed Insured) .,,/
1. Social Security No. 188-32-3141 2. Sex: 0 Male Iill Female
3. Marital Status: 0 Single Iill Married 0 Widowed 0 Separated 0 Divorced
4. Date of Birth: Mo...m!- Day ~ Yr. 1940 5. Age ~ 6. State of Birth (Country if not U.S.) PA
7. Billing Address (City, State and Zip): 6023 HUMMINGBIRD DRIVE. MECHANICSBURG. PA 17055
8. Home Address (if different):
9. Home Telephone Number (717) 766-4610 10. Business Telephone Number (
11.Current Employer NONE
B. ALL OTHER PROPOSED INSUREDS (Include Applicant for Applicant's Waiver of Premium Benefit)
Name Relationship to Sex Date of Age State of
primary proposed Birth Birth (country
Insured (mo" day, yr.) if not U.S.)
Total Ufe
Insurance in
all companies
C. COVERAGE INFORMATION
1. Plan of Insurance PRUDENTIAL CLASSIC UFE 2. Initial Amount $ 10.000
If AUVAL or applicable to the product, check one: 0 Level Death Benefit 0 Variable Death Benefit
3. SUPPLEMENTARY BENEFITS AND RIDERS (Please indicate amount where applicable)
o Waiver of Premium Iill Accidental Death Benefit $ 20.000
o Uving Needs Benefit 0 Option to Purchase Additional Insurance $
o Applicant's Waiver of Premium 0 Option to Purchase Paid Up Ufe Insurance Additions
o Automatic Premium Loan (include details in special request)
OTHER RIDERS AND BENEFITS: (Please indicale amount where applicable)
D. BENEFICIARIES/OWNERSHIP (If Trus/, provide name of trust, trustee and date of trust.)
1. Beneficiary: Name Relationship to primary proposed Insured Age
Primary (Class 1). ROBERT E HECK HUSBAND 55
Contingent (Class 2) ROBERT CHECK
(Class 2) TERRANCE E HECK
fClass 2) TODD M HECK
2. Is the owner other than the primary proposed Insured?
If yes: Name
Address
SON
SON
SON
32
30
29
DYes Iill No
Owner's date of birth
liaRD 96200-96 II Pennsylvania
6. PAYMENT DETAILS
.,1. Wiitjin the' last 12 months. has any proposed Insured had a heart attack, stroke or cancer other than
of the skin1 ' , .
. 2. Is a medical examination required On: Primary Proposed Insured?
Second Proposed Insured?
3. Premium Payment Mode: (collect full modal premium if prepaid)
D Pru-matic D Annual D Semi-annual D Quarterly ~ Monthly D Payroll Budget D Gov't Allotment
4. Amount paid with this application $ 42.20 D None (Must be "None" if E1 is answered
Yes, except Gibraltar products.)
5. Date premium collected 12.11-1997
F. REPLACEMENT
For any proposed Insured, would this insurance replace or cause a change in any existing insurance
or annuity in any company? . , / DYes 181 No
(If yes, give insurance company, plan, amount and policy number(s), Enclose all required state replacement forms.)
DYes
DYes
DYes
181 No
181 No
o No
G. SPECIAL REQUESTS
H. BACKGROUND ON PROPOSED INSUREDS
1. Total Life Insurance on the primary proposed Insured in effect $15.000
2. What are the primary proposed Insured's occupation and duties? HOMEMAKER
3. Has any proposed Insured participated in the following activities within the last 2 years (or does anyone
plan to do so in the future):
a. operated or had any duties aboard an aircraft, glider, balloon, or like device?
If yes, complete Aviation Questionnaire.
b. hazardous sports, such as auto, motorcycle, snowmobile or powerboat competitions/exhibitions;
scuba diving; mountain climbing; parachuting; sky diving or any other such sport or hobby?
If yes, complete Avocation Questionnaire.
For any questions answered yes below, give the details in 8.
4. Is any proposed Insured applying for or requesting reinstatement or policy change(s) of any other life
or health insurance policy? If yes, give insurance company, policy plan and amount.
5. Has any proposed Insured been convicted of, or currently charged with, the commission of any
criminal offense, other than the violation of a motor vehicle law within the last 5 years?
6. a. Primary Proposed Insured driver's license number and state of issue:
10704569 PA
b. Has any proposed Insured in the last 3 years:
(1.) had a driver's license denied, suspended or revoked?
(2.) been convicted of or cited for:
(a) 3 or more moving violations? DYes
(b) driving under the influence of alcohol or drugs? DYes
(3.) been involved as a driver in 2 or more auto accidents? DYes
If yes, give details including type of violation, accident or reason for denial, . suspension or revocation.
7. Does any proposed Insured plan to live or travel outside the United States or Canada within the next
12 months? If yes, give countries, purpose and duration of each trip. DYes
8. Details of yes answers for questions 4.7. Give question number, proposed Insured's name and full details
Check here if None D.
DYes 181 No
DYes 181 No
DYes 181 No
DYes 181 No
DYes 181 No
181 No
181 No
181 No
181 No
FOR ADDITIONAL DETAilS USE ANOTHER APPLICATION
I. Dividend Option Ejection - Complete only If applying to The Prudential Insurance Company of America
181 Paid-up additions 0 Accumulate at interest 0 Cash
D Reduce premiums (not available for monthly mode) D
IIORD 96200-96 II Pennsylvania
Polley Number 63483092 N
-
,
On this 'page the words "I" and "my" refer to the primary pfoposed Insured and applicant, if different. The words "the
. Company" refer to the company checked at the beginning of this application, If a policy change, "I" and "my" refer to
Insured or Owner, if other than Insured.
TERMS AND CONDITIONS , , .
No new coverage requested in this application starts on any proposed Insured until all required. initial medical exams and
tests agreed to are completed, even if an amount has been paid to the Company.
When the Company gives a LImited Insurance Agreement form dated on the same date shown below, coverage
will start as written In that Agreement. Otherwise, coverage will start on the contract date, provided:
. The Company Issues a contract and I accept It; and
. the first premium Is paid In full while all proposed Insureds' health remains as stated In the application.
/
If the Company enters any change in section I, I approve the change by accepting the contract, unless the law requires
written consent to changes. Then, a change can be made only if I approve it in writing. No agent can make or change
a contract, or waive any of the Company's rights or requirements.
The beneficiary named in the application (or in the contract if requesting a policy change) is for insurance payable in
either of the following cases:
. at the death of the primary Insured; and
. at the death of an Insured child after the death of the primary Insured if there is no Insured spouse.
If this is a policy change and no beneficiary has been named in the application, the beneficiary for any insurance payable
will be carried over from the contract that is being changed.
The Owner of the contract is the primary proposed Insured or applicant if other than the primary proposed Insured unless
a different owner is named in the application. If this is a policy change, the ownership arrangement will be carried over
from the contract that is being changed unless a different owner is named in the application. This is subject to any
provisions for the automatic transfer of ownership stated in the contract. If joint owners are named, ownership will be
with the right of survivorship unless otherwise specified.
SIGNATURES
By signing below:
. I affirm that to the best of my knowledge and belief the statements in this application are complete, true and correctly
recorded.
. I understand that new coverage could be invalidated if any information in the application is materially misrepresented.
. I confirm that if I have requested the Living Needs Benefit, I have read the disclosures in the brochure (ORD 87246).
. I agree to the Terms and Conditions shown above and on the Important Notice About Your Application, which I have
received and read. 1
>(,.,ftUv?~
(City/State)
Signed at:
Signature of primary proposed Insured, if age 8 or over X
or current Insured, if policy change {j
Signature of Spouse. if proposed for coverage X
Signature of Applicant (must be age 18 or over), if different than primary proposed Insured X
or if a policy change, Signature of Owner, if different than Insured
If applicant is a firm or corporation, give that company's name and have an officer sign below.
Signature and title of Officer of firm or corporation X
Signature of Owner X '
Signature of Beneficiary, if policy change and rights are limited X
Signature of Witness (Ucensed Writing Representative must witness) X
LIcensed Writing Representative's Certification:
Do you have any information, other than what is stated in this applicatio ,
may replace or change any current insurance or annuity in any 0 pany,
Witness (Ucensed Writing Representative must witness) X
, /
liaRD 96200-96 II Pennsylvania
/
Polley Number 63483092 N
.
,PART 2 - MEDICAL INFORMATION
SECTION C - TO BE COMPLETED FOR GIBRALTAR PLANS ONLY
1. Doctor Information:
A. Primary Proposed Insured
Physician last consulted: GEORGE HARHIGH MD
Date last seen: 06/97
Reason: COLD
Address and Phone no.: 32ND ST. CAMP HILL PA
Primary Physician: GEORGE HARHIGH MD
Date last seen: 06/97
Reason: COLD
Address and Phone no.: 32ND ST. CAMP HILL. PA
.~/
B. Second Proposed Insured or AWP Applicant
Physician last consulted:
Date last seen:
Reason:
Address and Phone no.:
Primary Physician:
Date last seen:
Reason:
Address and Phone no.:
2. Build:
a. Primary Proposed Insured
b. Second Proposed Insured or AWP Applicant
Height
5' 1"
Weight
125
3. Has either the primary proposed Insured or second proposed Insured, if proposed for coverage, ever used
tobacco or other nicotine products? I8lYes D No
If yes, give date last used: Cigarettes Any other nicotine product such as cigar, pipe, smokeless
(MoNr) tobacco, nicotine gum or nicotine patch (MoNr)
Primary Proposed Insured 12/1997
Second Proposed Insured
4. Within the last five (5) years, has anyone proposed for coverage:
a. taken prescription medication, or been treated for or diagnosed as having: high blood pressure, any
disease or disorder of the heart, arteries or veins, diabetes, cancer, respiratory disorder (including aSlhma,
recurrenl bronchilis, emphysema), a mental illness or psychiatric disorder or any disease or disorder of
the nervous system, alcohol or drug use? I8lYes DNo
b. been treated for or diagnosed as having AIDS or AIDS related complex, other sexually transmitted
diseases or positive test results for HIV? DYes 181 No
5. Has anyone proposed for coverage been declined or charged an increased premium for new life insurance or
reinstatement of life insurance? DYes I8lNo
6. Is anyone proposed for coverage currently unable to perform the normal duties of their occupation and/or
normal daily activities? DYes I8lNo
Please include the details of any "Yes" answer to the questions 4-6: GLORIA J HECK:SCHIZOPHRENIA:DIAGNOSED 25
YRS AGO: TAKES 1 1.5 MG INJECTION OF HALDOL PER MDNTH: HER CONDITION IS OK: DR ROSARIO:
All the answers are, to the best of my knowledge and belief, complete, true and correctly recorded. It is understood that
any new coverage could be invalidated if any information in the application is materially misrepresented.
X
Date Signature of primary proposed Insured (if age 15 or over)
otherwise Applicant (must be age 18 or over)
x X
Witness Signature of Spouse, if proposed for coverage
IIORD 96200-96 II Pennsylvania
,
OPTION I TABLE
....
en
....
MINIMUM AMOUNT OF
MONTHLY PAYMENT FOR
EACH $1,000, THE FIRST
PAYABLE IMMEDIATELY
Number Monthly
of Years Payment
I $84.65
2 43,05
3 29,19
4 22.27
5 18.t2
6 15,35
7 13.38
8 11.90
9 10.75
10 9.83
It 9.09
t2 8.46
13 7.94
t4 7.49
15 7.10
t6 6.76
17 6.47
18 6.20
19 5.97
20 5,75
21 5.56
22 5,39
23 5.24
24 5.09
25 4.96
Multiply the monthly amount
by 2.989 for quarterly,
5,952 for semi-annual or
I I .804 for annual.
'"
....
8
'"
en
o
M
<Xl
..
M
<D
-'
(WL-98)
SETTLEMENT OPTIONS TABLES
, .
OPTION 2 TABLE '---
MINIMUM AMOUNT OF MONTHLY PAYMENT FOR EACH $1,000. THE FIRST
PAYABLE IMMEDIATELY
KIND OF LIFE INCOME KIND OF LIFE INCOME
AGE 10-Year Instalment AGE 10-Year Instalment
LAST Certain Refund MST Certain Refund
BIRTHDAY Male Female Male Female ~IRTHDAY Male Female Male Female
10 $3,18 $3.11 $3,17 $3.10 45 $4.06 $3.82 $3.99 $3,78
and under 46 4.12 3.86 ' 4.03 3,81
11 3.19 3.12 3.18 3.1 I 47 4.17 3.90 4.08 3.85
12 3.20 3.t3 3.19 3.12 48 4.23 3.94 4.13 3.90
13 3.21 3.14 3.20 3.13 49 4.28 3.99 4.18 3,94
14 3.22 3.15 3.2t 3.14
50 4.35 4.04 4.24 3.98
15 3.24 3.16 3.23 3.15 51 4.41 4.09 4.29 4.03
16 3.25 3.17 3.24 3.16 52 4.48 4.15 4.35 4,08
17 3.27 3.19 3.25 3.18 53 4.55 4,21 4.41 4,13
18 3.28 3.20 3,27 3.19 54 4.62 4.27 4.48 4,19
19 3.30 3,21 3.28 3.20
55 4.70 4.33 4.55 4,24
20 3.31 3.22 3,30 3.21 56 4.78 4.40 4.62 4,30
21 3.33 3.24 3.32 3,23 57 4.86 4.47 4.69 4,37
22 3.35 3.25 3.33 3.24 58 4.95 4,54 4.77 4.43
23 3.36 3.26 3.35 3.25 59 5.05 4.62 4.86 4,50
24 3.38 3.28 3,37 3.27
60 5.15 4.71 4.94 4,58
25 3.40 3.30 3,39 3.29 61 5.25 4,79 5,03 4,66
26 3.42 3.31 3.41 3.30 62 5.36 4,89 5.13 4,74
27 3.45 3.33 3.43 3.32 63 5.48 4.98 5,23 4.82
28 3,47 3.35 3.45 3.34 64 5.60 5.09 5,34 4,92
29 3.49 3.37 3.47 3.35
65 5.73 5.20 5.45 5,01
30 3,52 3.39 3.49 3.37 66 5.87 5,31 5.57 5,1 I
31 3.54 3.41 3.52 3.39 67 6.01 5.43 5.70 5.22
32 3.57 3.43 3.54 3.41 68 6.15 5.56 5.83 5,34
33 3.60 3.45 3.57 3.44 69 6.30 5.70 5.97 5.46
34 3,63 3.47 3.60 3.46
70 6.46 5.84 6.1 I 5.58
35 3,66 3.50 3.63 3.48 7t 6.62 5.99 6.27 5.72
36 3.69 3.52 3.66 3.50 72 6.79 6. t5 6.43 5,86
37 3.72 3.55 3.69 3.53 73 6.96 6.31 6,60 6.01
38 3.76 3,58 3.72 3.56 74 7.13 6.49 6.78 6.18
39 3,80 3.61 3.75 3.58
75 7.30 6.67 6,97 6.35
40 3,84 3.64 3.79 3.61 76 7.48 6.85 7.17 6.53
41 3,88 3,67 3.82 3.64 77 7.66 7.04 7.38 6,72 i
42 3,92 3.70 3.86 3.67 78 7.83 7.24 7.60 6,93 :
43 3,97 3.74 3.90 3.71 79 8.00 7.44 7,83 7,15 :
44 4.01 3.78 3.94 3.74
80 8.t7 7.64 8.07 7,38
and over
Page 1 5
SWL1 3 I
" to \'
,
'-
. ,
Whole Life Policy. Life insurance payable upon death. Premiums payable during Insured's lifetime. Eligible for
annual dividends as stated under Dividends.
WL-98
Page 16
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ROBERT E. HECK,
vs.
.....1-'
)
)
)
)
)
)
)
)
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND
COUN1Y, PENNSYLVANIA
CIVIL ACTION - LAW
Plaintiff
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA,
Defendant
NO. 99-142 CIVIL TERM
JURY TRIAL DEMANDED
PLAINTIFF'S REPLY TO DEFENDANT'S NEW MATTER
AND NOW comes the above-named Plaintiff, Robert E. Heck, by his attorney,
Samuel L. Andes, and makes the following Reply to Defendant's New, Matter:
.,'
1. The statement in Paragraph 1 of Defendant's New Matter is a conclusion of
law to which no answer is required. To the extent an answer is required, Plaintiff
denies that he has failed to state a claim upon which relief may be granted.
2. The statements contained in Paragraph 2 of Defendant's New Matter are
conclusions of law to which no answer is required. To the extent an answer is
required, Plaintiff denies that his claim must be dismissed because it is based upon
an act of fraud and Plaintiff denies there was any fraud committed by Plaintiff or
anyone on his behalf.
3. No answer is required to the statements contained in Paragraph 3 of
Defendant's New Matter because they are mere conclusions of law. To the extent
an answer is required, Plaintiff denies that the contract was rescinded or that
Plaintiff's claim must be dismissed for any reason.
\ .
,
."
.'
WHEREFORE, Plaintiff's prays that judgment be entered in his favor in
accordance with the original Complaint in this matter.
al-~~
Attorney for Plaintiff
Supreme Court ID # 17225
525 N. 12th Street
Lemoyne, PA 17043
(717) 761-5361
~
.'
.'
COMMONWEALTH OF PENNSYLVANIA
)
( 55.:
)
COUNTY OF CUMBERLAND
ROBERT E. HECK, being duly sworn according to law, deposes and says that
the facts set forth in the foregoing REPLY are true and correct to the best of his
knowledge, information, and belief.
/I~/ ~ ~/
ROBERT E. HECK
,.,. ,
./11~;~:;~{::~.::-\
__ :;&f' -
:~;~S>-"~::'\~~~/
, ",.' ,,'
Sworn to and subscribed
befo.!:!'L'1l~ ,this \ (d::h day
of --eut.Uo..Jl...y , 1999.
~\..fy)\--R~o ~ k
Notary "c.
NOfNuAI. Sl!AI.
"",,--. ~ ~NlII
LII . I.... Cl.6..1l..Jlf00clnly. PA
Cb.. btL.'~~\2\1 2lKlO
---.,.-." ..~.&-.~~. . -.....-.--.~,~-
,"
.
LEGACy/eSTATE HISTORY PRINTOUT - 12/17/1997
RHQ#/CK DGT 63-483-092/N INSUREO.S NAME GLORIA u HECK
REJECTIONN
PAGE 0001
OFFICE \II SH
CONTROL SCREEN:
......................................................-.........................
,
FIELD REP NAME FRANK LOVARI
OFFICE W SH
BASE PLAN PRUDENTIAL CLASSIC LIFE
AMOUNT ??oo 1 ??oo
CASE MGR H14
ROC CAD
TRAN TYPE NEW BUSINESS
WILL THE CLIENT BE AVAILABLE TO COMPLETE THE INTERVIEW AT THIS TIME?
WITHIN THE LAST 12 MONTHS. HAS ANY PROPOSED INSURED HAD A HEART ATTACK, STROKE.
OR CANCER. OTHER THAN OF THE SKIN?
CHECK RECEIVED?
CHECK/APP DATE
RECEIVEO DATE
DELIVERY 5T
MIB AUTHORIZED?
TAX CERT?
PRIMARY INSURED - PAGE 1:
NAME
HAS NAME CHANGED IN LAST 5 YEARS?
SEX
SOCIAL SECURITY
MARITAL STATUS
BIRTHPLACE
BIRTH DATE
DRIVER'S LICENSE
DL STATE
HOME PHONE
MAILING ADDRESS
CITY
ST
ZIP
PRIMARY INSURED - PAGE 2;
OCCUPATION/DUTIES
CURRENT EMPLOYER
HAVE YOU BEEN WITH THE CURRENT EMPLOYER FOR
ANNUAL INCOME
IS MORE THAN 50% OF THE PRIMARY INSURED'S
MILITARY
MOTHER'S MAIOEN NAME
IS OWNER OTHER THAN INSURED?
IS PAVOR OTHER THAN INSURED?
IS APPLICANT OTHER THAN INSURED?
IS THIS BUSINESS INSURANCE?
IS EXAM REQUIRED ON PRIMARY INSURED?
IS OWNER A UNITED STATES CITIZEN?
WERE SMOKER RATES QUOTED?
WERE SELECT RATES QUOTE07
Y
12-11-1997
12-11-1997
PA
Y
Y
GLORIA " HECK
N
FEMALE
188-32-3141
MARRIED
PA PENNSYLVANIA
08-08-1940
10704S69
PA
717-766-4610
6023 HUMMINGBIRD DRIVE
NECHANICSBURG
PA
17055
HOMEMAKER
NONE
LESS THAN 2 YEARS?
0002??oo
SUPPORT SUPPLIED BY SOMEONE ELSE?
N
KELLER
N
N
N
N
N
Y
Y
N
Y
N
'..' ,."
:>~I,
N
Y
DEFENDANT'S
I ~HIBIT
.
LEGACY/ESTATE HISTORY PRINTOUT - 12/17/1997
RHO NICK OGT 63-483-092/N INSURED#S NAME GLORIA V HECK
RE~ECTICN'"
PAGE 0002
OFFIce W SH
..******.***********.**************.....***..**....***-------.-.*--.-.----.-..-.
PRIMARY INSURED - SUPPORT POPUP:
NAME
REALTIONSHIP TO INSURED
AMOUNT OF INSURANCE INFORCE
PRIMARY INSURED - PAGE 3:
ROBERT HECK
HUSBAND
??oo46000
BENEFITS
DIVIDEND OPTION
APL OPTION?
TOTAL LIFE INSURANce INFORCE - PRU
LIVING NEEDS BENEFIT
IS THERE AWP?
PRIMARY INSURED - BENEFIT POPUP:
V
PAID-UP ADDITIONAL INS
N
??oo t 5000
N
N
~x:::;.>
BENEFIT 1
AMOUNT
AOB
??oo2??oo.00
-:..., ~~\f:~:~~~i~0:;~ ~.: .
~~~ ~:;~i~=t~~~f~:;.~
BENEfICIARY:
..~ -.'
NAME
BENE CLASS
RELATIONSHIP TO INSURED
A?P AGE
NANE
BENE CLASS
RELATIONSHIP TO INSURED
APP AGE
NAME
BENE CLASS
RELATIONSHIP TO, INSURED
APP AGE
NANE
BENE CLASS
RELATIONSHIP TO INSURED
APP AGE
ASSIGNMENT?
BILLING:
ROBERT E HECK
l-PRIMARV
HUSBAND
055
ROBERT CHECK
2-CONTINGENT
SON
032
TERRANCE E HECK
2-CONTINGENT
SON
030
TODD M HECK
2-CONTINGENT
50N
029
N
PREMIUM PAYMENT MODE MONTHLY
AMOUNT PAID 0??oo42.20
ARE POLICY VALUES OF ANY KINO BEING USED TO FUND THIS SALE? N
PREMIUM DISCOUNT REQUESTED? N
ABBREVIATED PAYMENT PLAN (APP) N
FOR ANY PROPOSED INSURED. WOULD THIS INSURANCE REPLACE OR CAUSE A CHANGE IN ANY
EXISTING INSURANCE OR ANNUITY IN ANY COMPANY? N .
IS SPECIAL REQUEST NEEDED? N
REP - PAGE t:
,
LEGACY/ESTATE HISTORY PRINTOUT - 12/17/1997
RHON/CK OGT 63-483-092/N INSURED'S NAME GLORIA u HECK
REuECTIONjI
..................**............................................................
PAGE 0003
OFFICE W SH
REP 1
CONTRACT NO
CONN "
PHONE
AGENCY NO
IS MANAGER PRESENT?
00 YOU WANT EXPRESS COMMISSIONS?
REP - PAGE 2:
893560
100
717-97S-3625
168
N
Y
1.(A) HAVE THE IMPORTANT NOTICE ABOUT YOUR APPLICATION AND THE LIMITED
INSURANCE AGREEMENT BEEN PROVIDED TO THE PROPOSED INSURED?
(B) DO YOU HAVE ANY INFORMATION. OTHER THAN WHAT IS STATEO IN THIS
APPLICATICN THAT INDICATES THAT ANY PROPOSED INSURED MAY REPLACE OR
CHANGE ANY CURRENT INSURANCE OR ANNUITY IN ANY COMPANY?
2. PROPOSED INSURED'S
CALLBACK STATUS
ANY RELATED PENDING APP?
4. HERITAGE ACeT?
5. HOW WELL DO YOU KNOW THE PRIMARY PROPOSED
KNOW WELL FOR 06 YEARS AT:
CLIENT INFORMATION - PAGE 1:
CALL SUCCESSFUL
N
N
INSURED?
BUSINESS
1. HOW WAS THE PURPOSE AND AMOUNT FOR POLICY DETERMINED?
A. NEEDS ANALYSIS Y
2. PURPOSE fOR LIFE INSURANCE?
A. PERSONAL
2. BASIC LAST EXPENSES Y
CLIENT INFORMATION - PAGE 2:
3. SOURCE OF INITIAL AND FUTURE PREMIUMS?
A. INITIAL PREMIUM - CURRENT INCOME OR SAVINGS ACCOUNT
FUTURE - CURRENT INCOME OR SAVINGS ACCOUNT
B. WILL THE INITIAL AND/OR FUTURE PREMIUMS COME FROM DIVIDENDS.
POLICY LOANS. WITHDRAWALS. OR CASH SURRENOERS?
SUPPLEMENTARY RISK - PAGE 1:
1. IS ANY PROPOSED INSURED APPLYING FOR OR REQUESTING REINSTATEMENT OR POLICY
CHANGES OF ANY OTHER LIFE OR HEALTH INSURANCE POLICY?
2. HAS ANY PROPOSED INSURED PARTICIPATED IN THE FOLLOWING ACTIVITIES WITHIN
THE LAST 2 YEARS (OR DOES ANYONE PLAN TO DO SO IN THE FUTURE):
A. OPERATED OR HAD ANY OUTIES ABOARD AN AIRCRAFT. GLIDER, BALLOON. OR LIKE
DEVICE?
B. HAZARDOUS SPORTS. SUCH AS AUTO. MOTORCYCLE. SNOWMOBILE, OR POWERBOAT
COMPETITIONS/EXHIBITIONS; SCUSA DIVING; MOUNTAIN CLIMBING: PARACHUTING;
SKY DIVING, OR ANY OTHER SUCH SPORT OR HOBBY?
3. HAS ANY PROPOSED INSURED. IN THE LAST 3 YEARS:
A. HAD A DRIVER'S LICENSE DENIED, SUSPENDED. OR REVOKED?
B. BEEN CONVICTED OF OR CITED FOR 3 OR MORE MOVING VIOLATIONS?
C. BEEN CONVICTED OF OR CITED FOR DRIVING UNDER THE INFLUENCE OF ALCOHOL
OR DRUGS?
Y
N..
.'. ,'.
'...'~',;'/'-'~,-.,
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'-.y-,::;:~~':-.'.:..:;';y,".:
".- ....~"'. ',' -'.'
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y.
Y'
N.'
N'
N
N
N'":
N
N-
.:' .
LEGACV/ESTATE HISTORV PRINTOUT - 12/17/.997
RHON/CK OGT 63-483-092/N INSURED'S NAME GLORIA u HECK
REuECTIONAf
PAGE 0004
OFFICE W SH
--.............................-................................................
D. BEEN INVOLVED AS A DRIVER IN 2 OR MORE AUTO ACCIDENTS?
4. HAS ANY PROPOSED INSURED BEEN CONVICTED OF. OR CURRENTLY CHARGED WITH THE
COMMISSION OF ANY CRIMINAL OFFENSE, OTHER THAN THE VIOLATION OF MOTOR
VEHICLE LAW, WITHIN THE LAST 5 VEARS?
SUPPLEMENTARY RISK - PAGE 2:
5. aOES ANY PROPOSED INSURED PLAN TO LIVE OR TRAVEL OUTSIDE THE UNITED STATES
OR CANADA WITHIN THE NEXT 12 MONTHS? N
RISK DOCTOR INFORMATION - PRIMARY;
PHYSICIAN LAST CONSULTED
ADDRESS
DATE SEEN
REASON
IS THE P{iNARV PHVSICIAN
PRIMARY PHYSICIAN
ADDRESS
GEORGE HARHIGH MD
3200 ST
CAMP HILL. PA
06/97
COLD
THE SAME AS THE LAST PHYSICIAN CONSULTED?
GEORGE HARHIGH MO
32NO ST
CAMP HILL. PA
06/97
COLD
TOBACCO OR OTHER NICOTINE PRODUCTS?
5 FT 01 IN
125 LBS
DATE SEEN
REASON
HAS THE
HEIGHT
WEIGHT
PRIMARY PROPOSED INSURED EVER USED
RISK - LAST DATE NICOTINE USED POPUP (PRIMARY):
DATE LAST USED CIGARETTES:
12/1997
RISK - GIB:
HAS EITHER THE PRIMARY PROPOSED INSURED OR SECOND INSURED. IF PROPOSED FOR
COVERAGE. EVER USED TOBACCO OR OTHER NICOTINE PRODUCTS?
WITHIN THE LAST fIVE (5) YEARS. HAS ANYONE PROPOSED FOR COVERAGE BEEN TREATED
fOR OR DIAGNOSED AS HAVING:
(4) HIGH BLOOD PRESSURE
(B) ANV DISEASE OR DISORDER OF THE HEART. ARTERIES OR VEINS
(C) DIABETES
(D) CANCER
(E) RESPIRATORY DISORDER (INCLUDING ASTHMA. RECURRENT BRONCHITIS, EMPHYSEMA)
(F) A MENTAL ILLNESS OR PSYCHIATRIC DISORDER OR ANY DISEASE OR DISOROER OF
THE NERVOUS SYSTEM
(G) ALCOHOL OR DRUG USE
(H) BEEN TREATED FOR OR DIAGNOSED AS HAVING AIDS OR AIDS RELATED COMPLEX.
OTHER SEXUAllY TRANSMITTED DISEASES OR POSITIVE TEST RESULTS FOR HIV?
WITHIN THE lAST FIVE (5) YEARS. HAS ANYONE PROPOSED FOR COVERAGE;
(I) TAKEN PRESCRIPTION MEDICATION FOR ANYTHING NOT ALREADY MENTIONED
HAS ANYONE PROPOSED FOR COVERAGE BEEN DECLINED OR CHARGED AN INCREASED PREMIUM
FOR NEW LIFE INSURANCE OR REINSTATEMENT OF LIFE INSURANCE?
IS ANYONE PROPOSED FOR COVERAGE CURRENTLY UNABLE TO PERFORM THE NORMAL DUTIES
OF THEIR OCCUPATION AND/OR NORMAL DAILY ACTIVITIES7
N
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LEGACY/ESTATE HISTORY PRINTOUT - 12/17/1997
RHON/CK OGT 63-483-092/N INSUREO.S NAME GLORIA u HECK
RE..JECTIONI
PAGE 0005
OFFICE W SH
***.....................................................*..........*............
PRINT REMARKS - RISK DETAIL:
GLORIA u HECK.SCHIZOPHRENIA;DIAGNOSED 25 VRS AGO. TAKES
HALDOL PER MONTH; HER CONDITION IS OK. OR ROSARIO; .
fiNAL ACTION - PAGE 1:
1.5 MG INJECTION OF
APPROVAL coDe
SMOKER
RATING
ADB/GAB RATING
WP coo E
ADDITIONAL fORMS
APPROVAL
SMOKER
o SPECIAL CLASS
1
EXCLUDED
N
NOTE PAD REMARKS:
NTE-99 12/11/97 CALLBACK COMP..IPB/Y.REP-NO.FIN*NO.APP*NO..AGENT
W/CLIENT. .ELH/H14..
DRILL DOWN FILE INFORMATION:
GLORIA u HECK - SCHIZOPHRENIA
Doctor: DR ROSARIO Clinic (it any): Street Address: Ctty.
State. Zip code: What were your symptoms? SHE WAS HEARING THINGS AND
PEOPLE THAT WERE NOT REAL Did you have any time los~ from work o~ normal
activities? (Provide details) SHE LOST TIME FROM HER NORMAL ACTIVITIES WHEN SHE
WAS HOSPITALIZED ABOUT FIVE YEARS AGO Have you eve~ been hospitalized fo~
this conditton? What we~e the dates and duratton ot each hospttaltzatton?
SHE WAS HOSPITALIZED FOR ONE WEEK ABOUT FIVE YEARS AGO What was the date of
the diagnosis? DIAGNOSED 25 VRS AGO What type of treatment and I or
medicatton was prescribed? TAKES 1 What is the current status of your
condition? HER CONDITION IS OK Comments printed on the application:
Underwriter notes for file (not printed on the application):
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LEGACY/ESTATE HISTORY PRINTOUT - 12/17/1997
RHCNICK OGT 63-483-092/N INSUREO.S NAME GLORIA ~ HECK
REuECTION'"
PAGE 0006
OFFICE W SH
MIB DATA:
***.******.*.....**..**..*.......***...**......*......-.-..*.-.---.-.....-.-.-.-
765 004 F TRY
HOOK.
GLORIA'" .
06AG40 PA
FOOO
G23NV94 315H2N-
258GZN-932HZN
2 NO IAI RECORD LOCATED
3 766 004 R HIT
HECK.
GLORIA U.
08AG40 PA
PN ..080013968
SC -2
PN -73935288
SC "2
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2157842498 TO ';Ii" '79753667
P.il2
JAN 26 "38 13:03 FR A" . 'ISIT ION SU"PCRT
ThePrudentJal ($
'APPLICAlION FOR UFE INSURANCE
ORPOUCY CHANGE
1m The PnldOOliallnalllarlCe Company 01 America
o Pnx:o Lire Insurance Company , .
A Subsidi:ary of Tho PrudeIniaIlnsur3nC9 Company of America
Corporal9 Offices, ~, NGw Jersey
Po6cy No. 63483092 N
lJCheclc here if pallcyclumge.
GLORIA J HECK
Name of primary proposed Insured (or currenllnsurad, if poncy Cll8Jl9ll) (first, initial, 1aSl)
PART 1
A. PIORSONAL INFOAIlATION (primary Propoae<llnlured) ,
1. SocieI SIlClJr!ty No. 188-32-3141 " 2.. Sex: 0 Male . l!!l Female
3.. M3rita1 $t;otus: 0 Single I!!llllanied 1J Wiclowod IJ Separated , 1J DNcn:ed
4. Dale of Bir1h: Mo.~ Oay~ Yr..H!JL S. e g S. Slate of Birlh (Country if nor U.S.) PA
7. Billing Adtlress (Cily, State and Zip): Gll23 H II MECl/ANlCSBUR PA 1785&
8. Horne Mc1r98S (iI dffererll):
9. Home Telephone Number (717) 766-4610 10. Business TelBphone Number I )
11.0lm8nt EmplDyer NONE "
B. AU. OTHER "ROPOSED I~.SUREDS (InclUde Applicant lor AppPeant.... woiII&i 01 Premium Benefit]
Name , RoIationship to . Sex Da19 of ,.;" Age Sta19 of .
primary proposod .., . BiI1h' Birth (country
JnSUled " ,(mo., day, yr.) If not U.S.)
\ll
TDbll.ife \ll
Insurance in{.oj
all companiBJ
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Co COVDlAGE INFORMATION . ...' " "',,. . " '
1. I'lan olln$urance PIlllDEM'IAL CUISSIC U1E " ' : ' 2. Initial Amount S 10.DOO
111>J..N1>J.. or .ppllcallle lD lha product, Cll9ck one: 1J leYeI DeIl1l1 Senelit IJ V;>riable Death Benoflt
3. SUPPLEMENTARY BENEATS AND RIDERS (F'feaSe';iK1ii:8teamount whmeappkable)
o Waiver 01 Premlum 1!51 Accidental Death Benefit $ 2ll.000 ' ,
D Uving /lleeds Benefit 0 Optlon to Purchase Addilionallnsurance $ .
1J Applicant's Wtiier 01 Premium 0 OptiOl\ lD Purt:hasG Pald Up life Insurance Ad<litions
o Automatic Premium Lean lincIude details il\ speclal requeot) '.'" ;".: ' ' '
OTHER RIDERS AND BENE'FlTS: (plllasa irn5cale amoun! ~bt;re BPf'IcabIo)
,...0'
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D. BEHI;FlClARIESlD.iNERSHIP (It Trust, provide name 01 b'~I,l1ustoo and da"ie'oI /nrst) ~~"
1. Beneficiary: . NBmtI, , Rsllllionslllp 10 primary prClpOSQd Insured Age
Primery(CIess 1). _BERT EHECIf Hll/lBllND 55
Contingent (Class 2) IlOBEAr C >lEeK
fCla5s 2\ TEl/RANCE l! HECK
'Cb"g 2\ I'Ot.tl) III HECK
2. 10 tha owner 011\.. thin Il1B primary proposed Insurad?
Ifye": Name
Addr98s
'SON
SON
SON
32
30
29
DY!'S I!!lNo
Owner's date cl birth
liaRD 96200-9& ~ Pennsylvania
11~lellll~~llmIDlml
DEFENDANT'S
I EXHIBIT
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JRN 26 '98 13'e3 FR A("P'tSITlON suPPORT
........-..-.... --
2157842498 TO 917\79753667
- -
P.W
- -
'I
E. PAYMENT DCTAILS
'I. Wit!lin the last 12 rnonth~, has any proposed Insured had a he<vt attad<, stroke or cancet other 111~
of lhe skin? .
2. Is a medical e~aminalion required on: Primary Pro~ Insured?
Second Proposed 1nsUr'ed?
S. Premium P8yment Mode: (coallCt full mOdal premivm If pIepSid) ,
o Pru-matic a Annual 0 Saml-annual [J Ooatterty liiI Monthly a Payroll Budgel 0 Gcv', Allotment
4. Amount paid with this applicalion S "UO D None (Must bl> "None" if EI i3 enj..;e,ed
V.., ."""'pt Gbra/Iar products.)
5. Date p!1lmlum coReClod 12'''.11/!17
F. REPLACEMENT
For rrrry proposed Insured. woulcllhis Insurance replace Dr C3U98 a change in any existing insurance
or annuity in any company? . ... . . 0 Ye.o liiI No
(If yes, gMJ insuranOl> compeny. plan, amount and policy numb9t(s). Enclose aJf required sIBle replscemerrt forms.)
DYes l!!lNo
DYes Ii!I No
DYes DNo
I .
on ":
Go SPECW. RCQUESTS
:it .:
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H. BACKGROUND ON PROPOSJaD INSUAEOS . "
1. TolaI Lf& Insurance on lIIe primary proposed Il'ISUrod In BlfIlCt S15 0llG 'l:iheck hers if None 0. 0
2. What a-e \he primary proposed Insurad's occupation ane! duties? HOlIIatfAIIEIl
3. Has ""Y proposeclln5unld partlci;>a!ed in \he following activities wilhin the las' 2 Y6= (or des:;' ahyone
plan, to do so In the I'u!ure): "I
a. operaIecI or had at'ti dutillS aboard an aIn::raft. g!idst. balloon. or ikG dovic&? ._ a Yes li!l No
. If yes. compIllle Aviation Ouesrionnsirt>. _
b. hazardous 9pOrts. such lIS 1I1J1o. mot<<eyde. anowmob.,.. or powert>olit ""mpetltionsl"""ibilion.:
scuba diving; mountain clmbing; paracIluting; sky diving or any other such sport or hobby1t
'yes, ~ AlIOCelian Que:rtiotltlal.... . . .
Fot-.~ IJL'B'I~ - )'1>. beIo.... give the delBi/s inS.
4. Is any p-oposed lnsImJd applying lot or requesting feinstalem8nt or policy change(sl of any olber Hf&
Of hBanIlln!IunInce perleY? U )I'IIS, g;.,e j""w8JlCe co.'lpd,. parscy p/Iln and smounI. aVes I!lI No 0
5. Has SlY P'QllOS&d Ir>9umd been convicted 01. or currently clrarged >oith. lI1e commiSSion of My : '
criminal otIense. Cl1!Ier than It\e violation of a motor vehicle law within the last 5 years?
S. a. Primary Proposed Insured driver's Iic9nsG number and Slate of Issue:
111101569 PA
b. Has any proposecllnsured in the lasl 3 years:
11.) had a driver's license deniod. suspended or revolted?
(2.) be8rI convicted Of or citecllor.
(8) 3 or more IIlllvlng vialalions? . '" eVe. Il!l No
(b) drMng under the inflUence of alcohol or drugs? 0 Yes 1ilI No
13.) ~""n involved as a driver In 2 or mora atIlO 1IeeideI1lS? - 0 Yes li!l No
H)I'IIs, gi... def8ils induding type of MoIaI'on, accident or r9/J$Oll for denieJ,~per.sion or ~alion.
7. Does any pl'llposecllnSured plan 10 r_ ortravol outaItIe the United States or Canada within the next
12 monlIIs? If)'l>" give countr~, purpose and dur1ttion oIeathtrlp. . DVes I8lNo
8. Daml1s Of yes answers lor qv&atians 4-7. Giv.. qusslion number, proposed ""U'ed's oame and lull dstais '
eyllS mNo
DYes I!lINo
,
. .
ayes Il!lNo
.,
"
fOR ADDmoNAL DETAILS USE ANOTHER APPUCATION
L Dividend Option EIeet10n - Comp~ only If llpplyl"9lD 1ha PrIldenu.ollnauram;e coml!any Of Aml'1lca
iI Paid-up :adcitions 0 AcaJmuIala at i_st 0 Cash ~ , .
a Reduc. pAlIfIUms (not available for rnonlhly mocl9) D
~ORD 96200-9& ~ P8I1OS)'hr.lnia
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POlicy Nult,ber 63<183092 N
PART 2 - MEDICAL INFORMATION
SECTION C. TO BE COMPLETED FOR GIBRALTAR PLANS ONLY
1. Doctor Information:
A. Primary Proposed Insured
Physician last consulted: GEORGE HARH/GH MD
Date fast seen: 05197
Reason: COLD
Address and Phone no.: 32ND ST. CAMP HILI.. PA
Primary Physician: GEORGE HARH/GH MD
Date last seen: 05197
ReasOn: COLD
Address and Phone no.: 32ND ST. CAMP HILL. PA
B. Second Proposed Insured or AWP Applicant
Physician last consulted: .
Date last seen: .
Reason:
Address and Phone no.:
Primary Physician:
Date last seen:
Reason:
Address and Phone no.:
2. Build:
--a: Primary Proposed Insured
b. Second Proposed Insured or AWP Applicant
Height
5- 1"
Weight
125
3. Has either the primary proposed Insured or second proposed Insured, if proposed for coverage, ever used
tobacco or other nicotine products? I8IYes DNo
If yes, give date last used: Cigarettes Any other nicotine product such as cigar, pipe, smokeless
(MolYr) tobacco, nicotine gum or nicotine /lll!ch(MoIVr) ...' ~",
Primary Proposed Insured 1211997 ; .':, '~"""'"""l''''''\~:r,,,,,,,~>,,,,,''''--~,,,:,,''rI-~''''_'*\,jl!:!:",,,,,'..,"". .. . ,," ",".
Second Proposed Insured
4. Within the last five (5) years, ha~ anyone proposed for coverage: ,
a. taken prescription medication. or been treated for or diagnosed as having: high blood pressure, any
disease or disorder of the heart, arteries or veins, diabetes, cancer, respiratory disorder (including asthma,
recurrent bronchitis, emphysema), a mental illness or psychiatric disorder or any disease or disorder of
the nervous system, alcohol or drug use? ' I8IYes DNo
b. been treated for or diagnosed as having AIDS or AIDS related complex, other sexually transmitted
diseases or positive test results lor HIV? DYes l1i1No
6. Has anyone proposed for coverage been declined or charged an increas~ premium for new lile insurance or
reinstatement of life insurance? DYes I8lNo
6. Is anyone proposed lor coverage currently unable to perform the normal duties of their occupation andlor
normal daily activities? ., , DYes I8lNo
Please include the details of any 'Ves' answer to the questions 4-6: GLORIA J HECK:SCHIZOPHRENIA;/1/AGNOSED 25
YRS AGO: TAKES 1 1.5 MG INJECTION OF HALDOL PER MONTH: HER CONDITION IS OK: DR ROSARIO: '
osed Insured (d age 15 or over)
ust be age 18 or over)
x
, Si nature of Spouse, if proposed for coverage
llORD 96200.96 II Pennsylvania
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3AN 26 '98 13'64 FR prQU1SnlON SUPFffiT
2157842498 TO 917179753567
P.04
PolIcy Number 834l130112 N
On !his pag<: /he word! "I" 8Ild "my- rafer to !he primary pioposgd Insumd Bt!d Ilpplicant, if different. The wolds "tfle
Compar1r" rBIer ID !he company ch~ Illlhe b6ginnjng o(lhis ~icalfon. I( a poliCy C/lange; 't'" SlId "my". refer III
InSlJl8d Of' Owner, if oIJtet Ihltn Insured.
I
TERMS AND CONDITIONS
No nr1W coverage requosled in this IIIllllication starts on any proposed IllSuted until all required initial med"ocaI exams end
lBsIs egreed to are COf1lpleled, even if en amDlml has been paid to lI1e Company.
Wh<!n the Company gIvea 8 Umlted InIurance Agruament fOrm Clated an the samo dale shown below, coverage
will atart as wrtllltn In !hat AgreeIllent. Otherwise, CDvenge win SllIlt Dn the conltllct data, pIOvldod:
. The Company I.....". a c_cc ..". I .ccept It; anCl' '
. !heftm promlllm Is pAId In full wh!!e ::liB p<Clpoaed Insureds' hOllllll remalna as a1atI!d In the application.
I !he Company ent9rS any change in section I. IItRlfO\I& the el\llnge by 30Cepling the ccnlraet. unless the Ia.. reqUl9S
written consent 10 ch::lInges.. Then. a change can be mad9 only if I apprO't& it in writing. No agenl can make Dr change
a contrDCt or waive MY of the Company's rights or requhments. , .
Tho bene6cillry namod In the applicatlon (or In 1119 comract if reqU951ing a policy. Cllanse) is lor insurance pnyable in
either of !he loIlowing CIlS"": ,.'
. BIlIle death '" 111& primaty Insured; and _ '11
. a1l1le death of an Insured dIilc:I Bfter lII& d93lh of lI1e prirmuy Insured if th..... is no Insured s~ .
U this is a policy change and no beneficiary has been namsd in the ::lIpplication, Ihe benerJCi8IY Ior:any ilSlllance p.,yab/8 ;;;
will be anleCl 0YDf' frOm .... contract lhllt IS being changed. . '"
Th. owner of the c:ontrad is 1M I'rirn::lIry proposed Insured or epl'l'.cant W other than the primary prcpDSBd Jnsurecl unless to
II cfiff9rent owner ill r>amed in tho applic:alion. Ilhbals a policy chang.. tha ownBtSlUp arrangement will be carried ovet .
(rom 100 ccntract lhalls being changed _ a dilforant ownor is: n""".d In the appliOlllion. This b ~ubjact to any C
pft:Mslon91or tho automalic tr3ll$fs. 01 ownership sbtad In the contract. I joint owner. ",a named, ownorship will b. .
with thlI righl 01 suMvors/lip unless otharNise specified.
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SIGNATURES ',..0'.' ...
By signing below: ,- 0
t;l
. I affitm lIl"t to the best of my knowledge and I>eIief Ile statemenl3 in this "PPllcation are complelB, true und canlCIIy W
. ~nd lha1 new <XMlfOlg8 could bel inv:lIdatBd If any Information i"n the application is melerially misrep~enl8d. -;-
. I conlirnlthat if I have rBQlJIISlDd IIla l.Mng Needs Bono6t. I have read the cliecloSlIl'9$ in the brochure (ORD 872A6l. 0
. I agree to the T....ms and Conditione ahawn ebove and on the Important Notice About Your Applic:lj;on, wItich I hey..
...ceived and .e . ,
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Sign:ll..e of prmary pnlpOSed ured. if ago 8 or eNe. X
... CUJ1enllnsured.. II paIicy change
51gn;nura '" SpclllSe, . proposed lor COY8ragg X
Signalu'e '" AppIle_ (must be II!IlI ,8'or _rl. if dllfe",n! lhDn primary propoaed Insured X
or H a policY ehange. Slgnaturo of Own.... iI diff8ranl than lnAured
If sppliCM!t Is a Iirrn ~~. lli~.lhsl C<lrl7pllrly'$ ~ !!r!!! hswJ "" cllcar sif1" below.
Signatu'D end or corp>nJIlon X
Si of QwnllrX'.
ignaIUre 01 BeneIIcIary, If flOIicy ~ In! rigIrts anI!hnited X
SigMtu'" ol Witness (lJcatlSed Vol' . 'J>(t1,fHlfativrJ must wilnessJ
UC_ WrlllnO Repreae on:
00 - than what is sta1ed il1l1is 8p!JIi
~ or y currenl in....1Ir1C9 or 3nnuitv in
WI1n.SS rUDer/sed Wri6no Re~senralive _ wilnessJ
IIORD 962/lGo98 ~ PeMSylvania
p
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ThePrudentlal ~
, -
The Prudential Insurance Company of America
a rllutuallife insurance company
Prudential Plaza, Newark, New Jersey 07102
Insured GLOR I A J HECK
63 483 092
DEC I I, 1991.
Policy Number
Contract Date
Agency 4-w SH-G- I 68
.A/
Whole Life Policy. Life insurance peyable upon death. Premiums payable during Insured's lifetime. Eligible te
annual dividends as stated under Dividends.
We will pay the beneficiary the death benefit described In this contract promptly if we receive due proof that the Insured died,
We make this promise subject to all the provisions of this contract.
If there is ever 8 question about this contract, just see a Prudential representative or contact one of our offices.
10.Day Right to Cancel Contra ct.-If you return this contract to us no later than 10 days after you receive it, we will refund
your money promptly. The contract will be canceled from the start. All you have to do is take it or mail It to one of our offices
or to the representative who sold it to you.
Signed for Prudential.
1..-
~.~
*
~-T4<1">-
Secretary
President
DEFENDANT'S
, E~HJBlT
PLEASE REAO YOUR POLICY CAREFULLY; it is a legal contract between you and Prudential.
'0:
WL-98
~"''''''.'"""",,~, ~,...,..
GUIDE TO CONTENTS
Page
Contract Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ';" .
Basic Contract Information About Insurance Coverage and Premiums Payable Under the Contract
. . 3
Table of Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
A table showing Cash and loan Values, amounts of Reduced Paid-Up Insurance, and Extended Insurance, if any
Definitions
..x.!.
5
The Contract 5
Entire Contrsct; Contrsct Modifications; Incontestability
Ownership. . . 5
Death Benefits .' . 6
Premium. Paying Basis;, Extended Insurance; Reduced Paid..Up Insurance; Optional Benefit: Computations;
Unearned Premium; Interest on Death Benefit; Suicide Exclusion; Method of Payment
Beneficiary 8
Dividends . 8
Dividend Options; Dividend Credits Described
loans .. . . . . . . . . . . . .. . .. . .. . . . ... ........ . . . . . . . . .. . . . . . .. . . . 9
loan Requirements; Interest Charge; Amount You May Borrow; loan Value; Contract Debt; Repayment; Excess
Contrsct Debt; Postponement of loans
Premium Payment . . . . . . . . . . . . . . . . . . . . .
Payment of Premiums; Change of Frequency; Grace Period
t1
Cash Value Option Upon Surrender 11
Reinstatement. . . 12
General Provisions 12
Currency; Misstatement of Age or Sex; Assignment; Change in Plan or Basic Amount of Insurance; Voting Rights
Basis of Computation. . .'. . . . . . . . . . . . . . . . . . . . . . . . . .
Monality Basis and Interest Rate; Exclusions; Values; Minimum legal Values
13
Settlement Options . . . . . . . .
Options Described; Interest Rate
. . . . . . . . . . . . . . . . . . . 14
Settlement Options Tables . . . .
15
A copy of the application and any riders or endorsements can be found at the end of the contract.
(Wl-98)
Page 2
.'
CONTRACT DATA
Insured
GLORIA J HECK
Female, Issue Age 57
'~
Rating Class
Glb Standard R"No Extended Insurance
....
/
BasIc Contract Information
"
Po I I cy Number
Contract Date
Premium Period
Initial Dividend
63 483 092
December 11, 1997
Li fe
We do not expect to credit a dividend before the third
anniversary (see Dividends) .
See Beneficiary Provision attached.
Beneficiary
LIfe Insurance on the Insured
Basic Amount
$10,000.00
Other Beneflt(s) on the Insured (see appropriate form for details)
Rider MSB 220 - Insured's Accidental Death and Dismemberment Benefit.
Amount varies. Refer to the form for details on the amount payable.
CONTRACT DATA CONTINUED ON NEXT PAGE
Page' 3 (95)
ThePrudentlal ~
-
rOllCY NO. 63 483 092
.
CONTRACT DATA CONTINUED
,
Schedule of Premiums
--
Contract premiums are due on the contract date and at intervals of 1 month
after that date. They start at $55.30 and change as shown below.
Premium Chanqe Date(s)
DEC 11, 2017
Contract Premiums
$39'.90
Each contract premium consists of the premium for the basic amount and
the premlum(s) for the benefit(s) shown in the section that follows.
Prem I urn (s) for Bertef I t (s)
Premium for Beneflt-MSB 220 (accidental death and dismemberment benefit):
Starting on the Contract Date
$3.00
END OF CONTRACT DATA
,--'
Page' 3A (95)
ThePrudentlal ~
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LPW5TO-F57
.aLICY NO. 63 483 092
TABLE OF GUARANTEED VALUES
These are the values for the basic amount if all due premiums. have been paid,
there is no contract debt. and there are nO d I vi dend cred its. <These val ues
are determined as provided in the Basis of Computation provision.
Guaranteed
End of Guaranteed Reduced Paid-Up
Contract Year Cash Insurance
1 $0.00 I $0.00
. ,
2 $0.10 $ 1.00
3 $239.40 $510.00
4 $484.90 $ 1 ,003.00
5 $735.80 $1,479.00
6 $999.60 $1,954.00
7 $1,266.70 $2.410.00
8 $1.537.10 $2,846.00
9 $1.810.30 $3.264.00
10 $2.087.30 $3,667.00
11 $2,368.80 $4,055.00
12 $2.656.00 $4,432.00
13 $2.948.30 . $4.797.00
14 $3,245.30 $5,150.00
15 $3.545.30 $5.489.00
16 $3,846.40 $5.815.00
17 $4.146.60 $6.125.00
18 $4.445.30 $6,421.00
19 $4,741.80 $6,704.00
20 $5,031.00 $6,976.00
Age 60 $239.40 $510.00
Age 62 $735.80 $1,479.00
Age 65 $1,537.10 $2.846.00
If we need to compute these values during a contract year. we will take
Into account the time since the start of the year and any premiums paid for
the year. If you ask us, we will tell you the values for durations other
than those shown in this table.
Nonforfeiture Factor
Factor (per $1,000 of Basic Amount): 28.77238
Contract Years: 21 and later
This Nonforfeiture Factor Is appllcab!e during the premium period.
END OF TABLE (5)
Page'4 (95)
ThePrudentlal Git
-
DEFINITIONS
We, our and uS.-Prudential.
You and Your..-The owner of the contract.
~
Insured.- The person named as the Insured on the first page. He or she need not be the owner.
Issue dale.-Same as the contract date.
Anniversary or contract anniversary.-The same day and month as the contract date in each
later year. /
. ~'
Contract year.-A year that starts on the contract date or on an anniversary.
Attained age.-The Insured's issue age plus the length of time since the contract date. You will
find the Insured's issue age near the top of page 3. '
THE CONTRACT
Entire Contract This policy and any attached copy of an application, including an application requesting a
change, form the entire contract. We assume that all statements in an application are made to
the best of the knowledge end belief of the person(s) who maka them; in tha absence of fraud.
they are deemed to be representations and not warranties. We rely on those statements when
we issue the contract and when we change it. We will not use any statement, unless made in an
application, to try to void the contract, to contest a change. or to deny a claim.
Contract Modifications Only a Prudential officer with the rank ortitle of vice president may agree to modify this contract,
and then only in writing.
Incontestability Except for non-payment of premium, we will not contest this contract after it has been in force
during the Insured's lifetime for two years from the issue date.
OWNERSHIP
On the contract date, the Insured is the owner of the contract, unless a different owner is named
in the application. If a different owner is named, we will show that owner in a provision we
endorse in the contract. The ownership arrangement in effect on the contract date will remain in
effect unless you ask us to change it. ;' < < ' ,"
, If you wish to change the ownership of the contract, your request must be in a form that meets
", our needs. The change will take effect only when we file the request; this will be after you send
us the contract, if we require it to issue an endorsement. Then any previous owner's interest will
end as of the date of the request, even if the Insured is not living when we file the request:
While the Insured is living, the owner alone is entitled to any contract benefit and value, and to
the exercise of any right and privilege granted by the contract or by us.
(WL-98)
Pege 6
DEATH BENEFITS
We will pay a benefit at the Insured's death (except as we state in the Suicide Exclusion) if this
contract is in force at the time of death, that is, the initial premium has been paid and the
contract has not been surrendered or expired without value. It may be in force on a premium.
paying basis, as extended insurance, or as reduced paid.up insurance.
Premium-Paying Basis The contract will be in force on a premium,paying basis if no premium is past due beyond the 31-
day grace period we describe under Premium Payment.
The benefit payable at the Insured's death will be equal to thy life Insurance on the Insured as
described on page 3, plus any dividend credits, plus a returli 'of any unearned premium less any
contract debt and less any past due premium.
This contract may provide benefits on the death of other insureds. If it does, each bene~it will be
listed on a contract data page. and a form describing the benefit and the conditions under which
it is payable will be included in this contract. Any such benefit will be payable only lithe contract
is in force on a premium.paying basis, unless the form that describes the benefit states
otherwise.
Extended Insurance Unless the contract continues as reduced paid,up insurance as described below, the contract will
be in force as extended insurance if a premium is past due beyond tha 31-day grace period and
you have not surrendered the contract for its net cash value.
Extended insurance is term insurance that pays a death benefit only if tha Insured dies within the
term period. The term period starts on the due date of the past due premium. The duration of the
term period will be what is provid~d when we use the net cash valua at the net single premium
rate. This rate depends on the Insured's issue age and sex and on the length of time since the
contract date. The amount of term insurance will be the basic amount shown on page 3, plus any
dividend credits, less any contract debt. At the end of the term period, the extended insurance
expires without value. The guaranteed durations of extended insurance provided by the contract
are shown in the table on page 4.
We will grant extra days of term insurance if the due date of the past due premium is before the
dete that the duration of the guaranteed extended term insurance (see page 4) first equals or
exceeds gO days or the number of days for which premiums have been paid, if less. The number
of extra days will be gO or the numbar of days for which premiums have been paid, if less, minus
the number of days of any extended insurance. Extra days start on the day after the last day of
term insurance provided by any net cash value. If there is no such term insurance, they start on
the due date of the past due premium. There will be no extra days if you replace the extended
insurance with reduced paid-up insurance or you surrender the contract before the extra days
stan.
The contract will be in force as reduced paid-up insurance if a premium is past due beyond the:'
31-day grace period, you have not surrendered the contract for its net cash value, and the "
staiement No Extended Insurance is shown with the Rating Class heading on page 3. It will also'
be in force 8S reduced paid.up insurance if the amount of that insurance equals or exceeds the
amount of extended insurance. The guaranteed amounts of reduced paid.up insurance provided
by the contract are shown in the table on page 4.
If the contract is in force as reduced paid-up insurance, the benefit payable at the time of the
lnsured's death is the amount of reduced paid-up insurance, plus any'dividend credits, minus
any contract debt. The amount of this insurance will be what is provided when we use the net
cash value at the net single premium rate. This rate depends on the Insured's issue age end sex
and on the length of time since the contract date.
Reduced Pald.up
Insurance
(Wl-98)
Page 6
Optional Benefit
Computations
Unearned Premium
Interest on Death
Benefit
Suicide Exclusion,
Method of Payment
(WL-98)
Within three months alter the due date of a past due premium, you may replace any extended
insurance that has a cash value with reC;uced paid-up insurance. You must tell us in a form that
meets our needs, and we may require you to send us the contract to be endorsed.
We will make all computations for either extended insurance or reduced paid.up insurance as of
the due date of the past due.premium. But we will consider any dividend credits you surrender
and any loan you take out or pay back in the grace period of that premium.
When we pay a death benefit on any insured, we will return that part of the last premium paid for
that benefit that covers the period alter the date of death.
Any death benefit described above will be credited with interest from the date of death according
to the laws of the jurisdiction where this contract is delivered.
/
If the Insured, whether sane or insane, dies by suicitJe within two years from the issue date, this
contract will end and we will return the premiums paid. The contract will provide no funher
, benefit.
You may choose to have any death benefit paid in a single sum or under an optional mode of
settlement (see Settlement Options).
Page 7
BENEFICIARY
You may designate or change a beneficiary. Your request for a change must be in a form that
meets our needs. The chango will take effect only when we file the request; this will be after you
send us the contract. if we require it to issue an endorsement. Then any-previous beneficiary's
interest will end as of the date of the request, even if the Insured is not living when we file the
request. Any beneficiary's interest is subject to the rights of any assignee we know of.
When a beneficiary is designated, any relationship shown is to the Insured, unless otherwise
stated. To show priority, we will use numbered classes, so that the class with first priority is
called class 1, the class with next priority is called class 2, pn& so on. When we use numbered
classes, these statements apply to beneficiaries unless the form states otherwise:
1. One who survives the Insured will have the right to be paid only if no one in a prior class
survives the Insured. .
2. One who has the right to be paid will be the only one paid if no one else in the same class
survives the Insured.
3. Tw~ or more in the same class who have the right to be paid will be paid in equal shares.
4. If none survives the Insured, we will pay in one sum to the Insured's estate.
Before we make a payment. we have the right to decide what proof we need of the identity, age
or any other facts about any persons designated 8S beneficiaries. If beneficiaries are not
designated by name and we make payment(s) based on that proof, we will not have to make the
payment(s) again.
DIVIDENDS
We will decide each year what part, if any, of our surplus to credit to this contract as a dividend.
We will credit any dividend on an anniversary if the contract is then in force as other than
extended insurance. But we do not expect to credit one before the anniversary shown under
Initial Dividend in the Contract Data pages.
If the contract is in force as extended insurance, it is not eligible for a dividend.
Dividend Options If the contract is in force on a premium-paying basis and if you ask us in a form that meets our
needs, you may choose any of these uses for any dividend:
1. Cash.-We will pay it to you in cash.
2. Premium Reduction.-We will use it to reduce any premium then due.
3. Paid-Up life Insurance Addition.-We will use it at the net single premium rate as of the
enniversary to provide a paid-up life insurance addition. We will pay the amount of this
insurance at the Insured's death.
4. Accumulation.-We will hold it at interest. The rate will be at least 30/0 a year.
(Wl-98)
Page 8
Dividend Credits
Described
If you hdve not made another choice by 31 days after the anniversary, we will use the dividend
as we state under dividend option 3. If a past due premium remains unpaid at the end of the
grace period, we will use the dividend as we state under Cash Value Option Upon Surrender.
You may surrender paid-up life insurance additions or withdraw accumulations if: (1) we have
not included them in the net cash value used to provide extended or reduced paid-up insurance:
(2) we do not need them as -..ecurity'for contract debt; and (3) 'we have your request in a form
that meets our needs. The surrender value of those additions willnot be less than the dividends
we used to provide them.
If the contract is in force as reduced paid-up insurance, we will credit any dividend as a paid-up
life insurance addition.
When we describe the amount of any death benefit.,the phrase "dividend credits" means the
total of: ..-
1. The amount of any paid-up life insurance additions;
2. Any dividends and interest we hold under dividend option 4; and.
3. Any other dividends we have credited to the contract but have not yet used or paid.
. When we describe loan values and net cash values, the phrase "dividend credits" means the
total of:
1. The net value of any paid-up life insurance additions;
2. Any dividends and interest we hold under dividend option 4; and,
3. Any other dividends we have credited to the contract but have not yet used or paid.
LOANS
Loan Requirements You may borrow from us on the contract if it has a loan value. We describe loan value below. The
contract must be in force 8S other than extended insurance; the Insured must be living; and as
sole security for the loan you must assign the contract to us in a form that meets our needs.
If there is already contract debt when you borrow from us, we will add the new amount you
borrow to that debt.
Interest Charge We will charge interest daily on any loan. Interest is due on each contract anniversary, or when
the loan is paid back if that comes first. If Interest is not paid when due, it will become part of the
loan. Then we will start to charge interest on it, too.
The loan interest rate is the annual rate we set from time to time. The rate will never be greater
than is permitted by law.
(WL-98)
Page 9
Amount You May
Borrow
Loan Value
Contract Dabt
Repayment
Excess Contract Debt
Postponemant of
Loans
(Wl-9B)
Before the stHrt of each contract vear, we will determine the loan interest rate we can charge for
that contract year. To do this, we will fi'st find the rate that is the greater c.f: (1) The Published
Monthly Average (which we describe below) for the calendar month ending two months before
the calendar month of the contract anniversary; and (2) the rate we use to compute the cash
value described on page 4 for the same contract year, plus 1 %.
,. .
If that greater rate is at least Y, % more than the loan interest rate we had set for the current
contract year, we have the right to increase the loan interest rste by at least * %, up to that
greater rate. If it is at least Y, % less, we will decrease the loan interest rate to be no more than
the greater rate. We will not change the loan interest rate by less than Y, %.
When you make a loan we will tell you the initial interest rate for the loan. We will send you a
notice if there is to be an increase in the rate. /
. <
The Published Monthly Average means:
1. Moody's Corporate Bond Yield Average--Monthly Average Corporates, as published by
Moody's Investors Service, Inc. or any successor to that service; or
2. If that average is no longer published, a substantially similar average established by the
insurance regulator where this contract is delivered.
,
You may borrow any amount up to the difference between the loan value and any existing
contract debt, both of which we describe below.
If the contract is in force on a premium,paying basis, the loan value on a premium due date is the
guaranteed cash value shown in the Table of Guaranteed Values on page 4 plus the value of any
dividend credits. In the grace period of a past due premium, the loan value is what it was on the
due date of that premium. We will subtract the value of any dividend credits you surrender in the
grace period. At any other time, the loan value is the amount that would grow at the loan
interest rate 10 equal the loan value on the next premium due date.
If the contract is in force as reduced paid-up insurance or has become paid.up, the loan value is
the net value we describe in the Basis of Computation. On a contract anniversary, the loan value
is determined as of that date. At any other time, the loan value is the amount that would grow at
the loan interest rate to equal the loan value on the next contract anniversary.
Contract debt at any time means the loan on the contract, plus any interest we have charged that
is not yet due and that we have not yet added to the loan.
All or part of any contract debt may be paid back at any time while the Insured is living. But if
there is contract debt at the end of the grace period of a past due premium, it may be paid back
only if the contract is reinstated. When we settle the contract, any contract debt is due us. We
will make an adjustment so that the proceeds will not include the amount of that debt.
If contract debt ever grows to be equal to or more than the loan value, the contract will expire
without value 31 days after we mail a notice to you and any assignee we know of. We will also
send a notice to the Insured's last known address. In the notice we will state the amount that, if
paid to us, will reduce the contract debt enough to keep the contract's benefits from ending for a
limited time.
We will usually make a loan promptly. But we have the right to postpone making a loan for up to
six months unless it will be used to pay premiums on this or other contracts with us.
Page 10
Payment of Premiums
Change of Frequency
Grace Period
PREMIUM PAYMENT
Premiums are due under this contract while the Insured is living. The Schedule of Premiums
shows the amounts of the premiums and when they are due. The premium period, which WE
show on a contract data page, starts on the contract date. Premiums may be paid to us or to any
of our authorized representatives. We will give a receipt upon request.
If you ask us and we agree, you may change the frequency of premium payments. The more
often premiums are due, the larger the total amount that will have to be paid for a contract year.
We grant a 31-day grace period for paying each premjum except the first one. If a premium has
not been paid by its due date. the contract will st." rn force On a premium.paying basis during
the grace period. If a premium has not been paid when the grace period is over,the contract will
end and have no value, except as we state under Cash Value Option Upon Surrender and under
Death Benefits, .
,
,.
,
(WL-98)
CASH VALUE OPTION UPON SURRENDER
You may surrender this contract at any time for its net cash value. To doso, you must ask us in a
form that meets our needs. We may require you to send us the contract. Here is how we will
compute the net cash value:
1. If no premium is past due, the net cash value as of any date will be the guaranteed cash
value computed as deScribed on page 4, plus any dividend credits, minus any contract debt.
2. If premium payment is past due three months or less, we will compute the net cash value as
of the due date of the first unpaid premium. But we will adjust this value for any dividend
credits you surrender and any loan you take out or pay back in the grace period of that
premium.
3. If premium payment is past due more than three months, the net cash value as of any date
will be the net value on that date of any extended insurance benefit then in force, excluding
the net value of any extra days described under Death Benefits. Or it will be the net value on
that date of any reduced paid-up insurance benefit then in force, including any dividend
credits, less any contract debt.
However, within 30 days after an anniversary, the net cash value under 2 and 3 will not be less
than the net cash value on that anniversary, adjusted for any dividend credits you surrender and
any loan you take out or pay back in those 30 days.
We will usually pay any net cash value promptly. But we have the right to postpone paying it for
up to six months. If we doso for more than 30 days, we will pay interest at the rate of 30/0 a year.
You may choose to have any net cash value paid in a single sum or under an optional mode,of ,
settlement (see Settlement Options).
Page 11
REINSTATEMENT
You may reinstate this contract after the grace period of a past due premium if:
1. The premium payment is not past due more than five years; "
2. The contract has not been surrendered for its net cash value; and.
3. You prove to us that the Insured is insurable for the contract.
You must pay us all premiums in arrears with compound interest; the rate will not exceed 6% a
year. Any contract debt must be restored or paid back with i~terest to date at the loan interest
rate. If that debt with interest would exceed the loan value 6f the reinstated contract, the excess
must be paid to us before reinstatement.
Currency
Misstatement of
Age or Sex
Assignment
Change In Plan or
Basic Amount of
Insurance
Voting Rights
(Wl-98)
GENERAL PROVISIONS
Any money we pay, or that is paid to us, must be in United States currency.
If the Insured's stated age or sex or both are not correct, we will change each benefit and any
amount to be paid to what the premium would have bought for the correct age and sex.
The Schedule of Premiums may show that premiums change or stop on a certain date. We may
have used that date because the Insured would attain a certain age on that date. If we find that
the issue age was wrong, we will correct that date.
We will not be deemed to know of an assignment unless we receive it, or a copy of it. We are not
obliged to see that an assignment is valid or sufficient. This contract may not be assigned to any
employee benefit plan without our consent. This contract may not be assigned if such
assignment would violate any federal, state, or local law or regulation prohibiting sex distinct
fates for insurance.
You may be able to have this contract changed to another plan of life insurance or you may be
able to reduce the Basic Amount of insurance. Any change will be made only if we consent, and
any change or reduction in the Basic Amount of insurance will be subject to conditions rules, and
monetary adjustments that are then applicable.
We are a mutual life insurance company. Our principal office is in Newark, New Jersey, and we
, are incorporated in that State. By law, we have 24 directors. This includes 16 elected by our
policyholders (four each year for four year terms), two of our officers, and six public directors
named by New Jersey's Chief Justice.
The election is held on the first Tuesday in April from 10:00 A.M. to 2:00 P.M. in our office at
Prudential Plaza, Newark, N.J. After'this contract has been in force for one year, you may vote
either in person or by mail. We will send you a ballot if you ask for one. Just write to the
Secretary at Prudential Plaza, Newark, New Jersey 071 02, at least 60 days before the election
date. By law, your request must show your name, address, policy number and date of birth. Only
individuals at least 18 years old may vote,
Page 12
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ENDORSEMENTS
(Only we can endorse this contract.)
BASIS OF COMPUTATION
'-
Mortality Basis and
Interest Rate
We compute all net single premiums. net values, and the guaranteed cash, and reduced paid.ul
insurance values shown on page 4 using:
1. the Commissioners 1 980 Standard Ordinary Mortality Table (for extended insurance we us.
the Commissioners 1 980 Extended Term Insurance Table) based on age last birthday;
2. the Insured's issue age and sex and the I,mgth of time since the contract date; and
3. an effective interest rate of 4% a year.
Exclusions When we compute net values and the values shown on page 4, we exclude the value of an\
supplementary benefits and any other additional benefits added by rider to this contract.
Values . Values for durations not shown on page 4 will in accordance with the Standard Nonforfeiture
Value Method. We show any applicable nonforfeiture factor(s) for such values at the end of the
Table of Values.
:;;
When we use the words "net value" in connection with extended insurance, reduced paid.up
insurance and paid.up insurance provided by dividends we mean the present value of future
benefits.
Mlnl!"um Legal Values The cash. loan and other values in this contract are at least as large as those set by law where it is
delivered. Where required, we have 9iven the insurance regulator a detailed statement of how
we compute values and benefits.
The Prudential Insurance Company of America,
::
"
n
is
By
~t.~
~.~
-*
"
"
:>
"
"
..
~
.
..r
Secretary
ORD 97164-98
(WL-98)
Page 13
Options Described'
OptIon 1 (Installments
for a FIxed Period)
Option 2 (Life Income)
Option 3 (Interest
Payment)
Option 4 (Installments
of a Fixed Amount)
Option 5 (Non.
Participating Incomal
Interest Rate
(Wl-98)
SETTLEMENT OPTIONS
You may choose to have the proceeds (that is. any death benefit or any amount payable upon
surrender of the contract) paid in a single sum or under one of the optional modes of settlement
described below. '~
If the person who is to receive the proceeds of this contract wishes to take advantage of one of
these optional modes, we will be glad to furnish, On request. details of the options we describe
below or any others we may have available at the time the proceeds become payable.
We will make equal payments for up to 25 years. The Option 1 Table shows the minimum
amounts we will pay. . A .'
We will make equal monthly payments for as long as the person on whose life the settlement is
based lives. with payments certain for 120 months or until the sum of the payments equals the
amount put under this option. The Option 2 Table shows the minimum amounts we will pay.
But, we must have proof of the date of birth of the person on whose life the settlement is based.
The settlement will share in our surplus to the extent and in the way we decide.
,
We will hold an amount at interest. We will pay the interest annually. semi-annually, quarterly.
or monthly.
We will make equal annual, semi.annual, quarterly, or monthly payments for as long as the
available proceeds provide.
We will make payments like those of any annuity we then regularly issue that: (1) is based on
United States currency; (2) is bought by a single sum; (3) does not provide for dividends; and
(4) does not normally provide for deferral of the first payment. Each payment will be at least,
equal to what we would pay under that kind of annuity with its first payment due on its contract '
date. If a life income is chosen. we must have proof of the date of birth of any person on whose
life the option is based. Option 5 cannot be chosen more than 30 days before the due date of the
first payment.
Payments under Options 1 and 4 will be calculated assuming an effective interest rate of at least
3lfi% a year. Under Option 3 it will be at an effective rate of at least 3% a year. We may include
more interest.
J
Page 14
SW112,
RIDER FOR INSURED'S ACCIDENTAL DEATH AND
DISMEMBERMENT BENEFIT
This benefit is a part of this contract only if it is listed on a coniract date page.
~
Benefits Subject to all the provisions of this benefit and of the rest of this contract, we will pay the
amount(s) we show below for any of the listed losses,
For the Insured's
Accidental loss of: Payment:
life, Twice the basio an!6unt
Both hands;
Both feet;
Sight of both eyes;
One hand and one foot; The basic amount
One hand and sight of one eye;
, One foot and sight of one eye.
One hand; ]
One loot; One-half the basic amount
Sight of one eye.
As used here, loss of a hand means physical severance at or above the wrist. loss of a foot
means physical severance at or above the ankle. loss of sight means permanent and complete
blindness,
Amount limitation We will not pay a total of more than twice the basic amount for all losses caused by the same
accident.
,
.'
.
Payment of Benefit We will include in the death benefit of this contract any payment under this benefit for loss of
life. For any other loss. we will make payment to whoever is the owner as of the date of loss. If a
payment is due the Insured under this benefit and he or she is not living when we pay, we have
the choice of paying the beneficiary for insurance payable upon the death of the Insured or the
Insured's estate,
Conditions Both of these conditions must be met: (1) We must receive due proof that the Insured's loss was
the direct result, independent of all other causes, of accidental bodily injury that occurred on or
after the contract date. (2) The loss must occur (a) while the contract is in force on a premium-
paying basis; and (b) before the end of the contract's term or endowment period, if any.
Excluslo'ns We will not pay a benefit under this rider for any loss caused or contributed to by: (1) suicide or
attempted suicide while sane or insane; or (2) infirmity or disease of mind or body or treatment
. " for it; or (3) any infection other than one caused by an accidental cut or wound.
Even if a loss is caused by accidental bodily injury, we will not pay a benefit for it under this rider
if it is caused or contributed to by: (1) service in the armed forces of any country at war; or,
(2) war or any act of war; or (3) travel by, or descent from, any aircraft if the Insured had any
duties or acted in any capacity other than as a passenger at any time during the flight. But we
will ignore (3) if all these statements are true of the aircraft: (a) It has fixed wings and a
permitted gross takeoff weight of at least 7 5,000 pounds. (b) It is operated by an air carrier that
is certificated under the laws of the United States or Canada to carry passengers to or from
places in those countries. (c) It is not being operated for any armed forces for training or other
purposes. As used here, the word "aircraft" includes rocket craft or any other vehicle for flight
in or beyond the earth's atmosphere. The word "war" means declared or undeclared war and
includes resistance to armed aggression.
.. . . ~.
MSB 220-95 CP
Benefit Premiums We show the premiums for this benefit on a contract data page.
Termlnetlon Thl. ben.llt will .nd on the ..rll..t 01:
1. the end of the last day of the grace period of a past due premium; it will not continue if either
extended or reduced paid-up insurance takes eftect;
,. ,
2. the date the contract is surrendered under its Cash Value Option Upon Surrender, if it has
one; and
3. the date the contract ends for any other reason.
If you ask us in a form that meets our needs in the premium period, we will cancel this benefit as
of the date to which premiums are paid. Contract premiums due then and later will be reduced
accordingly. . '- /
This Supplementary Benefit rider attached to this contract on the Contract Date
The Prudential Insurance Company of America,
By
t.-
-.
~.~
*
Secretary
MSB 220-95 .
ThePrudentlal ~,... The Pruden t i';'l
-
, Insurance Company
of America
Insured '
GLORIA J HECK
Policy No.
6J::~83-092
Settlement of the proceeds of this contract will be made in accord with the following Beneficiary Provision. The
texts on the reverse headed Beneficiaries for Other Proceeds and Special Conditions are a part of this Beneficiary
Provision in any case to which they apply.
Beneficiary Provision
/'
. ...
The proceeds that arise from the Insured's death will be settled in one sum with the beneficiary(ies) sJ:\Own below.
If a contract provides, by rider or otherwise, for income payments to begin upon the Insured's death, the word
proceeds includes the one sum value of those payments that arise from his or her death.
Beneficiary Schedule .
Beneficiaries in Order of Priority:
CLASS 1 ROBERT E HECK. HUSBANO.
CLASS 2 ROBERT C HECK, TERRANCE E HECK AND TODD M HECK, SONS.
CLASS 3 NONE
CLASS ~ NONE
CLASS '5 NONE
These statements apply to the beneficiaries: (1) One who survives the Insured will have the right to be paid only
if no one in a prior class survives the Insured: (2) One who has the right to be paid will be the only one paid if
no one else in the same class survives the Insured: (3) Two or more in the same class who have the right to be
paid will be paid in equal shares, but if children by representation are included in that class they will only
have the right, as we state under Special Conditions on the reverse, to the share to which their deceased parent
would have been entitled if that parent were then living; and (4) If none survives the Insured, unless we state
otherwise below, we will pay in one sum to the Insured's estate.
This contract might have an Automatic Mode of Settlement provision. If so, beneficiaries who do not have a
right to be paid at .the Insured's death may still have a right to be paid under that provision.
lORe 85046
I 85
(Continued on Reverse)'
Beneficiaries for Other Proceeds
This section applies only to a contract that provides for insurance on the lives of the Insured, the insured
spouse and dependent children:
The beneficiary for insurance payable upon the death of the insured spouse will be the Insured if living,
otherwise the estate of the insured spouse.
The beneficiary for insurance payable upon the death of a dependent child will be the Insured if living,
otherwise the insured spouse if living, otherwise the estate of the later to die of the Insured and the
insured spouse. .l
d
This section applies only to a contract that provides for insurance on the lives of the Insured and depen..
dent children:
The beneficiary for insurance payable upon the death of a dependent child will be the Insured if living,
otherwise the beneficiary(ies) in the order of priority and in accord with the distribution shown in this
beneficiary provision, ot~erwise the estate of the later to die of the Insured and the beneficiary(ies).
This section applies only to 8 contract that provides for insurance on the lives of the Insured and the insured
spouse (other than a joint whole life contract):
The beneficiary for insurance payable upon the death of the insured spouse will be the Insured if
living, otherwise the estate of the insured spouse.
Special Conditions
The phrase their children by representation might be included in a designation of a class of beneficiaries who
are to receive settlement of the proceeds. If so, here is what that means. If a beneficiary (other than a child
by representation) in that class is not living at a time when he or she would otherwise have been entitled to
settlement, and if any child of his or hers is then living (his or her child by representation), we will pay the
amount to which that beneficiary would have been entitled In one sum to such child or, if there is more than
one such child, in equal shares to such children. .
In the case of a variable annuity or a retirement annuity: (a) the word policy means contract; (b) the word
Insured means Annuitant; and (c) the word proceeds means any amount that may arise from the Annuitant's
death before the annuity date.
Unless otherwise stated, the relationship of any beneficiary shown in this form is to the Insured.
In this form, the words child and children mean only sons and daughters. They do not mean grandchildren or
other descendants. .
8efore we make a payment, we have the right to decide what proof we need of the identity, age or any other
facts about any persons designated as beneficiaries. If beneficiaries are not designated by name and we make
paymenl(s) based on that proof, we will not have to make the payment(s) again.
Endorsed by attachment on Contract eate for the Company
By
Ju.-
~.~
-*'
Secretar
ThePrudEmtlal ~
-
APPLICATION FOR LIFE INSURANCE
OR POLICY CHANGE
lEI The Prudential Insurance Company of America
o Pruco Life Insurance Company
A Subsicjia{Y of The Prudential Insurance Company of America
Co~porate Offices, Newark, New JersQY
Policy No. 63483092 N
o Check here if policy change.
GLORIA J HECK
Name of primary proposed Insured (or Current Insured. if policy change) (first. initial, last)
PART 1
A. PERSONAL INFORMATION (Primary Proposed Insured) .~/
1. Social Security No. 188-32.3141 2. Sex: 0 Male lEI Female
3. Marital Status; 0 Single lEI Married 0 Widowed 0 Separated 0 Divorced
4. Date of Birth: Mo..QL Day.QL Yr. 1940 5. AgeR- 6. State of Birth (COUnlryifnot U.S.)'PA
7. Billing Address (City, State and Zip): 6023 HUMMINGBIRD DRIVE, MECHAN/CSBURG. PA 17055
8. Home Address (if different):
g. Home Telephone Number ( 717) 766-4610 10. Business Telephone Number (
11.Current Employer NONE
B. ALL OTHER PROPOSED INSUREDS (Include Applicant for Applicant's Waiver of Premium Benefit)
Name Relationship to, Sex Date of Age State of
primary proposed Birth Birth (country
Insured (mo., day, yr.) if not U.S.)
Total Life
Insurance in
all companies
C. COVERAGE INFORMATION
1. Plan of Insurance PRUDENTIAL CLASSIC LIFE 2, Initial Amount $ 10,000
If ALNAL or applicable to the product. check one: 0 Level Death Benefit 0 Variable Death Benefit
3. SUPPLEMENTARY BENEFITS AND RIDERS (Please indicate amount where applicable)
o Waiver of Premium lEI Accidental Death Benefit $ 20,000
o Living Needs Benetit 0 Option to Purchase Additional Insurance $
o Applicant's Waiver of Premium 0 Option to Purchase Paid Up Life Insurance Additions
o Automatic Premium Loan (include details in special request)
OTHER RIDERS AND BENEFITS: (Please indicate amount where applicable)
D. BENEFICIARIEs/OWNERSHIP (If Trust. provide name of trust. trustee and date of trust.)
1. Beneficiary: Name . Relationship to primary proposed Insured Age
Primary (Class 1). ROBERT E HECK HUSBAND 55
Contingent (Class 2) ROBERT CHECK
(Class 2) . TERRANCE E HECK
(Class 2) TODD M HECK
2. Is the owner other than the primary proposed Insured?
If yes: 'Name
Address
SON
SON
SON
32
30
29
o Yes lEI No
Owner's date of birth
II ORe 96200-96 II Pennsylvania
Ilflllllll 1111 111II1II11f If III
E. PAYMENT DETAILS
. 1. Within the last 12months, has any proposed Insured had a heart attack, stroke or cancer other than
of the skin?
2. Is a medical examination required on: Primary Proposed Insured?
Second Proposed Insured?
3. Premium Payment Mode: (collect full modal premium if prepaid)
a Pru-matic a Annual a Semi-annual a Quarterly rEI Monthly a Payroll Budget a Gov't Allotment
'~,
a None (Must be "None" if Et is answered
aYes
aYes
aYes
I8J No
I8J No
aNo
4. Amount paid with this application $ 42.20
Yes, except Gibraltar products.)
5. eate premium collected 12-11-1997
F. REPLACEMENT
For any proposed Insured. would this insurance replace or cause a change in any existing insurance
or annuity in any company? ./ a Yes I8J No
(If yes, give insurance company. plan, amount and policy number{s). Enc/o'se all required state replacement forms.)
G. SPECIAL REQUESTS
H. BACKGROUND ON PROPOSED INSUREDS
1. Total Life Insurance on the primary proposed Insured in effect $15,000 Check here if None a.
2. What areJhe primary proposed Insured's occupation and duties? HOMEMAKER .
3. Has any proposed Insured participated in the following activities within the last 2 years (or does anyone
plan to do so in the future):
a. operated or had any duties aboard an aircraft. glider, balloon. or like device?
If yes, complete Aviation Questionnaire.
b. hazardous sports, such as auto, motorcycle, snowmobile or powerboat competitions/exhibitions;
scuba diving; mountain climbing; parachuting; sky diving or any other such sport or hobby?
tfyes, complete Avocation Questionnaire.
For any questions answered yes below, give the details in 8.
4. Is any proposed Insured applying for or requesting reinstatement or policy change(s) of any other life
or health insurance policy? If yes, give insurance company, policy plan and amount.
5. Has any proposed Insured been convicted of, or currently charged with, the commission of any
criminal oftense, other than the violation of a motor vehicle law within the last 5 years?
6. a. Primary Proposed Insured driver's license number and state of issue:
10704569 PA
b. Has any proposed Insured in the last 3 years:
(1.) had a driver's license denied, suspended or revoked?
(2.) been convicted of or cited for:
(a) 3 or more moving violations?
(b) driving under the influence of alcohol or drugs?
(3.) been involved as a driver in 2 or more auto accidents?
If yes, give details including type of violation, accident or reason for denial, 'suspension or revocation.
7. Does any'proposed Insured plan to live or travel outside the United States or Canada within the next
12 months? If yes, give countries, purpose and duration of each trip. a Yes lEI No
B. Details of yes answers for questions 4-7. Give question number, proposed Insured's name and full details
a Yes I8J No
a Yes I8J No
a Yes I8J No
a Yes I8J No
a Yes I8J No
aYes
aYes
aYes
lEI No
I8J No
I8J No
FOR ADDITIONAL DETAILS USE ANOTHER APPLICATION
I. DivIdend Option ElectIon - Complete only If applylng,to The Prudential Insurance Company of America
lEI Paid-up additions a Accumulate at interest 0 Cash . . .
a, Reduce premiums (not available for monthly mode) a
II ORe. 9.6200-96 II Pennsylvania
Policy Number 634B3092 N
On this page the words "I" and "my" refer to the' primary proposed Insured and applicant, if different. The words "the
. Company" refer to the company checked at the beginning of this application. If a policy change, "I" and "my" refer to
Insured or Owner, if o.ther than Insured.
TERMS AND CONDITIONS . . .
No new coverage requested in this application starts on any proposed Insured until all required initial medical exams and
tests agreed to are completed, even if an amount has been paid to the Company.
When the Company gives a Limited Insurance Agreement form dated on the same date shown below, coverage
will start as written In that Agreement. Otherwise, coverage will start on the contract date, provided:
· The Company Issues'a contract and I accept It; and
· the first premium Is paid In full while all proposed Insureds' health remains as stated In the application.
/
If the Company enters any change in section I, I approve the change by acceptinri the contract, unless the law requires
written consent to changes. Then, a change can be made only if I approve it in writing. No agent can make or change
a contract, or waive any of the Company's rights or requirements. '.
The beneficiary named in the application (or in the contract if requesting a policy change) is for insurance payable in
either of the following cases:
· at the death of the primary Insured; and
e at the death of an Insured child after the death of the primary Insured if there is no Insured spouse.
I! this is a policy change and no beneficiary has been named in the application, the beneficiary for any insurance payable
will be carried over from the contract that is being changed:
The owner of the contract is the primary proposed Insured or applicant if other than the primary proposed Insured unless
a different owner is named in the application. If this is a policy change, the ownership arrangement will be carried over
from the contract that is being changed unless a different owner is named in the application. This is subject to any
provisions for the automatic transfer of ownership stated in the contract. If joint owners are named, ownership will be
with the right of .survivorship unless otherwise specified. .
SIGNATURES
By signing below:
· I affirm that to the best of my knowledge and belief the statements in this application are complete, true and correctly
recorded. , .
· I understand that new coverage could be invalidated if any information in the application is materially misrepresented.
e I confirm that if I have requested the Living Needs Benefit, I have read the disclosures in the brochure (ORD 87246).
· I agree to the Terms and Conditions shown above and on the Important Notice About Your Application, which I have
received and read.
't,1tU1/C~
(City/State) .
Signed at:
Signature of primary proposed Insured, if age 8 or over X
or current Insured, if polic}! change {/
Signature of Spouse, if proposed for coverage X
Signature of Applicant (must be age 1 B or over), if different than primary proposed Insured X
or if a policy change, Signature of Owner, if different than Insured
If applicanUs a firm or corporation, give that company's name and have an officer sign below.
Signature and title of Officer of firm or corporation X
, Signature of Owner X .
Signature of Beneficiary, if policy change and rights are limited X
Signature of Witness (Licensed Writing Representative must witness)
Licensed Writing Representative's CertifIcation:
Do you have any information, other than what is stated in this applicatio ,
may replace or change any CUrrent insurance or annuity in any 0 pany,
Witness (Licensed Writing Representative must witness) X
IIORD 96200-9S II Pennsylvania
."
/
,
Policy Number 63483092 N
. PART 2 - MEDICAL INFORMATION
SECTION C - TO BE COMPLETED FOR GIBRALTAR PLANS ONLY
1. Doctor Information:
A. Primary Proposed Insured
Physician last consulted: GEORGE HARHlGH MD
Date last seen: 06/97
Reason: COLD
Address and Phone no.: 32ND ST, CAMP HILL PA
. , ,
Primary Physician: GEORGE HlJRHIGH MD
Date last seen: 06/97
Reason: COLD
Address and Phone no.: 32ND ST, CAMP HILL PA
.~/
B. Second Proposed Insured or AWP Applicant
Physician last consulted:
Date last seen:
Reason:
Address and Phone no.:
Primary Physician:
Date last seen:
Reason:
Address and Phone no.:
2. Build:
--a. Primary Proposed Insured
b. Second Proposed Insured or AWP Applicant
Height
5' 1"
Weight
125
3, Has either the primary proposed Insured or second proposed Insured, if proposed for coverage, ever used
tobacco or other nicotine products? I8IYes DNo
If yes,. give date last used: Cigarettes ,Any other nicotine product such as cigar, pipe, smokeless
. (MoNr) tobacco, nicotine gum or nicotine patch (MoNr)
Primary Proposed Insured 12/1997
Second Proposed Insured
4. Within the last five (5) years, has anyone proposed for coverage:
a. taken prescription medication, or been treated for or diagnosed as having: high blood pressure, any
disease or disorder of the heart, arteries or veins, diabetes, cancer, respiratory disorder (including aSlhma,
recurrenl bronchilis, emphysema), a mental illness or psychiatric disorder or any disease or disorder of
the nervous system, alcohol or drug use? ' 181 Yes DNo
b. been treated for or diagnosed as having AleS or AIDS related complex, other sexually transmitted
diseases or positive test results for HIV? DYes I8INo
5. Has anyone proposed for coverage been declined or charged an increased premium for new life insurance or
reinstatement of life insurance? DYes . 181 No
6. Is anyone proposed for coverage currently unable to perform the normal duties of their occupation and/or
normal daily activities? DYes I8INo
Please include the detai/s,of any .Ves" answer to the questions 4-6: GLORIA J HECK;SCHIZOPHRENIA;DIAGNOSED 25
YRS AGO; TAKES 1 1.5 MG INJECTION OF HALDOL PER MDNTH: HER CONDITION IS OK; DR ROSARIO:
All the answers are, to the best of my knowledge and belief, complete, true and COrrectly recorded. It is understood that
any new coverage could be invalidated if any information in the application is materially misrepresented.
Date
X
Signature of primary proposed Insured (if age 15 or over)
otherwise Applicant (must be age 1 B or over)
X
Witness
Il?RD 96200-9~1 Pennsylvania
X
Signature of Spouse, if proposed for coverage.
'.
.
SETTLEMENT OPTIONS TABLES
, . .
OPTION 1 TABLE
OPTION 2 TABLE -..:.
"
MINIMUM AMOUNT OF
MONTHL Y PAYMENT FOR
EACH $1,000, THE FIRST
PAYABLE IMMEDIATELY
Number Monthly
of Years Payment
1 $84.65
2 43.05,
3 29.19
4 22.27
6 18.12
6 16.35
7 13.38
8 11.90
g 10.75
10 9.83
.
11 9.09
12 8.46
13 7.94
14 7.49
15 7.10
16 6.76
17 6.47
18 6.20
19 5.97
I 20 5.75
21 6.56
22 5.39
23 5.24
24 5.09
26 4.96
"
Multiply the monthly amount
by 2.989 for quarterly,
6.952 for semi-annual or
11.804 for annual.
MINIMUM AMOUNT OF MONTHLY PAYMENT FOR EACH $1,000, THE FIRST
PAYABLE IMMEelATELY
KINe OF LIFE INCOME KINe OF LIFE INCOME
AGE 10.Year Instalment AGE 10-Year Instalment
LAST Certain Refund ,A:AST Cenain Refund
BIRTHeAY Male Female Male Female 61RTHeAY Male Female Male Female
10 $3.18 $3.11 $3.17 $3.10 45 $4.06 $3.82 $3.99 $3.78
and under 46 4.12 3.86 . 4.03 3.81
11 3.19 3.12 3.18 3.11 47 4.17 3.90 4.08 3.85
12 3.20 3.13 3.19 3.12 48 4.23 3.94 4.13 3.90
13 3.21 3.14 3.20 3.13 49 4.28 3.99 4.18 3.94
14 3.22 3.15 3.21 3.14
50 4.35 4.04 4.24 3.98
16 3.24 3.16 3.23 3.15 61 4.41 4.09 4.29 4.03
16 3.25 3.17 3.24 3.16 62 4.48 4.15 4.35 4.08
17 3.27 3.19 3.25 3.18 63 4.55 4.21 4.41 4.13
18 3.28 3.20 3.27 3.19 54 4.62 4.27 4.48 4.19
19 3.30 3.21 3.28 3.20
55 4.70 4.33 4.65 4.24
20 3.31 3.22 3.30 3.21 56 4.78 4.40 4.62 4.30
21 3.33 3.24 3.32 3.23 67. 4.86 4.47 4.69 4.37
22 3.35 ' 3.25 3.33 3.24 68 4.95 4.54 4.77 4.43
23 3.36 3.26 3.35 3.25 59 5.05 4.62 4.86 4.50
24 3.38 3.28 3.37 3.27
60 5.15 4.71 4.94 4.58
25 3.40 3.30 3.39 3.29 61 6.26 4.79 5.03 4.66
26 3.42 3.31 3.41 3.30 62 6.36 4.89 6.13 4.74
27 3.45 3.33 3.43 3.32 63 5.48 4.98 5.23 4.82
28 3.47 3.35 3.45 3.34 64 5.60 5.09 5.34 4.92
29 3.49 3.37 3.47 3.35
65 6,73 5.20 5.45 5.01
30 3.62 3.39 3.49 3.37 66 5.87 6.31 5.57 5.11
31 3.54 3.41 3,52 3.39 67 6.01 5.43 6,70 6.22
32 3.57 3.43 3.54 3.41 68 6.15 6.56 6.83 5.34
33 3.60 3.45 3.57 3.44 69 6.30 6.70 6.97 5.46
34 3.63 3.47 3.60 3.46
70 6.46 5.84 6.11 5.58
35 3.66 3.50 3.63 3.48 71 6.62 5.99 6.27 6.72
36 3.69 3.62 3.66 3.60 72 6.79 6.16 6.43 6.86
37 3.72 3.65 3.69 3,53 73 6.96, 6.31 6.60 6.01
38 3.76 ,3.68 3.72 3.56 74 7.13 6.49 6.78 6.18
39 3.80 3.61 3.75 3,58
76 7.30 6.67 6,97 6.35
40 3.84 3.64 3.79 3.61 76 7.48 6.85 7.17 6,53,
41 3.88 3.67 3.82 3.64 77 7.66 7.04 7.38 6.72 !
42 3.92 3.70 3.86 3.67 78 7.83 7.24 7.60 6.931
43 3.97 3.74 3.90 3.71 79 8.00 7.44 7.83 7.15 ;
44 4.01 3.78 3.94 3.74 ,
,
80 8.17 7.64 8.07 7.38 i
and over ,
I
,...
'"
,...
,...
8
"
"
o
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..
,~
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-l
(WL-98)
Page 15
SWL13
i
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"
Whola Life Policy, Life Insurance payable upon death. Premiums payable during Insured's lifetime. Eligible for,
annual dividends as stated under .DIvidends.
WL-98
Page 16
9paoIaI rating clast
~
~
~ Prudential
-
The Prudential Insurance ComjJalit of America
Customer Service Office
P. 0, Box 7390
Philadelphia, PA 19101
Carol Hartman
Senior Claim Examiner
October 9, 1998
ROBERT E HECK
6023 HUMMINGBIRD
MECHANICSBURG PA
DRIVE
17055
Insured:
Gloria J. Heck
Policy #: 63 ~83 092
Dear Mr. Heck:
Thank you for your continued patience during these difficult days, and for
your assistance in providing the information we requested. As you may
recall, we have been reviewing information that your wife provided when she
applied for this insurance. This is a routine procedure whenever an insured
dies within the first two years of coverage.
During our review of Dr. Harhlgh's records, we learned that your wife had
stress tests on January 29, 1993 and March 8" 1993, The January 93 test
showed mild ischemia. The March 1993 test showed a complete left bundle
block and resting EKG abnormalities. In addition, while she told us she was
taking Haldol, she didn't tell us she was taking Cogentin as well.
If all the facts concerning her medical history had been included on the
application for insurance, we would not have issued this policy. As a
result, no benefit is payable. Prudential assumed that all statements in the
application were made to the best knowledge and belief of the person who made
them. The company relied on those statements when issuing the policy, and
coverage can be invalidated if any of the Information was materially
misrepresent'ed. '. ,;
Although we cannot pay a death benefit, I am enclosing a check In the amount
of ~56.78, which is the total premium payments for the policy plus interest
of $1~.38. For your 'Information, I have also enclosed a copy of your wife's
signed application.
I
DEFENDANT'S
EXHIBIT
tf
Corporate Offlce: 751 Broad Street. Newerk. NJ 07102~771
'\
Please don't hesitate to call me collect at 215-78~-3625 if you have any
questions regarding our findings.
Sincerely,
CL/~
Carol Hartman
Senior Claim Examiner
cc: fi Ie
Enclosure
"
~ ~
-.
M~II to
Field Office Instructions
.llH 16B
... 'Ivery of the attached check end statement Is:
UNCON. tONAL
.53-;30
":';;
.
Address
BATCH NO. T062
ThePrudentlal $
FOR INSURANCE SERVICE, GET IN
TOUCH WITH YOUR REPRESENTATIVE
OR THIS OFFICE
CHECK STATEMENT
The Prudential Insurance Company of America
Central Atlantic Operating Center
P.O. Bo)( 631
Fort Wuhington. PA 19034
CLAIMS & RECOROS OIV
POBOX 388
FT WASHINGTON PA 19034
OEATH CLAIM
Contract Number
Insured/Annuitant
Check Number
63 4B3 092
GLORIA u HECK
0207 0521472
OCT 9. 1998
WE HOPE WE HAVE BEEN OF HELP TO YOU DURING THIS DIFFICULT TIME. THIS CHECK FOR $456.78 REPRESENTS THE
PROCEEOS FROM THE OEATH CLAIM ON CONTRACT 63 4a3 092.
SOURCE OF FUNOS
$456.7B
FACE AMOUNT OF INSURANCE
AMOUNT OF CHECK
$456.78
*...*... ....... '" ........"'......... .................... .......... **....... _.1It **...
,
IF THE OECEASEO WAS NAMED AS A BENEFICIARY ON ANY OTHER INSURANCE CONTRACTS, WE SUGGEST THAT A NEW
BENEFICIARY BE NAMED AS SOON AS POSSIBLE.
SOCIAL SECURITY BENEFITS MAY ALSO BE AVAILABLE.
GOVERNMENT OFFICE IN YOUR AREA.
FOR MORE INFORMATION, GET IN TOUCH WITH THE APPROPRIATE
IF WE CAN BE OF ANY AOOITIONAL SERVICE, PLEASE LET US KNOW.
REPRESENTATIVE OR THE OFfICE SHOWN ABOVE~
uUST GET IN TOUCH WITH YOUR PRUDENTIAL
,
~
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.
.
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(FK985TD51B)
(**S15HECK) PLEASE DETACH CHECK - KEEP STATEMENT FDR RECORDS
;.' '. ...', ...',..,:,:". ,;,;,~t~?~' . ~,7':""~~"~:,,": .....,..,..'::;~;:~.:.:..~":..':':.:".."...."~;~',,':'...:":;:";;:~:.....:'..:-;H.' 207 .05 2,1 ~7; ~';
...~..,. ..\~... .,;~..":.t~' '~'~The Prudential Insurence Company, of Amerlce:': ," ,,"*.\~,?.."4~\ ,.1 'l.'6'2 22 ,,~., I
:.ThePrlJ~E;t~JI~~..,-~~J:r~~:~;~t'c..,~9P~,r,~t"/~~:7'~~~~~_~~ :.' ,'.~- ~ ':.\ .: , ~oN:RAC~!.."",~l\:~~~?,~~ ,j~$',~OO 532391 ,~,', ~'\'~ . > ~.' ,
r' ., . ...~, "rp~'''~';f:(~.~_~~''t'~ - ...:1 Fort Washi~gton~~~A'V_9Q~~_ :~~~;~"'- " .: ;':' }:' ~':'~fs"'~<,\'~<~'~'-l>,t ~..'" : ~ ".' '~-~'~~ff~:~~~~~~~::;:~~:S'\(~;;:~
: ~f:~l~~;~;~t(~:J:~:t~t~~w~t~';~~~i~~~;~t ~:: ~c ~ * ~\~:~~~~~~~~y~Y:1;" ".: ''1\;\f';;~{,~~'}~~'~ ;.~.?;~,~':{;
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717~7G1-4317
November 10,1998
Mr. Samuel L. Andes
Attorney At Law
525 North Twelfth St.
Lemoyne, Pa. 17043
reo Gloria Heck
Dear Sam:
Your attention is invited to your letter of October
23, 1998 regardini the captioned patient and submitted
herewith is the requested information.,
Mrs. Heck was diagnosed SChizophrenic 25 years ago.
Holdol was prescribed,by her psychiatrist; this belongs
to a class of drugs that can cause a movement disorder
(Chorea) and, to avoid this, cogent in is Usually prescribed
concomitantly. Cogentinis not'used for any cardiac or cir-
cUlatory disqrder. .
During a routine'physical in 1993, an ERG disClosed a
bundle block. This is an inocuous electrical ~ondition of the
heart. Because of this an abnormality of the blood SUpply
to the heart cannot be diagnosed. Because of her many risk
factors of smoking and a Positive family history I suggested
a thallium stress test. As you. can see from the copies submitted
to you by Mr. HeCk, because Of her claustrophobia, the thallium
stress was considered non-diagnostic. She was not, to my know-
ledge, given a diagnosis of heart disease by Dr. Althouse nor
myself. , , .
Because of this discrepancy another,thallium stress was
recently repeated 'on June 18,1998. As you can see, there was
no evidence of ischemia(abnormal blood sup~ly)to the heart.
There was an area ofa remote heart attac which apparently was
silent i.e., as.ymptomatic.
Hoping this meets with your
"
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The patient exercised on the treadmill for 8 minutes achieving 10 METS : ::0.:'1 ..
~~~e~ peak heart rate of 160 beats' per minute, 'IS: of the target heart "I:':!K:~'?
The delayed resting Images are normal, When we reconstruct the
, I n It I a 1 stress SPECT I mages we see that tl)ere I s a s,ll ght degree of pat lent
motion durIng the InitIal' phase >"of"acqulsltlon which 15 probably
responsIble for the shape of the left ventricle, not quite rounded. But
there Is a clear cut anatomic ;:one of mIld hypoperfuslon Involving the
,~ lower lateral wall of the left ventricle, stretching 'from the base of the
::: heart almost to tile apex. DespIte the motion on the stress' Images this Is
:....., ,
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J' significance In this case.. The left ventricle does not look to be ..' '. ' .
! significantly dilated on the stress as compared to the resting Images and "'\:!7!I,~'~i::'
'~\),;.;: the perfus 10~ .:~f~~~~"~cthe l~~er l,:,~e~:l..w:Il,.I:~:~I,~tl::l~,mlld. ",_ " . ." :r;; ':")!t!W?f~
r~. : i" " CONCL~SION:, A1.:1~Oug'.~ >1-~e,~ J1<!ye;:~~o!n~ ~r.teft;Q!.'r<1h.~a!;,t 1.f:3ct,;,,9~nng ;the"str~ess!">;i" .:, :':i~.,(li;\;;;.;:~
.,i;:!' ; ; f"pqr;t! Orl;~Fz~~ne l"exa!'!.:;:~~h.l S;;;:;I,S:~':prol:?ab,ty;;^~ ~c,t,r::u~,i:po,sJ.t.i~e.~:,is tUdY~i'for. ml.l.dl:~~J ';';'!,ih4\~1''i
,;"f ';. ii, 11.~l=l)e.f!lJa.;;Jrl_;o<"l:lJe::, louer'::.1 ater:~l;:;:;,W<l.JJ&r..g,f:>'~~.ei::.) ~f.~;;,;'l:',e,0~r.l f.le ~>"Th~', on 1 y,1..,...: ,';S'\:/:1:;:~Wi
h"';~ :', f.erl~l.l,I,s.1 ~~,way/ ~f proy I ng.th Is;.' hOlJ~v.~r'.uou.l dbe, ,for;,t!'e,p~t! ent:to un.qer..9?;;'IJ; ~;;i;';)ll'ii)
r.', '.' ,.,' ' a);fepeat',stress'portlon'ofc'the 'exam,":.,The.-.restlng; Images :are, unquestlonably"j;...'::,,,,',,.;,'t:.\;
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HOLY SPIRIT HeSPITAL.
et.. .,KTMENT OF RAeIOLOGY ANe eIAGNO~. ,.;
CAMP HILL, PENNSYLVANIA 17011
(717) 763-2600
.IMAGING
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PATIENT: HECK, GLORIA J
MR: 318
SOC SEC: 188-32-3141 II J l '
ORe eR.: AGGARWAL, SHIV 11M I'\-lc.Jv
PT TYPE: W 109 01. . a
AeM eATE 01/21/1993 12:,SOPM
LOCATION CMHC 109 01
eICTATION eATE:' 01/29/1993 "":;->i
TRANSCRIPTION DATE 01/29/1993 06:3SPM,;:":~;
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HOSP"SERVICE:
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EXAMINATION: STRESS/REST MYOCARDIAL PERFUSION SCAN, SPECT IMAGING:
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COMMENTS: eose-.,.3.3mCI of Thallium 201 as Thallus ChlorIde.
....,.
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'.
eICTATEe BY:
eATE OF EXAM:
H. J, Bronfman, M.e./dlb
01/29/1993
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Associated
Cardiologists, P.C.
L. Bruce Althouse, M.D.. PACe
Donald C. Durbeck. M.D., PACC ,
Jeffrey S. Pugate, 0.0.. PACC
Stuart B. Pink, M.D., PACC
Kenneth J. May, Jr.. M.D., PACC
Robert A. Skotnlckl, 0.0.. PACC
Davld L. Scher, M.O.. PACP
Rlchard A. Cytryn, M.O.. PACC
March B, 1993
j
"
..;;,., George H. Harhigh, D.O.
::':~>~;"'. P.O. Box 245
.'<::.' 25 S. 35th street
:,:,.,~;,. Camp Hill" PA 17011
mfz;1j;:'::RE: Gloria Heck
~-:;::S'<:,,,.":-SS# 188 32 3141
;;::::,~.:"~ eOB: 8 - 8 - 40
';':"..;'.\.' Subject: Office Consultation
,'.'::::::;',:,.,: ex: Abnormal thallium stress test, complete left bundle branch block
.~U;~~F:~~>' .
......-.:,.'..:... eear George:
~:p~~:~~,~~S :'::',~ ' '. ' ~ .
.'D:',:....,;', '.'Gloria Heck is a 52 year old lady who I saw in my office on the 3rd of
. .~..:.. ",' . . . .
:~:~~:::March; 1993, She states'that she has been active and generally
:,'~;:.~";;':'asymptomatic. An electrocardiogram was recorded for a routine
::::::~~'''';:'-' physical; examination' recently and it showed an 'abnormality. ' Because
;'::::\~::;'.",(jf,this abnormality 'a thallium stress test was ordered'and it appeared
::,,';,:::~::.',:';. to show :an' area of ,ischemia which was interpreted iri the' lower lateral
:,.:.:,:~,.:"". .wall of the left ventricle , This was not considered a good thallium
. ~.;:'::' '-~ s.can because of some fear and anxiety during the scanning procedure.
:::,.. The images are not available for review at the present time. During
::f!~<.-. this test she exercised very well for 8 minutes of a standard Bruce
':.:;:.',;,.. protocol, achieving a maximum heart rate of 160. Because of the
'):~::';":'., complete left bundle branch block pattern on the electrocardiogram,
';~;";::".':',:: .there were no useful ST or T wave changes to screen for ischemia.
',:~i.~:;~~.i~:::'r:: '~ . ..
:;~;;:Y';;:;;';Her. past medic.al' history is significant for treatment of peptic ulcer
,\'~;:~\:;':disease,. She sees Les Lifton and the, last' EeG was performed six "
;:"::',;';' , months 'ago which appeared to be satiSfactory. , 'There has never been
';."".. . any major GI bleed. She, has been treated for schizophrenia during.the,
::.': ..' ,past 13 years.
..""... "~' -.
::.~:.::.::..: :..
:.~~j,,:~:,.., Past surgical history includes an appendectomy, in 1952 and T and A in
:;~:,,':'. '.. .1943.
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.
Family history is significant in' that her mother had coronary bypass
surgery at the age of 74: 'Additional risk factors 'include cigarette'
smoking'1111 p~ckage~ of ci~artittis for ~n ixcess cf 30years~' ,,"
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.' shi' has. no known'allergies. '
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'Present medications: Haldol 2 mg b.i.d. and 5 mg 1/3 dose, Cogentin 1
mg t.Ld.
.
856 Century Drive . Mechanlcsburg, Pennsylvania 17055 . Telephone: (717) 697-3304
4319 Londondeny Road . l1arrisbur~, Pennsylvania 17109 . Telephone: (717) 697-3304
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Page 2
. March 8, 1993
RE: Gloria Heck
..".,.... .
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Her weight was 126 pounds, blood pressure 100/70. HEENT revealed no
remarkable abnormalities. Examination of heart was felt to be normal.
. Pulses were full in all extremities.
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~,;' "" . [M:.i;:7:inip'fe ~.s}:9.~~Il s. th.~"t" .sh~,,: doe,s., .!lo~ ,. .pr.~ s ~n t:,s Y![1p,!:,?ms. ?r. P!:Y s}ca}", ;,)
;.;';,:i:,;, findings ;"suggest~ ve '.of,'ischemic,heart d~ sease, or' organ:l.c heart,"
,:::;;, .::td1's'e'a~s'e'~::-::::Th'ey::thal'lluin 'test I fe'el' wa'sU]:n'conclus'i ve 'a's"'performed';on~:;;'
'. ':.' itii.E;:'i9th~e:-Janua:rY7'".'1'993\"!, . . .'. , . , . ,
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.' :;;:;}7R~i;>: ;{[hIv;~i;:"~5ip;:-I!l~~~.~d::~Fat >, ::t.ha.lY,u~, .~x!",:;d s ': s t~e s ,st~ s t b~ rel'ea,ted,/"
.ir.._;;....,.",:,ana'cI-....am,,~~ques:tang:;.that.,it;, be.done'.,in our' office so that, .I:. have 'an.;"
........'....,'.~.l"".t""""...It.'._..- .. ..l..........._ -.' ..'~,..~~ ',.. - ~~.......~~.-~.r'. ''',~,. ..... .' . .. '_'.< ... ~,...
,:'S{;~r",<I()p,p,.?r.!;.ul).,:h1:X"';~..'?):.loo1<::.a t:..the ..,i.mage~ ,!'..:: .Tpe: complete.~'left "bundl'e "br.an:c:h:~; ,
":,!"~;;,,,'.,, J:jlock..does~predispose;.. to' its own .,set:.of 'artifacts"'in' the".thallium:;- .'
,:"::1j',::,:, t:racl"ng, 'and:'th'eeie must~'be'taken: frito"coriside.rationdurin~i"< ..,,'.. .--"
::~;;;.;:;: ::.: riiterimi.tati~on-;':"'I"hav:e~'also-'reqtiest~d:that.a"screening blood work, be'
:':\Y:::<:~:1 perforiiled':;anCl'::r";wil:J.":'make"both"'these':available~ to' you' when. they, are:::: f
',"~'r-!;."'("~"'l.. """"'''''~-'l''''''-''t''d'''-,",:....~f';"""".'" "., ,~" .'. '. " 4 ..;:., . ........ . .,~'_,_.. .'. .' .._".... ..,..~.~~;;..:
;:':~~:;',':&2.,e'l'~ e e .: '". , '. .
':;':Oi:F~,":': Than!c;:'y.o.u:ver:cmuchi" George, for the privilege 'of meeting Gloria and
. :,', " part'i'c'ipat'e~j:ri"this;'::evaltiation~"
.:". '. t..,,'.- ,'" ""l~:' '.';:''.:~:::.'':I.':~~-''::'' . -- '.
Sincerely,
,,'X ~ ~ /Jfot~
L. Bruce Althouse, M.e,
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;~~it.:t:,> April 15, 1993
;;';;,:/:,'}":',,:George H. Harhigh, D.O.
""".~""t".".. .
~~;~.:.~~~~~..;,:P.O. Box 245
.!,n'.t~.7f,'~:25' S 35th Street
.........-.,.. -" . .
5,::,:;:-;, : Camp Hill, PA 17011
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......"..,.. Dear er. Harhigh.
::.::~~;:'~'<~,~ .
;F;~::,:' 'Ibis patient performed a thallium stress test in our office on 4-13-93 to evaluate
.. functional capacity due to an abnormal EKG.
Associated
Cardiologists, P.C.
L. Bruce AIUlouse, M.D., fACe
Donald C. Durbeck. M.D.. fACC
Jeffrey S. fugate, 0.0.. fACC
Stuart B. Pink, M.D.. fACC
KenneUl J. May, Jr.. M.D.. fACC
RobertA. Skolnick!, 0.0.. fACC
David L, Scher, M.D.. fACP
RIchard A. Cytryn, M.D.. fACC.
.
~ -',,' t '. .
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,:<::',':,;'. The patient is presently taking no med:lcation.
..:;:;'.;,"" ,'A resting Electrocardiogram was performed and showed nonspecific ST-T changes, a
,..::co.:'}',:: lateral Q-wave, ~d nonspecific intraventricular conduction delay.
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::!.',:,'::.:,:' The exercise stress test was performed as follows:
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',C.':: '.,', Pre-test 72.- HR
t1~1',':- 7" H
,''<2- "~';~:". ~l:'
..,;""".' 2,'40" 1 2 5
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Speed
Inph
1
2
'on:
110/8Q...BR...,
Grade HR :YP COD1lnents
% !!!!!!. !!9: .'
.!Q. . 124 120/80
.,g 154
Iniected at j,'2l", heart ~ ~
HR B/P
128
101
. ,
Rare PVC
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The patient exercised, for 5 minutes, 40 seconds of a modified BrUce protocol,
achieving a peak heart rate of 154 beats, per minute, 92% of the maximum predicted
heart rate, a peak work load of 7 MET units and a peak double product of 18,480.
.',.', ",
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'Ibe onset' of ST segment changes occurred at 5 minutes 40 seconds of exercise.
Maximum ST segment depression was 2 nun and showed a down slope. The ST segment.
changes were considered to be ischemic. .
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856 CenluryDrive - Mechanlcsburg. Pennsylvania 17055 _ Telephone: (717) 697-3304
4319 Londonderry Road - Harrisburg, Pennsylvania 17109 _ Tclephonc: (717) 697-3304
'.
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~:);;::di.t,>'"
,,"'"," '.Page 2
'.';"~';April 15, 1993
" " ...,: RE: Gloria Heck
......
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"':':,~>;:;"',~'~-;;;': '<ili~;;;;;;;l exercise stress test by ERG but resting EKG abnonnalities.'
: ,? ':' j:PrEi#?:i.ide "diagnosis':.~
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L. Bruce Althouse, M.D., FACC
Donald C. Durbed.. M.D., FACe
Jeffrey S. Fugate, 0.0.. FACC
Stuart B. Pink. M.D., FACC
Kenneth J. May, Jr., M.D.. FACC. '
Robert A. Skolnick!, 0.0.. FACC
" David L, Scher, M.D., FACP
.' Richard A..C~; M.D.. FACC
.;. .'~.., .... .::' .:'~:': :.:-~;:~.
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Associated
Cardiologis.ts, ~!.C~
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April 15,
1993. ,
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George,'H. Harhigh; e.o:-',
P.'O; Box 245 ,.,., , ,
25'S. 35th Street
~~mp HiJ.l" PA ,17011
'.... .;.
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RE: Gloria 'Heck" ':..:.....
",.'. Stress Thallium '4-13-.93,"
~::!,,: eOB 8-08-40: '.', ,':::":':':':~: ,',,'
:::.' SSN'188,,32-',31'41 , " ,
:::,;: Monitorin9:.Physi'cian: ,Dr; ,'F\!-gate,.
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D~~r Dr. Harhigh:
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Stress and resting images of t;he' 'left ventricle' were"obtainedusing' a :'~::
SPECT. imaging ,technique. "The,' pa.tier:>t ex~rcised':,on' a: Bruce' protocol; >;':',":; .,: ':
stress, test' and' one 'minute :prior.:.to:,cessation' of 'exercise:, she,~ was..':.,' .::"~'.!. . ' ',,":,,:.'
injected with :3 '.04,:' m'iJ.licuries:",;f,;:Thal:liuni,; 20 h",:::Subs,equent' images':.;of~f'€ :...:,,:::.~;,;,
. : - '. ,. , . " ...' . .. , . ~". .... ,''''"'''' " ., '.'. ' "'. . "-, . - -' ~". . ""~' -. _ '. ',.~.. .
the...'left ventricle" obtained" re:vealed~'an:.:area' of;:,?ignifican tly::.'\:..,.::.:.;;:::'::,.;.:\.::~y. ; '.,-':'::.::.
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decreased radionucl~de uptake';' ~n" the.~:proximal~. one""half':of '. the-:.lateral:!':1;.....;'.,.: ..:':';
p~rtion of, the. anter,ior wa'n., I~.~dd~,tipn,the;.pro?'inI1Cil,.t,w.o:;-,third~ "o~0':';J>
the lateral wall, also re~ealed "a:s~gn~ficantly.:.decreased, rad~onucl.~.de::.~..::;, ' .' .'..,~:'
uptake,' ;'The,'distal :;one,:-half' :o.f::>1:,he,:',i.nferior':laterai:,walJ:"als'o:: was':'\:;;,~:l' ,.:::',~,;2
. . .. . . " . .~, ,,'.' .",-,' "...~.., ~''''.' .~'..\......,..'.. '., -....,.t.. . ','~""~_' ,.,...~.:.'.
remarkable",for decreased':rad~onucl'ide"uptake""" ,,:., ...... ...'.. "" . ',' '.,.:,::" ,......,.,.:.', .,",'~''''
:,:1.:; ,,' . . '.-.. .';' .:'~'- >::. ::,.: :~.: '..,...,~..."...::-- :". .:: \'~;~~':'< ~'~. :::. '.~< ''::.~'. . :."' '.....'. ::,.;.::>:~ .: ':,:: ~" :: ~," :-,. " " ..):~'::~'~' :~~~:.~::~~g".' ":~}:\~;~':
Pel'ayedimages perfo,rmed without r,einjection:' reyealed a signifi.cant,:.;.:;:~;' .:?'~:;",
a,lI\ount ,of washin; 'o.f ;the "la.teral' . wall: of the left: v!,!ntricle.' . ,The; :~7.i:t:,::.~i ',.'...~<!.
inferior segment :also:washe~,in quite"welL ,'There:'is' incomplete' ',~:: ';~l '..'.,',"J:::'
. ... . ... .". '-', ...... . ...... ...~.. . '. "_ I .'
washin' noted, of, the ,.highanterolateral' ,portion ;~:'. The: left ': ventricle::;~:~.1:~' ':,:.""':~:'
di'd dilate wi th',exercise,when', compared to. rest.. arid:. the "heart"to,:lung;;~:0~,." ,~~:,:-:;:.:~
t~~~~. w~s abno~,~~l3::;:i:.\:',fU~) ~ ':~,: i.,;';{:; V. ,,:qh ();:::} :;,r{,,:,>.; ; :,~:;;:.(:"U=,~5;~~::.}Jf.{~;~;::i~~*j
Co.nclusion:' . At':least' a: moderate "area:"",of:. significant . ischemia, 'notedc:'iIJ.~:':':/,;;:,;>
the distal. two-thirds',Of .the' inferolateraF waJ.J:: of:the.-left ventric'J.'e:~~".' :.';;:'::
The. proximal'on'e"haif'::of:~he::later'al: w~ll!::',i'l.'i.so';,revealed' si9:nif:i.'c.an:tN~;~?:~'';:::,:,~~:,:
i'schemia. 'There' was', evidence' of . a' high anterolateral ::wall infarct ':of:::;;, " .,::;.:.;.'
a' .;small 'size with: am'oderate' 'adj'';'centarea'''o':E ,ischemia:' . ".',. ' ',:::'..;;::,~:2" "':.:;S:~:
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05.20 06/19/9B FROM LE08.RRI
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PT NAME. HECK
PT LOC.
CLINIC VISI'1'.
RESULT ID.
PRIN'I' ImSUL'l'S
,GLORIA J
HOSP SIW. C'l'S
CARD 'fHAL
061898143027
1:1.096921
F AGE..~
MADAR VENKATESH I
06/11/9B
}'OR
HAD
SERVICES
P'f NO.
SEX.
A'11N ORl
ADM DA'I'l';.
----------------------------------------------------------------------------
SERVICE DESCRIPTION. SPECT HEART
ORDER NO. 1 OCCR NO. 1
COLLECTION D/T. 06/I8/9B
I2.2B
----------------------------------------------------------------------------
'.
COMMENTS. RADIONUCLIDE STRESS 3.13MCI OF THALLIUM 201 CHLORIDE.
1.1HCI OF THALLIUM 201 CHLORIDE.
R8S'1'
THE PERSANTINE STRESS ExAMINATION WAS PERFORMED. THE BAS8LINE HEART '
RATE ANe aLooe PRESSURE WERE HI ANO 124/80. THE PATIENT WAS AOHINISTEREe
35HG PERSAN'1'INE INTRAVENOUSLY. A'f "l'HALLIUM INJECTION. 'l'IlE IlEART RA'l'E. AND,.
BLOOD PRESSURE WERE 97 AND 155/91. .
. A PRIOR STUDY OF 1/29/93 IS AVAILABLE }'OR 'CORRELA'l'ION. "
PREVIOUSLY. INl:.EROL1\TJoJRAL LEl:Hf -'VEN'fRICULAR ISCHEMIA HAD BEEN ".'0
IeEN'l'IFIEe. 'fHE IN}'EROLA'l'ER.AL VEN'fR:[CLE NOW PERF-USES' NORHALLY AND TIlERE" 'I
NO SCINTIGRAPHIC EVIDENCE OF PHARHACOLOGIC STRESS INeUCED ISCHEMIA WITHIN:
THIS PORTION OF THE VENTRICLE. ON. THE CURRENT STUDY, THERE IS A FIXED'
PERFUSION DEFEC'l' \iI'1'HIN 'fHE AWfEROLA'nJRAL LE}"l' VENTRICLE A'l' 'l'HE CARDIAC ::.i_:
BASE WHICH APPEARS SLIGH'l'LY MORE PROHINEN'I', ON 'l'ODAY: s S'l'UDY WHEN, COMPAREe,
TO THE PRIOR EXAMINATION. RADIONUCLleE AXCTIVITY WITHIN THE REMAINeER;~F5
THE LEF'f VENTRICLE IS NORMAL AND 'I'm; L~J}"I' VEN'l'RICULAR SIZE DOES NO'1' CHANGE
BETWEEN THE STRESS AND THE REST STUDY. ._
CONCLUSION. . INFERci'LA'l'ERAL 1,E}"l':VEN~'R:[CULAR 'j:Scil'EMIA: HAS "REsor.VE'o ::'iiINCE""fHE'
f.!'lrioR~STUeY:',:6);'~.112:ii;l;,i:f;'''', 'l'mJRF. IS'NOW' FI' HOOr-;RFI'l'~: SIZED f.'J:Xf10 PERt;'USJ:OJoi"~'--'
em'ECT WITHIN 'l'HE, AN'fERor.A'fERAL I,E}"l' VEN'l'RICLE A '1' THf; CARDIAC BASE '.
, CONSISTEN'f ~ WI'l'H AN, .INf: FlRc'r~ il'HImj;;':Zfs 'NO' SCIWl'IGIU\!-'HIC;:.Ev;rDENCE.:'O}'\ii .'.,'"..:.:'X:.,.I
PHARMACOLOGIC' S'l'RESS INDUCED: ISCEHH'rA":ON,"l'OADY'! S"'S'l'UDY~"'.:~;'" ,'-'" .' .. .-
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This is to certify that the informatlor 're given is correctly copied from an origin-' ~rtificate of death duly filed 'with me as
Local Registrar. The original certificat... will be forwarded to the State Vital Record~ Jffice for permanent filing.
WARNING: It Is Illegal to duplicate this copy by photostat or photograph.
No.
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Local Registrar '
Fee for this certificate. $2.00
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Horace P. Bair
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ABELN LAW OFFICES
37 EAST POMFRET STREET
CARLISLE, PA 17013
(717) 245,2851
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Plaintiff
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY,
PENNSYLVANIA
ROBERT E. HECK,
V.
PRUDENCE INSURANCE CO.
OF AMERICA,
Defendant
NO. 99-142 CIVIL
O~R OF COURT
AND NOW, thiS~daYOf
,1999, the Court having
determined that Laura Lee Baker, Esquire is only a social member of the Cumberland County Bar
Association, her previous appointment as an arbitrator in the above-captioned action is vacated
and Michael Scherer, Esquire is appointed in her stead.
cc: Laura Lee Baker, Esquire
William Daniels, Esquire
Gregory B. Abeln, Esquire
Samuel 1. Andes, Esquire
Lisa A. Balestrini, Esquire
240 North Third Street
Harrisburg, PA 17101
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KIRKPATRICK & LOCKHART LLP
ATTORNEYS AT LAW
240 NORTH THIRD STREET
IIARRISRURG, PENNSYLVANIA 17101-1501
TELEPHONE, (717) 2]1.-4500
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ROBERT E. HECK
Plaintiff,
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
v.
CIVIL ACTION - LAW
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA,
NO. 99-142 CIVIL TERM
JURY TRIAL DEMANDED
Defendant.
PRAECIPE FOR WITHDRAWAL AND ENTRY OF APPEARANCE
TO THE CLERK:
Please withdraw my appearance as counsel of record for Defendant, The
Prudential Insurance Company of America, Inc., in the above-captioned matter.
Date:
r-2z..-9Q
Respectfully submitted,
U!~B~~t&lk-
Pa. Supreme Ct. No. 78479
Please enter my appearance as counsel of record for Defendant, The Prudential
Insurance Company of America, Inc., in the above-captioned matter.
Date:
7-~J-"
Respectfully submitted,
~~~
Christ pher R. Nestor
Pa. Supreme Ct. No. 82400
KIRKPATRICK & LOCKHART LLP
240 North Third Street
Harrisburg, PA 17101
(717) 231-4500
HA-81570.0L
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CERTIFICATE OF SERVICE
I hereby certify that, on September 'ZZ- , 1999, I served a true and correct
copy of the attached document on the following by U.S. Mail, postage-prepaid:
Samuel L. Andes, Esquire
525 North 12th Street
P.O. Box 168
Lemoyne, PA 17043
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Affi:y.r~CA. OATH
In The Court of Co~on Pleas of
Cumberland County, Pennsylvania
'.},
~o~q ,l Y:2 CX.J ~ \19-,
We do solemnly swear (or affirm)
United States
discharge the
that we will support, obey and defend
and the Constieution of t is Common-
duties of our offic ith fidelity.
~
the Constitution of the
wealth and that we will
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AWARD
We, the undersigned arbitrators, having been duly appointed and sworn
(or affirmed), make the following award:
(Note: If damages for delay are awarded, they shall be
separately stated.)
t>J~ ~d ~N\ ~~" ~---MQ }-~~~ ~~()
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1fl,.cA.~r t:1.~~
applicab'le. )
. Arbitrator, dissents.
Date of Hearing:
(I <<~Cf1:
(( ~r (0 (CJ:'Y
Date of Award:
NOTICE OF ENTRY OF AWARD
Now, the /0 day of NO~'"eI\A~V ' 19 a; , at ~f~, fa., the above
award was entered upon the docket and notice thIreof given bY-mail to the
parties or their attorneys.
Arbitrators' compensation to be
paid upon appeal:
$ ,::210 .H
By:
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Cumberland Counly, Pennsylvania
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To
Prothonotary
10 c0.Q.c
19 <1. C(
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Attorney for Plaintiff
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No.
Term, 19 _
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PRAECIPE
Filed
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KIRKPATRICK & LOCKHART LLP
Attorneys At Law
Payne Shoemaker Building
240 North Third Street
Harrisburg, Pennsylvania 17101-1507
717.231.4500
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Plaintiff,
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
ROBERT E. HECK
v.
CIVIL ACTION - LAW
THE PRUDENTIAL INSURANCE
COMPANY OF AMERICA,
NO. 99-142 CIVIL TERM
JURY TRIAL DEMANDED
Defendant.
PRAECIPE TO SATISFY JUDGMENT
TO THE PROTHONOTARY:
Please mark the judgment in this action against defendant The Prudential
Insurance Company of America satisfied upon payment of your costs only.
Date: B ~h ~2.00c>
g~,~
ue L. Ande
Attorney for Plaintiff
Supreme Court 10 17225
525 North 12th Street
Lemoyne, PA 17043
(717) 761-5361