Authorization to Disclose

1. Account Information (Leave Blank for New Applications)

2. Annuitant Information - Required

*Required Field

Name*:

Address*:

State:—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Phone Number*:
() - x

Work Phone Number:
() - x

E-Mail Address*:

Date of Birth*:
/ /

3. Secret Control Question - Required

To help PRCUA employees with validating your identity when you call us, we will ask you your selected secret control question and anticipate the answer you provide in the boxes following the selected secret control question. You may select one of the predefined questions or you may enter your own custom question in order to provide a higher level of security.
Please select only ONE secret control question.

What city were you born in?

When is your wedding anniversary? / /

What is your favorite sports team?

What is your favorite color?

I want to enter my own custom secret control question:

4. Authorized Third-Party Individuals - Optional

You can specify third-party individuals, such as a family member, spouse or personal financial advisor, who are authorized to receive information about your account and the transaction relating to your account.

Name 1:

Name 2:

Name 3:

Name 4:

You can also authorize your current PRCUA sales representative (deputy/agent). Allowing your current PRCUA sales representative (deputy/agent) with access to your account information and transaction history will provide them with information necessary to effectively provide you with future assistance.

I authorize the PRCUA sales representative below to have access to my annuity account information:

5. Signature

* Please verify you are a human:

Submit Application