Transcription of Employee Statement - Prudential Financial
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Employee Statement - Prudential Financial
Group Disability Ed. 6/2017 Page 1 of 6 The 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 EmployerInformation2 Employee 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 No3 JobInformation Occupation MediumUp to 25 lbs. frequentlyUp to 50 lbs. occasionally Heavy25 to 50 lbs. frequently50 to 100 lbs.
GL.2003.239 Ed. 6/2017 *6920205* Page 5 of 6 *6920205* For residents of all states and jurisdictions except Alabama, Arizona, Arkansas, California, the District of Columbia, Florida, Kentucky, Louisiana, Maine, Maryland, New Hampshire, New
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