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

Check this box if you would like Prudential to provide assistance in locating suitable employment.

Check this box if you do not want assistance in locating suitable employment.

Enter the claimant's first name as it appears on official records.

Enter the claimant's middle initial (single letter), if applicable.

Enter the claimant's last name or family/surname as it appears on official records.

Enter the insurance claim number assigned to the claimant exactly as it appears on communications or paperwork.

Enter the 3-digit area code for the claimant's employee phone number.

Enter the next three digits (prefix) of the claimant's employee phone number.

Enter the final four digits of the claimant's employee phone number.

Enter the 3-digit area code for the claimant's mobile phone number.

Enter the next three digits (prefix) of the claimant's mobile phone number.

Enter the final four digits of the claimant's mobile phone number.

Enter the claimant's email address where they can be contacted about this claim.

Check this box if you do own or use a computer, smart phone, tablet, iPad or similar device.

Check this box if you do not own or use a computer, smart phone, tablet, iPad or similar device.

Describe which device(s) you use (computer, smartphone, tablet/iPad/Kindle) and the activities you use them for (for example: email, texting, online banking, web search, social media, reading, shopping, etc.). Fill only if 'Do you own/use a computer, smart phone or tablet/iPad? - Yes' is 'Yes'.

Check this box if you have used Microsoft Word at work and/or home.

Check this box if you have used Microsoft Excel at work and/or home.

Check this box if you have used Microsoft PowerPoint at work and/or home.

Check this box if you use internet search functions (e.g., web search engines) at work and/or home.

Check this box if you use e-mail at work and/or home.

Check this box if you have used database management software or performed database management tasks at work and/or home.

Check this box if you have created or worked with computer graphics or graphics software at work and/or home.

Check this box if you have used any employer-provided proprietary software at your current or past employers.

Check this box if you currently use or previously used a computer at your workplace (answer 'Yes').

Check this box if you have never used a computer at your workplace (answer 'No').

Describe how you used a computer while working and list the programs, applications or tasks you used (for example: word processing, spreadsheets, email, database software, specific program names, graphics, internet searches, etc.). Fill only if 'Do/did you use a computer at work? — Yes' is 'Yes'.

Enter the two-digit month when the claimant signed the form (e.g., 01 for January).

Enter the two-digit day of the month when the claimant signed the form (e.g., 05).

Enter the four-digit year when the claimant signed the form (e.g., 2026).

Check this box if you have received any college or other post‑secondary training.

Check this box if you have not received any college or other post‑secondary training.

Check this box if your college or post‑secondary training resulted in a formal degree (for example AAS, BA).

Check this box if your college or post‑secondary training did not result in a formal degree.

Enter the type or program name of your college training (for example: AAS, BA, BS, certificate). Fill only if 'College Training — Yes', 'Degree — Yes' is 'Yes' (all).

Enter the name and location of the college or institution where you received this training. Fill only if 'College Training — Yes' is 'Yes'.

Provide the date or dates when you attended or completed this college training. Fill only if 'College Training — Yes' is 'Yes'.

Enter the number of years you completed toward this college program. Fill only if 'College Training — Yes' is 'Yes'.

List your major(s), minor(s), or area(s) of concentration for this college training. Fill only if 'College Training — Yes' is 'Yes'.

Enter the highest grade level or educational level you completed (for example: 12, 11, or High School).

Enter the date you graduated from the education level shown.

Provide the name of your course, major, or primary field of study for the education listed (for example: Business Administration, Biology).

Check this box if you are not a high school graduate and you did obtain a GED.

Check this box if you are not a high school graduate and you did not obtain a GED.

If you obtained a GED, enter the date the GED was awarded. Fill only if 'If not a high school graduate, did you obtain your GED? — Yes' is 'Yes'.

Describe the steps you have taken to maintain or renew your certification or license (for example: continuing education courses, renewals, supervised practice, training programs, dates, hours, and issuing organizations).

Check this box if you have received military services training.

Check this box if you have not received military services training.

Enter the type or classification of the military training (for example, Basic Training, Technical School, MOS/AFSC, or course name). Fill only if 'Military Services Training: Yes' is 'Yes'.

Provide the location, base, installation, unit, or facility where the military training took place. Fill only if 'Military Services Training: Yes' is 'Yes'.

Enter the date or date range when the military training occurred. Fill only if 'Military Services Training: Yes' is 'Yes'.

Specify the duration of the training (for example, number of days, weeks, months, or total hours). Fill only if 'Military Services Training: Yes' is 'Yes'.

Describe how you applied or used the skills gained from the military training in your military duties or civilian work. Fill only if 'Military Services Training: Yes' is 'Yes'.

Enter the name and brief details of another training program, certificate, license or special designation you obtained (include institution/issuer and date or year if known).

Enter the name and brief details of an additional training program, certificate, license or special designation you obtained (include institution/issuer and date or year if known).

Enter the name and brief details of another training program, certificate, license or special designation you obtained (include institution/issuer and date or year if known).

Enter the type or name of the vocational training program or course (for example, welding, medical assisting, HVAC).

Provide the name and location of the school, training center, or employer where you received this vocational training.

Enter the date or year when the training took place or was completed.

Provide the total duration of the training (for example, in years, months, or hours).

List any certificates or licenses you received from this training, using the exact title of each credential.

Check this box if the listed vocational certificate or license HAS expired.

Check this box if the listed vocational certificate or license has NOT expired.

Enter the expiration month of the certificate or license using two digits (MM). Fill only if 'Has this certification or license expired? — Yes' is 'Yes'.

Enter the expiration day of the certificate or license using two digits (DD). Fill only if 'Has this certification or license expired? — Yes' is 'Yes'.

Enter the expiration year of the certificate or license using four digits (YYYY). Fill only if 'Has this certification or license expired? — Yes' is 'Yes'.

Check this box if the claimant is able to navigate and use the internet (e.g., browse, search, use websites) themselves.

Check this box if the claimant is not able to navigate or use the internet themselves.

Check this box if the claimant has access to and can use the internet from their home/residence.

Check this box if the claimant does not have access to or cannot use the internet at their home/residence.

Enter the name(s) of any IT certifications you hold (e.g., CompTIA A+, Cisco CCNA, Microsoft Certified: Azure Fundamentals); list multiple certifications separated by commas.

Enter how long you have been actively searching for a job (for example, '3 months', '6 weeks', or 'since January 2025').

Describe the kinds of jobs or positions you are looking for, including job titles, industries, or levels (for example, 'administrative assistant', 'entry-level accounting', or 'software developer').

List the type(s) of responses you have received from employers so far, such as interviews, phone screenings, rejection notices, offers, or no response.

Check this box if you used your state employment office or one-stop career center as a resource while looking for work.

Check this box if you used state vocational rehabilitation services to assist in your job search or return-to-work efforts.

Check this box if you searched for jobs online (job boards, company websites, or other internet resources) as part of your job-seeking.

Check this box if you relied on friends, acquaintances, or personal contacts to help find job leads or employment opportunities.

Check this box if you used printed want ads or classified advertisements (newspapers, flyers, etc.) to look for job openings.

Check this box if you used a job-seeking resource not listed above and provide a brief explanation of that resource in the space provided.

Enter any other job‑seeking resource(s) you used that are not listed (for example, local agencies, websites, personal contacts), briefly describing each resource or method. Fill only if 'Other (explain)' is 'Yes'.

Enter the full name of your most recent employer as listed on company records.

Enter the date you began working for this employer.

Enter the date your employment with this employer ended, or indicate that you are still employed if applicable.

Provide the job title or position you held at this employer.

Provide your annual gross (pre-tax) salary from this employer as a numeric amount.

Briefly state the reason you left this employer (for example: resignation, layoff, termination, or other).

Enter the employer's business address or main work location, including street, city, state and ZIP as applicable.

Enter a concise summary of your primary job duties at your most recent employer, including any supervisory responsibilities.

Provide a detailed description of your job duties including specific tasks performed, equipment or tools used, frequency or percentage of time spent on tasks, and any supervisory or managerial responsibilities.

Enter the name(s) of any certificate(s) or license(s) required to perform the job (for example: professional license or certification and issuing authority).

Check this box if you have been in contact with your employer about returning to work.

Check this box if you have not been in contact with your employer about returning to work.

Check this box if your employer is holding your job for you.

Check this box if your employer is not holding your job for you.

Enter how long your employer will hold your job while you are absent (for example: the length of time, expiry date, or other details your employer provided). Fill only if 'Is your employer holding your job? - Yes' is 'Yes'.

Check this box if you have discussed alternate or modified job duties or positions with your employer.

Check this box if you have not discussed alternate or modified job duties or positions with your employer.

Provide the name and phone number of the person at your most recent employer who you contacted (or should be contacted) about returning to work. Fill only if 'Have you been in contact with your employer regarding return to work? - Yes' is 'Yes'.

Enter the primary computers, tools, equipment or materials you used in this job (e.g., software, machinery, instruments), listing items separated by commas.

Provide any additional computers, tools, equipment or materials used in this job that did not fit on the first line, listing items separated by commas.

Enter the full name of the prior employer.

Enter the date you began working for this employer.

Enter the date you stopped working for this employer.

Enter the job title you held at this employer.

Provide the annual gross salary you earned in this position.

State the reason you left this position.

Provide the employer's full mailing address, including street, city, state and ZIP code.

List the computers, tools, equipment and materials you used to perform this job.

Provide any additional computers, tools, equipment or materials used in the job as a continuation of the previous field.

Enter a concise summary of the primary duties you performed in this prior job, including any supervisory responsibilities.

Provide a detailed description of all job responsibilities, tasks, typical daily activities, and any supervisory or managerial duties performed in this role.

Enter the name (and, if applicable, the issuing authority or license number) of any certificate or license that was required to perform this prior job.

Enter the full name of the employer for this prior employment entry.

Enter the start date when you began working for this employer.

Enter the end date when you stopped working for this employer (or indicate if still employed).

Enter the job title you held at this employer.

Enter the annual gross salary you received for this position.

Provide the reason you left this position (for example: resignation, layoff, termination, end of contract).

Enter the employer's address (street, city, state and ZIP) or other location details for this job.

List computers, tools, equipment or materials you used on the job (first line/short entry).

Provide additional details or a longer list of computers, tools, equipment or materials used in the job.

Provide a brief one-line summary of your primary job duties or responsibilities.

Describe your job duties in detail, including any supervisory responsibilities or specifics of daily tasks.

Enter any certificate or license that was required to perform this job (name and license number if applicable).

Enter the full name of the employer for this (third) prior employment entry.

Enter the date when you started working for this employer.

Enter the date when your employment with this employer ended or indicate if it is ongoing.

Provide the job title or position you held at this employer.

Enter the annual gross salary you received from this job as a numeric amount.

State the reason you left (or expect to leave) this position in a short phrase.

Provide the employer's mailing address or any additional employment details that do not fit in other fields.

List any computers, software, tools, equipment or materials you used to perform this job.

Enter any additional computers, tools, equipment or materials used in the job that did not fit on the previous line.

Provide a brief summary of your primary duties and responsibilities in this role.

Describe your job duties in detail, including any supervisory responsibilities and the scope of your work.

List any certificates or licenses required to perform this job, including identifying details if applicable.

Enter the name of the employer for this prior job.

Enter the start date of employment for this job.

Enter the end date of employment for this job.

Enter the job title or position you held at this employer.

Enter the annual gross salary you earned in this position.

Briefly state the reason you left this job.

Provide the employer's address or other identifying location details for this job.

List computers, tools, equipment, or materials you used performing this job.

Continue listing any additional computers, tools, equipment, or materials used in this job.

Describe the primary job duties you performed, including any supervisory responsibilities (first line).

Continue the detailed description of job duties and any supervisory requirements for this position.

List any certificates or licenses that were required to perform this job.

Enter the full name of the first prior employer or company where you worked.

Provide the date when your employment with this employer began.

Provide the date when your employment with this employer ended.

Enter the job title or position you held with this employer.

Enter your annual gross salary for this position as reported while employed there.

State the reason you left the job (for example: resigned, laid off, terminated, retirement, etc.).

Enter the employer's mailing address including street, city, state and ZIP code.

Provide a detailed description of the job duties you performed for the first prior employer listed, including any supervisory responsibilities, typical tasks, tools or equipment used, and how often you performed them.

Continue the detailed description of your job duties for the first prior employer if needed, adding any additional tasks, responsibilities, equipment, or examples that clarify the work you did.

Enter the name or description of any certificate, license or professional credential required to perform the job for the first prior employer listed.

Enter the name(s) of computers, tools, equipment, or materials you used in the first employer listed, using this first line for the initial items.

Enter any additional computers, tools, equipment, or materials used in the job for the first employer on this second line.

Check this box if you currently use social media (for example Facebook, Twitter, Instagram or similar platforms).

Check this box if you do not use any social media platforms.

Enter the names of the social media site(s) you use (for example: Facebook, Twitter, Instagram, LinkedIn), separated by commas. Fill only if 'Do you use social media? — Yes' is 'Yes'.

Check this box if you can keyboard/type (i.e., you are able to use a keyboard to enter text).

Check this box if you cannot keyboard/type (i.e., you are not able to use a keyboard to enter text).

Enter how many words per minute you can type if you can keyboard/type; leave blank if you do not keyboard/type. Fill only if 'Can you keyboard/type? — Yes' is 'Yes'.

Enter the full web page address (URL) for the relevant site where your work or profile can be found, including protocol (e.g., https://) if applicable.