Certain States have specific requirements that may change the coverage(s) you are insured for under the Prudential Group Contract. After providing your information and consent to receive information electronically, you may use this site to determine if a state specific requirement applies to you. You may then download or print this information if applicable.


If you do not wish to provide your information or consent for electronic delivery, please click the Contact Us link at the top right corner of this page to request information in paper form or for additional support.

All fields are required below.

Access Code

The Access Code can be found in the Foreword, Benefit Highlights or Notice of Change of your Group Insurance Certificate(s) or in your Outline of Coverage.

Date Picker

You can select dates in past up to today's date but not dates in the future.

Please read the terms and conditions of this Consent and acknowledge your agreement by clicking the "I AGREE" button below.

Consent to Electronic Delivery
I understand that I am required to provide my consent to electronic delivery each time I access this website to request information. If I do not want to provide electronic consent and/or if I want to request paper copies of electronic records maintained by Prudential concerning my coverage(s), I must contact Prudential through the phone number provided in the Contact UsOpens in a new modal or dialog section of this website.

Hardware and Software Requirements
I understand that to access and conduct transactions relating to my coverage via this website, I must have access to:
  • a personal computer at my home or workplace which is capable of supporting Internet access
  • a compatible up-to-date internet browser
  • an email account to receive communications as needed
  • software, such as Adobe Acrobat® Reader, that allows me to open communications accessible on this website sent in a Portable Document Format ("PDF"). Adobe Acrobat® Reader is available for download, free of charge, from the Adobe web site (www.adobe.com).

To retain a copy of a these certain state specific requirements which may change the coverage(s) I am insured for under the Prudential Group Contract, I may print copies of such requirements, save PDF files on my computer or mobile device, or email a copy to an address where I can print on paper or save it for my future reference.

Electronic Signature
I agree to the usage of electronic signatures and electronic records for this transaction pertaining to benefits conducted through this website, effective on the date I click the "I Agree" button. All electronic signatures and electronic initials will reflect the time and date they are applied in Eastern Time, regardless of the Time Zone in which you are located.

I understand that by clicking "I AGREE," I am signing this Consent electronically. My electronic signature is the legal equivalent of my handwritten signature and I will be legally bound by the terms and conditions of this Consent. I have read the terms and conditions of this Consent and agree to receive Communications electronically on this website.

You may print or save a copy of this agreementOpens in a new modal or dialog for your records.

      Print/SaveOpens in a new modal or dialog

Select Coverages

Please check the window in the same browser to view your document. This site uses pop-ups. You may have to temporarily allow pop-ups to see a PDF.