Exhibit 26(e)(3)
POLICY CHANGE APPLICATION PART 3 (UNDERWRITING)
AGREEMENTS AND AUTHORIZATION
INDIVIDUAL LIFE INSURANCE
MINNESOTA LIFE INSURANCE COMPANY - A Securian Company
Life New Business . 000 Xxxxxx Xxxxxx Xxxxx . St. Xxxx, Minnesota 55101-2098 [SECURIAN LOGO]
Proposed insured name (last, first, middle)
AGREEMENT: I have read, or had read to me the statements and answers recorded on
my application. They are given to obtain this insurance and are, to the best of
my knowledge and belief, true and complete and correctly recorded. I will notify
the company of any changes in the statements or answers given in the application
between the time of application and delivery of the policy. I understand that
any false statement or misrepresentation on this application may result in loss
of coverage under this policy subject to the incontestability provision. I agree
that they will become part of this application and any policy issued on it. The
policy adjustment applied for will not take effect unless the policy adjustment
is issued and delivered and the full first premium is paid while the answers, to
the best of my knowledge and belief as stated in this application remain true
and complete. The only exception to this is provided in the Life Receipt and
Temporary Insurance Agreement issued if the premium is paid in advance.
VARIABLE LIFE: I understand that the amount or the duration of the death benefit
(or both) of the policy adjustment applied for may increase or decrease
depending on the investment results of the sub-accounts of the separate account.
I understand that the actual cash value of the policy applied for is not
guaranteed and increases or decreases depending on the investment results. There
is no minimum actual cash value for the policy values invested in these
sub-accounts.
PERSONAL INFORMATION AUTHORIZATION: I authorize Minnesota Life to share any
information provided in this application with any physician, medical
practitioner, hospital, clinic or other health care provider, pharmacy, pharmacy
benefits manager, insurance or reinsuring company, consumer reporting agency,
the MIB, Inc., or any other data aggregator (collectively the "Sources") which
has any records or knowledge of my credit worthiness, credit standing, credit
capacity, character, general reputation, personal characteristics, mode of
living, purchase history, drug prescriptions, driving records, or physical or
mental health ("collectively, "Personal Information"), and/or the Personal
Information of each minor child listed as the proposed insured. This shall
include ALL INFORMATION as to any medical history, consultations, diagnoses,
prognoses, prescriptions or treatments and tests, including information
regarding alcohol or drug abuse and AIDS or AIDS-related conditions. To
facilitate rapid submission of such information, I authorize all the Sources to
give such records or knowledge to Minnesota Life Insurance Company or with the
exception of MIB, Inc., to any agency employed by Minnesota Life Insurance
Company to collect and transmit such information.
I understand the Personal Information is to be used for determining eligibility
for insurance and it may be used for determining eligibility for benefits, or
for the purpose of performing actuarial or internal business studies, research,
analytics and other analysis. I understand the Personal Information may be made
available to Underwriting, Claims, Actuarial, and support staff, licensed
representatives, and firms of Minnesota Life Insurance Company. I authorize
Minnesota Life Insurance Company or its reinsurers to release any such Personal
Information to reinsuring companies, the MIB, Inc., or other persons or
organizations performing business or legal services in connection with my
application, claim or as may be otherwise lawfully required or as I may further
authorize. I authorize Minnesota Life Insurance Company, or its reinsurers, to
make a brief report of my personal, or if applicable, my protected health
information to MIB, Inc. I understand that information used or disclosed under
this authorization may be re-disclosed by the recipient and may no longer be
protected by federal or state law.
I agree this authorization shall be valid for 24 months from the date it is
signed. The 24-month time limit complies with the time limit, if any, permitted
by applicable law in the state where the policy is delivered or issued for
delivery. I may revoke this authorization at any time by sending a written
request addressed to Individual Underwriting department, Minnesota Life
Insurance Company, 000 Xxxxxx Xxxxxx Xxxxx, Xx. Xxxx, XX 00000-0000. I
understand that a revocation is not effective to the extent that any action has
been taken in reliance on this authorization.
I understand that I, or my legal representative, have the right to request and
receive a copy of this Authorization and that a photocopy shall be as valid as
the original. I understand that no sales representative has the company's
authorization, to accept risk, pass on insurability or make, or void, waive or
change any conditions or provisions of the application, policy or receipt, as
applicable.
I acknowledge that I have been given the Securian Privacy Notice. I understand
that a copy of this entire application, including Part 2, will be attached to
the policy and delivered to the policyowner.
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USA PATRIOT ACT NOTIFICATION: The USA Patriot Act requires that Minnesota Life
Insurance Company establish an Anti- Money Laundering (AML) Program, notify
customers that we must verify the identity of the owner(s) of our contracts and
collect information sufficient to verify identity. Failure to provide us
identification information may result in the delay of insurance coverage and may
result in a decision not to accept your business.
FRAUD WARNING: Any person who knowingly presents a false statement in an
application for insurance may be guilty of a criminal offense and subject to
penalties under state law.
Insured signature Insured name (please print)
X
Date City State
Owner signature if other than proposed Owner name (please print)
insured (give title if signed on behalf
of a business or trust)
X
Date City State
Owner signature if other than proposed Owner name (please print)
insured (give title if signed on behalf
of a business or trust)
X
Date City State
Assignee signature (give title if signed Authorized signors name
on behalf of a business or trust) (please print)
X
Date City State
Irrevocable beneficiary signature if other Irrevocable beneficiary name
than proposed insured (give title if (please print)
signed on behalf of a business or trust)
X
Date City State
Parent/conservator/guardian for juvenile Parent/conservator/guardian name
applications signature (please print)
X
Date City State
IS REPLACEMENT OF EXISTING LIFE INSURANCE OR ANNUITY INVOLVED IN [ ] YES [ ] NO
THIS APPLICATION?
I believe that the information provided by the owner and proposed insured is
true and accurate. I certify I have accurately recorded all information given by
the owner and proposed insured(s).
Licensed representative Licensed representative Date
signature name (please print)
X
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