Employee Statement - Prudential Financial

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Group Disability Ed. 6/2017 Page 1 of 6The Prudential Insurance Company of America Disability Management Services Box 13480, Philadelphia, PA 19176 Tel: 800-842-1718 Fax: 877-889-4885 *6920201**6920201* Education: Highest Grade CompletedEmployee Statement1 EmployerInformation2Employee Information Control NumberEmployer NameLocation/Division Branch NumberAddress 1 Social Security Number Last NameState Date Last Worked (MM DD YYYY) Address 2 Mobile/Cell Telephone Number Home Telephone Number Birth Date (MM DD YYYY) Male Female Unmarried Married Divorced Widowed Email Address Date Expected to Return to Work (MM DD YYYY) Yes No3JobInformation Occupation MediumUp to 25 lbs.

GL.2003.239 Ed. 6/2017 Page 3 of 6 7 Correspondence Preference *6920203* *6920203* Employee Social Security Number Other Income and Workers’ Compensation

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