I agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my application conducted through this website, effective on the date I click "Submit".

I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s).

I understand that to obtain paper copies of electronic records kept by Prudential concerning my coverage(s), or to withdraw my consent to the usage of electronic records, I must contact Prudential through any of the means provided.

I understand that in the event my personal contact information changes, I must immediately notify Prudential of the changes through any of the means provided in the "Help" section of this website.

I understand that to access and conduct transactions relating to my coverage via any prudential.com Internet site, I must have access to a personal computer at my home or workplace which can support Internet access, and a compatible browser.

I represent that all statements and answers made within or attached to this Request Form are true and compliance to the best of my knowledge and belief. BY CHECKING THE BOX BELOW, YOU ACKNOWLEDGE THAT YOU AGREE TO THE ELECTRONIC DELIVERY OF THE AGREEMENT AND TO BE LEGALLY BOUND, WITH RESPECT TO THIS AGREEMENT, AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND-WRITTEN SIGNATURE. YOU MAY PRINT OR RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS.