Document:

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PRUCO LIFE INSURANCE COMPANY,                  STRATEGIC PARTNERS(SM) FLEX ELITE
a Prudential Financial company                      VARIABLE ANNUITY APPLICATION
                                      Flexible Payment Variable Deferred Annuity

ANNUITY PAYMENTS AND TERMINATION VALUES PROVIDED BY THE CONTRACT ARE VARIABLE
AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT.

On these pages, I, you, and your refer to the contract owner. We, us, and our
refer to Pruco Life Insurance Company.

1 CONTRACT OWNER INFORMATION

Contract number (if any)
                         --------------------

[ ] Individual   [ ] Corporation   [ ] UGMA/UTMA   [ ] Other

TRUST: [ ] Grantor   [ ]   Revocable   [ ] Irrevocable

TRUST DATE (mo., day, yr.)
                           ----  ----  --------

If a corporation or trust is indicated above, please check the following as it
applies. If neither box is checked, we will provide annual tax reporting for the
increasing value of the contract.

[ ] Tax-exempt entity under Internal Revenue Code 501

[ ] Trust acting as agent for an individual under Internal Revenue Code 72(u)

Name of owner (first, middle initial, last name)

--------------------------------------------------------------------------------

Street                                                                   Apt.

----------------------------------------------------------------------   -------

City                                          State  ZIP code

-------------------------------------------   ----   ---------- ------

Social Security number/EIN   Date of birth (mo., day, year)   Telephone number

--------------------------   ----   ----   --------           ---- ---- --------

A. [ ] Female  B. [ ] U.S. citizen

   [ ] Male       [ ] Resident alien

   [ ] I am not a U.S. person (including resident alien). I am a citizen of

       --------------------------------------------------------------------
       Attach the applicable IRS Form W-8(BEN, ECI, EXP, IMY).

2 JOINT OWNER INFORMATION (if any) Do not complete if you are opening an IRA.

Unmarried persons who wish to own the contract jointly should consult with their
tax adviser.

Name of joint owner, if any (first, middle initial, last name)

--------------------------------------------------------------------------------

Street (Leave address blank if same as owner.)                           Apt.

----------------------------------------------------------------------   -------

City                                          State  ZIP code

-------------------------------------------   ----   ---------- ------

Social Security number/EIN   Date of birth (mo., day, year)   Telephone number

--------------------------   ----   ----   --------           ---- ---- --------

A. [ ] Female  B. [ ] U.S. citizen

   [ ] Male       [ ] Resident alien

   [ ] I am not a U.S. person (including resident alien). I am a citizen of

       --------------------------------------------------------------------

3 ANNUITANT INFORMATION Do not complete if you are opening an IRA.

This section must be completed only if the annuitant is not the owner or if the
owner is a trust or a corporation.

Name of annuitant (first, middle initial, last name)

--------------------------------------------------------------------------------

Street (Leave address blank if same as owner.)                           Apt.

----------------------------------------------------------------------   -------

                                                                     (continued)

Pruco Corporate Office:
Pruco Life Insurance Company, Phoenix, AZ 85014              0RD99723 Ed. 1/2004
ORD 99723                                       FlexElite Kit order no: ORD01163

                                  Page 1 of 7
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3 ANNUITANT INFORMATION (continued)

City                                          State  ZIP code

-------------------------------------------   ----   ---------- ------

Social Security number       Date of birth (mo., day, year)   Telephone number

--------------------------   ----   ----   --------           ---- ---- --------

A. [ ] Female  B. [ ] U.S. citizen

   [ ] Male       [ ] Resident alien

   [ ] I am not a U.S. person (including resident alien). I am a citizen of

       --------------------------------------------------------------------

4 CO-ANNUITANT INFORMATION (if any) Do not complete if you are opening an IRA or
if the contract will be owned by a corporation or trust.

Name of co-annuitant (first, middle initial, last name)

--------------------------------------------------------------------------------

Social Security number       Date of birth (mo., day, year)   Telephone number

--------------------------   ----   ----   --------           ---- ---- --------

A. [ ] Female  B. [ ] U.S. citizen

   [ ] Male       [ ] Resident alien

   [ ] I am not a U.S. person (including resident alien). I am a citizen of

       --------------------------------------------------------------------

5 BENEFICIARY INFORMATION Please add additional beneficiaries in section 15.

[X] PRIMARY CLASS

Name of beneficiary (first, middle initial, last name) If trust, include name of
trust and trustee's name.

--------------------------------------------------------------------------------

TRUST: [ ] Revocable   [ ] Irrevocable

Trust date (mo., day, yr.)
                           ----  ----  --------

Beneficiary's relationship to owner
                                    -------------------------------------

Social Security number
                       ------------------------------

CHECK ONLY ONE: [ ] Primary class [ ] Secondary class

Name of beneficiary (first, middle initial, last name) If trust, include name of
trust and trustee's name.

TRUST: [ ] Revocable [ ] Irrevocable

Trust date (mo., day, yr.)
                           ----  ----  --------

Beneficiary's relationship to owner
                                    -------------------------------------

Social Security number
                       ------------------------------

6 ELECTION OF BENEFITS

This section contains various options available under your annuity contract. You
can choose any of the following benefits: (1) a Death Benefit; (2) the Earnings
Appreciator Benefit; (3) the Guaranteed Minimum Income Benefit; and (4) the
Income Appreciator Benefit. Prior to electing any of these benefits, you should
review the prospectus for a complete explanation of the features and their
costs.

A. Check one of the following four death benefit options:

   [ ] Base Death Benefit

   [ ] Guaranteed Minimum Death Benefit (GMDB) with a Roll-Up option

   [ ] GMDB with an annual Step-Up option

   [ ] GMDB with a Roll-Up and an annual Step-Up option

   Indicate below if you want to elect the Earnings Appreciator supplemental
   death benefit. ONCE ELECTED IN ND, THIS BENEFIT CANNOT BE REVOKED.

   [ ] Yes, I would like to elect the Earnings Appreciator Benefit.

B. Check all that apply. ONCE ELECTED, THE GUARANTEED MINIMUM INCOME BENEFIT
   (GMIB) CANNOT BE REVOKED.

   [ ] Yes, I would like to elect the GMIB. THIS OPTION IS NOT AVAILABLE IN ND
       AND OR.

   [ ] Yes, I would like to elect the Income Appreciator Benefit.

ORD 99723                            Page 2 of 7                       Ed.1/2004
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7 TYPE OF PLAN AND SOURCE OF FUNDS (minimum of $10,000)

PLAN TYPE.

Check only one: [ ] Non-qualified [ ] Traditional IRA [ ] Roth IRA/Custodial
                [ ] Custodial account (PSI only)

SOURCE OF FUNDS. Check all that apply:

[ ] Total amount of the check(s) included with this
    application. (Make checks payable to Prudential.)  $     ,      ,      .
                                                        ----   ----   ----  ----

[ ] IRA Rollover                                       $     ,      ,      .
                                                        ----   ----   ----  ----

If Traditional IRA or Roth IRA new contribution(s) for the current and/or
previous year, complete the following:

$     ,          .        Year            $     ,          .       Year
 ----   --------   ----        --------    ----   --------   ----       --------

[ ] 1035 Exchange (non-qualified only),
    estimated amount:                                  $     ,      ,      .
                                                        ----   ----   ----  ----

[ ] IRA Transfer (qualified), estimated amount:        $     ,      ,      .
                                                        ----   ----   ----  ----

[ ] Direct Rollover (qualified), estimated amount:     $     ,      ,      .
                                                        ----   ----   ----  ----

[ ] Roth Conversion IRA, establishment date:*
                                                        ----   ----  --------
                                                        month  day   year

    * This is the date you originally converted from a traditional IRA to a Roth
      Conversion IRA. (If omitted, the current tax year will be used.) This is
      required for the IRA five-tax year, holding period requirement.

A CONVERSION FROM A TRADITIONAL IRA TO A ROTH CONVERSION IRA WILL RESULT IN A
TAXABLE EVENT WHICH WILL BE REPORTED TO THE INTERNAL REVENUE SERVICE.

8 PURCHASE PAYMENT ALLOCATION(S)

Please write in the percentage of your payment that you want to allocate to the
following options. The total must equal 100 percent. IF CHANGES ARE MADE TO THE
ALLOCATIONS LISTED BELOW, THE APPLICANT MUST INITIAL THE CHANGES.

<TABLE>
<CAPTION>
                                           OPTION                                                        OPTION
INTEREST RATE OPTIONS                      CODES     %    VARIABLE INVESTMENT OPTIONS (continued)        CODES     %
---------------------                      ------   ---   ---------------------------------------        ------   ---
<S>                                        <C>      <C>   <C>                                            <C>      <C>
1 Year Fixed-Rate Option                   1YRFXD         SP AIM Aggressive Growth Portfolio             AIMAG
Dollar Cost Averaging (DCA) 6 Month*       DCA6           SP AIM Core Equity Portfolio                   AIMCEP
Dollar Cost Averaging (DCA) 12 Month*      DCA12          SP Alliance Large Cap Growth Portfolio         LARCP
2 Year Market Value Adjustment Option**    2YRMVA         SP Technology Portfolio                        ALLTC
3 Year Market Value Adjustment Option**    3YRMVA         SP Balanced Asset Allocation Portfolio         BALAN
4 Year Market Value Adjustment Option**    4YRMVA         SP Conservative Asset Allocation Portfolio     CONSB
5 Year Market Value Adjustment Option**    5YRMVA         SP Davis Value Portfolio                       VALUE
6 Year Market Value Adjustment Option**    6YRMVA         SP Deutsche International Equity Portfolio     DEUEQ
7 Year Market Value Adjustment Option**    7YRMVA         SP Growth Asset Allocation Portfolio           GRWAL
8 Year Market Value Adjustment Option**    8YRMVA         SP INVESCO Small Company Growth Portfolio      VIFSG
9 Year Market Value Adjustment Option**    9YRMVA         SP Jennison International Growth Portfolio     JENIN
10 Year Market Value Adjustment Option**   10YMVA         SP Large Cap Value Portfolio                   LRCAP
VARIABLE INVESTMENT OPTIONS                               SP MFS Capital Opportunities Portfolio         MFSCO
Prudential Equity Portfolio                STOCK          SP Mid Cap Growth Portfolio                    MFSMC
Prudential Global Portfolio                GLEQ           SP PIMCO High Yield Portfolio                  HIHLD
Prudential Jennison Portfolio              GROWTH         SP PIMCO Total Return Portfolio                RETRN
Prudential Money Market Portfolio          MMKT           SP Prudential U.S. Emerging Growth Portfolio   EMRGW
Prudential Stock Index Portfolio           STIX           SP Goldman Sachs Small Cap Value Portfolio     SMDVL
Prudential Value Portfolio                 HIDV           SP Strategic Partners Focus Growth Portfolio   STRPR
SP Aggressive Growth Asset                                Janus Aspen Series Growth Portfolio-
Allocation Portfolio                       AGGGW          Service Shares                                 JANSR
                                                          TOTAL                                                   100%
</TABLE>

*THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $2,000.
**THE DOLLAR EQUIVALENT OF THE PERCENTAGE ALLOCATED MUST EQUAL AT LEAST $1,000.

                                   Page 3 of 7
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9 DOLLAR COST AVERAGING PROGRAM

If you elect to use more than one Dollar Cost Averaging option, you must also
complete a Request for Dollar Cost Averaging Enrollment or Change form (ORD
78275).

[ ] DOLLAR COST AVERAGING: I authorize Prudential to automatically transfer
    funds as indicated below.

    TRANSFER FROM: (You cannot transfer from the 1 Year Fixed-Rate Option or any
    of the Market Value Adjustment options.)

    *If you selected the DCA6 or DCA12 option in section 8, only complete the
    TRANSFER TO information.

    Option code:                  $     ,        ,        .      OR        %
                 ---------------   ----   ------   ------   ----    ------
    TRANSFER FREQUENCY: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly

    TRANSFER TO: (You cannot transfer to the DCA Interest Rate options or any of
    the Market Value Adjustment options.) The total of the two columns must
    equal 100 percent.

    OPTION CODE             PERCENT         OPTION CODE             PERCENT

                                  %                                       %
    ------------------      ------          ------------------      ------

                                  %                                       %
    ------------------      ------          ------------------      ------

                                  %                                       %
    ------------------      ------          ------------------      ------

10 AUTO-REBALANCING

[ ] AUTO-REBALANCING: I want to maintain my allocation percentages. Please have
my portfolio mix automatically adjusted as allocated in section 8 under my
variable investment options.

Adjust my portfolio: [ ] Annually [ ] Semiannually [ ] Quarterly [ ] Monthly

Please specify the start date if different than the
contract date:
                                                        ----   ----  --------
                                                        month  day   year

11 TELEPHONE TRANSFERS

We will accept your transfers and reallocations over the telephone. Please
indicate below if you wish to extend authority as follows.

[ ] I authorize Prudential to accept telephone transfers and reallocation
    instructions from my Registered Investment Adviser.

12 REPLACEMENT QUESTIONS AND DISCLOSURE STATEMENT

YOU MUST CHECK ONE OF THE FOLLOWING TWO CHECK BOXES.

[ ] I do have existing life insurance policies or annuity contracts. (FOR STATES
    THAT HAVE ADOPTED THE NEW NAIC REGULATIONS *: The Important Notice Regarding
    Replacement form (COMB 89216) must be completed even if your new annuity is
    not replacing an existing policy or contract.)

    * Note: See the state replacement highlighter for applicable states or the
      attached list of state product restrictions.

[ ] I do not have existing life insurance policies or annuity contracts.

WILL THE PROPOSED ANNUITY CONTRACT REPLACE ANY EXISTING INSURANCE POLICY(IES) OR
ANNUITY CONTRACT(S)?

[ ] Yes [ ] No (If "Yes," provide the following information for each policy or
               contract and attach all applicable Prudential disclosure and
               state replacement forms.)

Company name

--------------------------------------------------------------------------------

Policy or contract number   Year of issue (mo., day, year)

-------------------------   ----   ----  --------

Name of plan (if applicable)

----------------------------

FOR VIRGINIA ONLY:

X
 ------------------------------------------------          ----   ----  --------
 Contract owner's signature and date                       month  day   year

REPRESENTATIVE'S QUESTION

THIS QUESTION MUST BE COMPLETED BY THE REPRESENTATIVE.

Do you have, from any source, facts that any person named as the owner or joint
owner above is replacing or changing any current insurance or annuity in any
company?

[ ] Yes [ ] No (You must check "Yes" if the customer has responded "Yes" to the
            replacement question above. If "Yes," please provide details in
            section 15, ADDITIONAL REMARKS.)

FOR VIRGINIA ONLY:

X
 ------------------------------------------------          ----   ----  --------
 Representative's signature and date                       month  day   year

                                   Page 4 of 7
<PAGE>
13 SIGNATURE(S)

If applying for an IRA or Roth IRA, I acknowledge receiving an IRA disclosure
statement and understand that I will be given a financial disclosure statement
with the contract. I understand that tax deferral is provided by the IRA, and
acknowledge that I am purchasing this contract for its features other than tax
deferral, including the lifetime income payout option, the Death Benefit
protection, the ability to transfer among investment options without sales or
withdrawal charges, and other features as described in the prospectus.

No representative has the authority to make or change a contract or waive any of
the contract rights.

I understand that if I have purchased another non-qualified annuity from
Prudential or an affiliated company this calendar year that they will be
considered as one contract for tax purposes.

I believe that this contract meets my needs and financial objectives.
Furthermore, I (1) understand that any amount of purchase payments allocated to
a variable investment option will reflect the investment experience of that
option and, therefore, annuity payments and surrender values may vary and are
not guaranteed as to a fixed dollar amount, and (2) acknowledge receipt of the
current prospectus for this contract and the variable investment options.

[ ] If this contract has a joint owner, please check this box to authorize
    Prudential to act on the instruction(s) of either the owner or joint owner
    with regard to transactions under the contract.

[ ] If this application is being signed at the time the contract is delivered, I
    acknowledge receipt of the contract.

[ ] Check here to request a Statement of Additional Information.

MINIMUM DISTRIBUTION UNDER AN IRA: IF YOU HAVE NOT MET THE REQUIRED MINIMUM
DISTRIBUTION FOR THE YEAR IN WHICH THE FUNDS ARE PAID TO PRUDENTIAL:

I understand it is my responsibility to remove the minimum distribution from the
purchase payment PRIOR TO sending money to Prudential with this application.
Unless we are notified otherwise, Prudential will assume that the owner has
satisfied their required minimum distributions from other IRA funds.

By signing this form, the trustee(s)/officer(s) hereby represents that the
trustee(s)/officer(s) possess(es) the authority, on behalf of the non-natural
person, to purchase the annuity contract and to exercise all rights of ownership
and control over the contract, including the right to make purchase payments to
the contract.

We must have both the owner's and annuitant's signatures even if this contract
is owned by a trust, corporation, or other entity. If the annuitant is a minor,
please provide the signature of a legal guardian or custodian.

THOSE AMOUNTS ALLOCATED TO ANY MVA OPTION WILL BE SUBJECT TO A MARKET VALUE
ADJUSTMENT IF WITHDRAWN OR TRANSFERRED AT ANY TIME OTHER THAN DURING THE 30-DAY
PERIOD FOLLOWING THE INTEREST CELL'S MATURITY. A MARKET VALUE ADJUSTMENT CAN BE
A POSITIVE OR NEGATIVE ADJUSTMENT. THERE IS NO MARKET VALUE ADJUSTMENT AT DEATH.

I hereby represent that my answers to the questions on this application are
correct and true to the best of my knowledge and belief. I have read the
applicable fraud warning for my state listed in section 17. ALL PAYMENTS AND
VALUES PROVIDED BY THE CONTRACT WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE
VARIABLE ACCOUNT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. I
acknowledge receipt of current product and fund prospectuses.

 ------------------------------------------------------
 SIGNED AT (CITY, STATE)

X
 ------------------------------------------------------    ----   ----  --------
 Contract owner's signature and date                       month  day   year

X
 ------------------------------------------------------    ----   ----  --------
 Joint owner's signature (if applicable) and date          month  day   year

X
 ------------------------------------------------------    ----   ----  --------
 Annuitant's signature (if applicable) and date            month  day   year

X
 ------------------------------------------------------    ----   ----  --------
 Co-annuitant's signature (if applicable) and date         month  day   year

OWNER'S TAX CERTIFICATION

Under penalty of perjury, I certify that the taxpayer identification number
(TIN) I have listed on this form is my correct TIN. I further certify that the
citizenship/residency status I have listed on this form is my correct
citizenship/residency status. I [ ] HAVE [ ] HAVE NOT (check one) been notified
by the Internal Revenue Service that I am subject to backup withholding due to
underreporting of interest or dividends.

X
 ------------------------------------------------------    ----   ----  --------
 Contract owner's signature and date                       month  day   year

                                   Page 5 of 7
<PAGE>
14 REPRESENTATIVE'S SIGNATURE(S)

This application is submitted in the belief that the purchase of this contract
is appropriate for the applicant based on the information provided and as
reviewed with the applicant. Reasonable inquiry has been made of the owner
concerning the owner's overall financial situation, needs, and investment
objectives.

The representative hereby certifies that all information contained in this
application is true to the best of his or her knowledge.

 ---------------------------------------------------    ---------------------
 Representative's name (Please print)                   Rep's contract/FA number

X
 ---------------------------------------------------    ----   ----  --------
 Representative's signature and date                    month  day   year

 ---------------------------------------------------    ---------------------
 Second representative's name (Please print)            Rep's contract/FA number

X
 ---------------------------------------------------    ----   ----  --------
 Second representative's signature and date             month  day   year

----------------------------------------------------
Branch/field office name and code

----- ----- --------
Representative's telephone number

15 ADDITIONAL REMARKS

ANY REMARKS ENTERED INTO THIS SECTION MUST BE INITIALED AND DATED BY ALL PERSONS
WHO HAVE SIGNED THIS APPLICATION IN SECTIONS 13 AND 14.

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                                   Page 6 of 7
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17 FRAUD WARNINGS

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policy holder or claimant for the purpose of defrauding or
attempting to defraud the policy holder or claimant with regard to a settlement
or award payable from insurance proceeds shall be reported to the Colorado
Division of Insurance within the Department of Regulatory Agencies.

CONNECTICUT: Any person who knowingly gives false or deceptive information when
completing this form for the purpose of defrauding the company may be guilty of
insurance fraud. This is to be determined by a court of competent jurisdiction.

NEW JERSEY: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.

NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to civil fines
and criminal penalties.

OKLAHOMA: WARNING -- Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an insurance
policy containing any false, incomplete or misleading information is guilty of a
felony.

PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim
containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.

VIRGINIA: Any person who, with the intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.

ALL OTHER STATES: Any person who knowingly gives false or deceptive information
when completing this form for the purpose of defrauding the company may be
guilty of insurance fraud.

STANDARD PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: PO BOX 7590
         PHILADELPHIA, PA 19101

OVERNIGHT PRUDENTIAL ANNUITY SERVICE CENTER
MAIL TO: 2101 WELSH ROAD
         DRESHER, PA 19025

If you have any questions, please call the Prudential Annuity Service Center at
(888) 778-2888, Monday through Friday between 8:00 a.m. and 8:00 p.m. Eastern
time.

                                   Page 7 of 7<PAGE>

(PRUDENTIAL FINANCIAL LOGO)
                                            PRUCO LIFE INSURANCE COMPANY
                                            2999 North 44th Street, Suite 250
                                            Phoenix, Arizona 85014

                                            a stock Prudential Financial company

            GUARANTEED MINIMUM INCOME BENEFIT ENDORSEMENT SUPPLEMENT

EFFECTIVE DATE OF THE GUARANTEED MINIMUM INCOME BENEFIT ENDORSEMENT: [The
Contract Date, or, if later, the date the Guaranteed Minimum Income Benefit is
elected.]

MAXIMUM ISSUE AGE: The GMIB benefit is not available if the Annuitant is [age 76
or more on the Effective Date of the GMIB Endorsement.]

INITIAL GMIB PROTECTED VALUE: [If the Guaranteed Minimum Income Benefit is
elected on the Contract Date, the Initial GMIB Protected Value is the initial
Invested Purchase Payment, or the Contract Value on the date of any reset. If
the Guaranteed Minimum Income Benefit is elected after the Contract Date, the
Initial GMIB Protected Value is the Contract Value on the date the benefit is
elected or the date of any reset.]

GMIB WAITING PERIOD: [7 years, beginning on the Effective Date of the GMIB
Endorsement, or the date of the most recent reset, if any.]

GMIB ROLL-UP PERCENTAGE:  [5.0%]

GMIB ROLL-UP CAP PERCENTAGE:  [200.0%]

GMIB ROLL-UP CUT-OFF DATE:  [The latest of:
      (a) the Contract Anniversary coinciding with or next following the
          Annuitant's 80th birthday;
      (b) 7 years from the Effective Date of the GMIB Endorsement; and
      (c) 7 years from the date of the most recent reset.].

GMIB DOLLAR-FOR-DOLLAR LIMIT PERCENTAGE:  [5.0%]

RESETS:
      [ ] Resets are available.
            Number of Times the GMIB Protected Value can be Reset: [2]
            Number of Times the GMIB Protected Value can be Reset Without Being
            Subject to a Possible Adjustment in the GMIB Charge: [2]
            Reset Age Limit: No resets are permitted on or after the Annuitant's
            [76th] birthday.

      [ ] Resets are not available.

MAXIMUM ANNUAL GMIB CHARGE:  1.00% of the average GMIB Protected Value.

MAXIMUM GMIB PROTECTED VALUE PER LIFE:
      [ ] Not applicable.
      [ ] Applicable. The Maximum GMIB Protected Value per Life is [$5 million].

GMIB BENEFIT EXERCISE LIMIT: [The Contract Anniversary coinciding with or next
following the Annuitant's 95th birthday, or earlier, if required by applicable
law.]

TERMINATION:
      [ ] You may not elect to terminate this Endorsement.
      [ ] You can terminate this Endorsement at any time.
      [ ] You can terminate this Endorsement [any time after the end of the GMIB
          Waiting Period.]

ORD 112963 SUPP

                                        1

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