The Prudential Insurance Company of America 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.

Check this box if you have completed or participated in college-level training.

Check this box if you have not completed or participated in any college-level training.

Check this box if you received a degree for the college training listed (for example, AAS, BA). Fill only if 'College Training — Yes' is 'Yes'.

Check this box if you did not receive a degree for the college training listed. Fill only if 'College Training — Yes' is 'Yes'.

Enter the type of college training or degree/program (for example AAS, BA, BS, Certificate) you pursued. Fill only if 'College Training — Yes' is 'Yes'.

Provide the name and location of the college, university, or school where you received the training. Fill only if 'College Training — Yes' is 'Yes'.

Enter the timeframe or dates when you attended this college training (for example the years or start and end dates). Fill only if 'College Training — Yes' is 'Yes'.

Indicate the number of academic years or total years of study you completed for this training. Fill only if 'College Training — Yes' is 'Yes'.

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

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

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

Enter which computer(s), smartphone(s), tablet(s) or eReader(s) you use and briefly describe what you use each device for (for example: email, texting, online banking, web search, social media). Fill only if 'Own/use computer, smartphone or tablet/iPad — Yes' is 'Yes'.

Enter the name(s) of any IT or computer-related certification(s) you hold (e.g., CompTIA A+, Microsoft Certified: Azure Administrator), optionally including the issuing organization and date obtained if space permits.

Enter the full web page address (URL) for any personal or professional website relevant to your computer skills or work (e.g., your portfolio, LinkedIn, or company page).

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

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

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

Check this box if you use or can perform internet searches (use search engines) for information or tasks.

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

Check this box if you have used or managed databases (creating, querying, or maintaining) at work and/or at home.

Check this box if you have experience with computer graphics (image editing, design, or related software) at work and/or at home.

Check this box if you have used any employer‑specific or proprietary software; list the software name(s) where requested on the form.

Check this box if you currently use or have previously used a computer at work.

Check this box if you have never used a computer at work.

Describe how you used a computer at work and list the programs, applications or tasks you performed (for example: word processing with Microsoft Word, data entry with Excel, email, internet research, graphics software, payroll system, etc.). Fill only if 'Do/did you use a computer at work? — Yes' is 'Yes'.

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

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

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

Enter the highest grade or level of school you completed (e.g., 12, 11, GED, some college).

Enter the date you graduated from the highest level of education listed.

Provide the name of your major, concentration, or primary course of study (for high school or equivalent).

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.

Enter the date when you obtained your GED if you are not a high school graduate. Fill only if 'Did you obtain your GED? — Yes' is 'Yes'.

Check this box if you are able to access the internet from your home.

Check this box if you are not able to access the internet from your home.

Check this box if you are able to navigate the internet (answer is Yes).

Check this box if you are not able to navigate the internet (answer is No).

Check this box if you used a state employment service or job center as a resource while looking for work.

Check this box if you used state vocational rehabilitation services to assist with your job search or job placement.

Check this box if you searched for jobs online or used internet search engines or job sites as part of your job-seeking efforts.

Check this box if you relied on friends for job leads, referrals, or information about employment opportunities.

Check this box if you used classified want ads (print or online) to find job openings.

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

Enter any other job‑seeking resources you used that are not listed (briefly name and describe each, e.g., local agencies, workshops, recruiters, personal contacts). Fill only if 'Other (explain)' is 'Yes'.

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

Describe the kinds of jobs or positions you are seeking, including job titles, industries, or roles (for example, 'administrative assistant', 'retail sales', or 'entry-level accounting').

List the types of responses you have received from employers (for example, 'no response', 'interview scheduled', 'rejection', or 'waiting list') and any brief details as needed.

Check this box if you have received any military services training to report on this form.

Check this box if you have not received any military services training to report on this form.

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

Provide the location where the military training took place (for example base name, city and state, or unit/facility). Fill only if 'Military Services Training: Yes' is 'Yes'.

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

Enter the duration of the training including units (for example, '6 weeks', '3 months', or '2 years'). Fill only if 'Military Services Training: Yes' is 'Yes'.

Describe how you applied the skills learned from this military training in your military or civilian work, including specific duties or examples. Fill only if 'Military Services Training: Yes' is 'Yes'.

List any other training, courses, certificates, licenses, special designations or professional development you have obtained through work or other avenues, including relevant details or dates as needed.

Describe what you have done to keep any certification or license active (for example: continuing education, renewal courses, professional memberships, or other maintenance activities).

Enter the full name of the prior employer for this job.

Enter the date you began employment with this employer.

Enter the date your employment with this employer ended (or write 'Present' if still employed).

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

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

Provide a brief explanation of why you left this job (for example: resignation, layoff, termination, end of contract).

Provide the employer's location details such as street address, city, state and ZIP or other contact/location information.

List the primary computers, tools, equipment or materials you used in the job (brief).

Provide additional details about specific software, models, tools or materials you used in the job.

Enter the number of employees you directly supervised in this role, or enter 0 if you supervised none.

Describe your job duties in detail, including any supervisory responsibilities and regular tasks performed.

List any certificate(s) or license(s) required to perform the job, or indicate 'None' if not applicable.

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

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 received for this position.

Provide the reason you left this job (for example: resigned, laid off, terminated).

Enter the employer's address or location details (street, city, state and ZIP or equivalent).

List computers, tools, equipment and/or materials used in the job (first line).

Continue listing any additional computers, tools, equipment and/or materials used in the job (second line).

Enter a brief supplemental note related to duties or supervisory details (short entry).

Describe your job duties in detail, including any supervisory responsibilities and examples of tasks performed.

List any certificate or license required to perform the job, including name, issuing authority or license number if applicable.

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

Provide the date when you started working for this employer.

Provide the date when your employment with this employer ended.

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

Enter the annual gross salary you earned in this position.

Describe the reason you left this job or ended your employment with this employer.

Provide the employer's address, phone number, or other contact information or additional employer details.

List any computers, tools, equipment or materials you used in this job (first line).

List any additional computers, tools, equipment or materials you used in this job (additional line).

Provide a brief summary of your primary job duties, including any supervisory responsibilities.

Describe your job duties in detail, including any supervisory responsibilities and specific tasks performed.

List any certificate or license required to perform the job, if applicable.

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

Enter the date when this employment began.

Enter the date when this employment ended (or leave blank if still employed).

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

Enter the annual gross salary you earned in this position.

Provide the reason you left (or expect to leave) this job.

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

List computers, tools, equipment and materials you used on the job (first line).

Continue listing any additional computers, tools, equipment or materials used in the job (second line).

Provide a short one-line summary of your main job duties or supervisory responsibilities.

Describe your job duties in detail, including any supervisory responsibilities and typical tasks performed.

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

Enter your first (given) name exactly as it appears on your employer or claim records.

Enter your middle initial (one letter) or leave blank if you have none.

Enter your last (family) name or surname exactly as it appears on your employer or claim records.

Enter your Prudential claim number as shown on your paperwork, including any letters or digits.

Enter the area code portion of your employee phone number (typically the first three digits).

Enter the central office (prefix) portion of your employee phone number (typically the next three digits).

Enter the final portion of your employee phone number (typically the last four digits).

Enter the area code portion of your mobile phone number (typically the first three digits).

Enter the central office (prefix) portion of your mobile phone number (typically the next three digits).

Enter the final portion of your mobile phone number (typically the last four digits).

Enter your primary email address that Prudential can use to contact you about your claim.

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

Provide the date when you began working for this employer (employment start date).

Provide the date when your employment with this employer ended, or indicate if you are still employed.

Enter the job title or position you held at your most recent employer.

Enter the gross annual salary you received for the position with this employer.

Provide the reason why your employment with this employer ended (for example: resignation, layoff, termination, etc.).

Enter the employer's full mailing address for your most recent employer, including street, city, state and ZIP code.

Enter any certificate or license (name, number, issuing authority or brief details) required to perform your job, or write 'None' if not applicable.

Check this box if you have been in contact with your employer regarding return to work.

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

Check this box if your employer is holding your job.

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

Provide the length of time your employer has said they will hold your job (for example '30 days', 'until return', or a specific date range) or explain the employer's policy if known. Fill only if 'Is your employer holding your job? - Yes' is 'Yes'.

Check this box if you have discussed any alternate jobs with your employer.

Check this box if you have not discussed any alternate jobs with your employer.

Provide the name and phone number of the person at your employer you have contacted about returning to work, including any job title or department if available. Fill only if 'Have you been in contact with your employer regarding return to work? - Yes' is 'Yes'.

Enter the names of computers, tools, machines, equipment, software or materials you used in this job (include make/model or specific software names when applicable).

Continue listing any additional equipment, tools, machines, software or materials used in the job that did not fit on the previous line.

Provide a short summary of your primary job duties and note any supervisory responsibilities or oversight.

Describe in detail your regular tasks, responsibilities, physical demands and any supervisory or managerial duties performed in the job.

Enter the name of the first prior employer (company or organization).

Enter the date when you began employment with this employer.

Enter the date when your employment with this employer ended.

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

Enter your annual gross salary from this employer.

Provide the reason you left this employer (for example: resignation, layoff, termination, or retirement).

Enter the employer's address or other identifying details (street address, city, state, ZIP, or any additional notes about this employer).

Enter the name or identification of any certificate, license, or credential that was required to perform this job (e.g., professional license name or certification title).

Enter a brief entry naming key computers, tools, equipment or materials you used in this job.

List additional computers, tools, equipment and/or materials used in the job with any relevant details or specifications.

Describe in detail the primary job duties you performed for this employer, including any supervisory responsibilities.

Continue describing job duties, tasks performed, frequency or examples of work not covered on the previous line.

Use this line to finish or add any remaining details about your job duties, special requirements or typical work activities.

Check this box if you currently use social media (for example Facebook, Twitter, etc.).

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

List the social media site(s) you use (for example, Facebook, Twitter, Instagram, LinkedIn); separate multiple platform names with 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 the number of words per minute you can type on a keyboard; provide a numeric value representing your typical typing speed. Fill only if 'Can you keyboard/type? — Yes' is 'Yes'.

Enter the type or title of the vocational training program or course you completed (for example, 'HVAC technician', 'welding', or 'medical assistant').

Enter the name of the school, business, or training institution where you received the vocational training.

Enter when the training took place, using a date or time period (for example, 'June 2018' or 'Summer 2019').

Enter the duration of the training program (for example, '6 weeks', '2 years', or '120 hours').

List any certificates or licenses you received from this training, including full names and any relevant credential or license numbers.

Check this box if the certification or license you obtained through vocational training has expired.

Check this box if the certification or license you obtained through vocational training has not expired.

If the certificate or license has an expiration date, enter the expiration month as a two-digit month (MM). Fill only if 'Certification/License Expired — Yes' is 'Yes'.

If the certificate or license has an expiration date, enter the expiration day as a two-digit day (DD). Fill only if 'Certification/License Expired — Yes' is 'Yes'.

If the certificate or license has an expiration date, enter the expiration year as a four-digit year (YYYY). Fill only if 'Certification/License Expired — Yes' is 'Yes'.