Term Life Insurance Health Questionnaire

To increase your term life insurance, you may need to answer some health questions for Prudential Insurance Company.  You can obtain the appropriate Prudential Short Form Health Statement Questionnaire by following the link at the bottom of this Web page.  Please read these important instructions before completing the form: 

• Fill out ALL boxes on the questionnaire.  You may leave the “Apt.” field blank if you do not live in an apartment. 
• If you are completing the form in an effort to increase your term life insurance coverage, you are both the “Employee” and “Applicant.”  If you are completing the form in an effort to add dependent coverage, your dependent is the “Applicant.”  Except for the employee's name and Social Security number, all questions on the form relate to the applicant -- whether that be you or your dependent. 
• You must complete a separate form for each dependent you want to add to coverage.  
• If you are seeking to increase your own term life insurance coverage amount, please note the coverage level you want in the blank space in the upper right corner of the form, next to “PURDUE UNIVERSITY.”  For example, if you want to increase your term life insurance benefit to a level equal to three times your annual salary, please mark “3X” in the blank area. 
• If you want to calculate your cost for life insurance, you may use the term life calculator.  Note that the cost of your life insurance is based on your age as of July 1 of the plan year.  Dependent coverage is priced at a flat rate. 
• Although the health questionnaire form indicates that you should mail the form to Prudential, to speed up your request you should instead mail the completed form to Staff Benefits at one of these addresses: 
  • Connie Ratcliff, Staff Benefits, Freehafer Hall, 401 S. Grant Street, West Lafayette, IN 47907-2024
  • Connie Ratcliff, Staff Benefits, FREH 
• If you have questions about the health questionnaire form, please call 49-41686 for assistance. 

Go to the Prudential Short Form Health Statement Questionnaire.