Prudential Group Disability Insurance – Education and Employment History Form (GL.2009.009, Ed. 06/2017) Completed Form Examples and Samples

View a detailed example of a completed Prudential Group Disability Insurance – Education and Employment History Form (GL.2009.009, Ed. 06/2017). Our sample guides you on how to accurately fill out your education, work history, and job duties for your disability claim.
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Sample of a filled Prudential Group Disability Insurance – Education and Employment History Form (GL.2009.009, Ed. 06/2017)

Prudential Group Disability Insurance – Education and Employment History Form Example

How this form was filled:

This sample illustrates how to complete the Prudential Education and Employment History form for a group disability claim. The example is for a construction project manager with a recent back injury, detailing their education, certifications, and a 15-year employment history with specific job duties and physical demands.

Information used to fill out the document:

  • Claimant's Name: Sarah J. Miller
  • Social Security Number: 987-65-4321
  • Date of Birth: 05/20/1981
  • Date Became Disabled: 11/15/2025
  • Last Day Worked: 11/14/2025
  • High School: Central High School, Graduated 1999
  • College/University: State University, B.S. in Construction Management, Graduated 2003
  • Trade/Vocational/Other Training: OSHA 30-Hour Certification, 2010
  • Most Recent Employer: BuildRight Inc.
  • Most Recent Job Title: Construction Project Manager
  • Most Recent Employment Dates: 03/2018 to 11/2025
  • Most Recent Job Duties: Oversaw large-scale commercial construction projects, managed crews of 20+ workers, conducted daily site inspections, prepared project budgets and timelines, and reviewed technical drawings. Required frequent lifting/carrying of materials up to 50 lbs, extensive walking and standing on uneven terrain for 6-8 hours daily.
  • Previous Employer 1: Keystone Construction
  • Previous Job Title 1: Senior Site Supervisor
  • Previous Employment Dates 1: 06/2011 to 02/2018
  • Previous Job Duties 1: Supervised daily on-site construction activities, enforced safety protocols, operated light machinery, and coordinated subcontractor schedules. Involved significant physical activity including climbing ladders, bending, and kneeling.
  • Previous Employer 2: Apex Builders
  • Previous Job Title 2: Assistant Project Manager
  • Previous Employment Dates 2: 08/2005 to 05/2011
  • Previous Job Duties 2: Assisted the Project Manager with administrative tasks, prepared daily field reports, ordered materials, and communicated with clients. Less physically demanding but still required regular site visits.
  • Signature: Sarah J. Miller
  • Date Signed: 01/22/2026

What this filled form sample shows:

  • Provides a complete 15-year employment history as required by the form.
  • Includes detailed descriptions of job duties and physical demands for each position, which is critical for a disability claim.
  • Lists all relevant education and vocational certifications that contributed to the claimant's career.
  • Uses clear and current dates for employment, disability onset, and form submission, reflecting a realistic claim scenario.

Form specifications and details:

Form Name: Prudential Group Disability Insurance – Education and Employment History Form
Form Number: GL.2009.009, Ed. 06/2017
Use Case: Disability claim for a professional with a physically demanding job (Construction Project Manager).
Filing Entity: Prudential Financial, Inc.
Categories: disability forms, disability insurance forms, education forms, employment forms, group insurance forms, insurance forms, Prudential forms, Prudential insurance forms
Created: February 03, 2026 07:17 PM
Sample of a filled Prudential Group Disability Insurance – Education and Employment History Form (GL.2009.009, Ed. 06/2017)