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.
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. |
Created: February 03, 2026 07:17 PM
