Exhibit 99.A10B
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MINNESOTA MUTUAL APPLICATION PART 3
AGREEMENTS, CERTIFICATION AND AUTHORIZATION
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The Minnesota Mutual Life Insurance Company . 000 Xxxxxx Xxxxxx Xxxxx . Xx.
Xxxx, Xxxxxxxxx 00000-0000
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Proposed Insured's Name (Last, First, Middle Initial)
[_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_][_]
AGREEMENTS/CERTIFICATION: I have read, or had read to me the statements and
answers recorded on Part 1 and Part 2 of 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 understand that any false statement or
misrepresentation on this application may result in loss of coverage under this
policy subject to the Time Limit on Certain Defenses, incontestability
provision, and legal proceedings. I agree that they will become part of this
application and any policy issued on it. The insurance applied for will not take
effect unless the policy is issued and delivered and the full first premium is
paid while the health of the Proposed Insured remains as stated in Part 1 and
Part 2 of the application. IF SUCH CONDITIONS ARE MET THE INSURANCE WILL TAKE
EFFECT AS OF THE POLICY DATE SPECIFIED IN THE POLICY; THE ONLY EXCEPTION TO THIS
IS PROVIDED IN THE RECEIPT AND TEMPORARY LIFE INSURANCE AGREEMENT, AND THE
CONDITIONAL HEALTH RECEIPT, ISSUED IF THE PREMIUM IS PAID IN ADVANCE. No deposit
has been made nor any premium paid on the policy applied for, either in cash or
by extension of credit, except as stated on this application.
VARIABLE ADJUSTABLE LIFE: I also agree that if this application is for a
Variable Adjustable Life policy, that Minnesota Mutual, if it is unable for any
reason to collect funds for units which have been allocated to a sub-account
under the policy applied for, may redeem for itself the full value of such
units. If such units are no longer available, it may recover that value from any
other units of equal value available under the policy.
I UNDERSTAND THAT THE AMOUNT OR THE DURATION OF THE DEATH BENEFIT (OR BOTH) OF
THE POLICY 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 INCREASES AND DECREASES DEPENDING ON
INVESTMENT RESULTS. THERE IS NO MINIMUM ACTUAL CASH VALUE FOR POLICY VALUES
INVESTED IN THESE SUB-ACCOUNTS.
AUTHORIZATION: I authorize any physician, medical practitioner, hospital, clinic
or other health care provider, insurance or reinsuring company, consumer
reporting agency, the Medical Information Bureau, Inc. (MIB), or employer which
has any records or knowledge of the physical or mental health of me or my minor
children, to give all such information and any other nonmedical information
relating to such persons to Minnesota Mutual or its reinsurers. 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, sickle cell disease and AIDS or AIDS-related
conditions. To facilitate rapid submission of such information, I authorize all
said sources, except MIB, to give such records or knowledge to any agency
employed by Minnesota Mutual to collect and transmit such information.
I understand this information is to be used for the purpose of determining
eligibility for insurance and may be used for determining eligibility for
benefits. I understand this information may be made available to Underwriting,
Claims and support staff of Minnesota Mutual. I authorize Minnesota Mutual or
its reinsurers to release any such information to reinsuring companies, the MIB,
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 agree this authorization shall be valid for twenty-six months from the date it
is signed.
I understand that I have the right to request and receive a copy of this
authorization and that a photocopy of this authorization shall be as valid as
the original.
I acknowledge that I have been given the Minnesota Mutual Consumer Privacy
Notice. (Notice Regarding Consumer Reports and Notice Regarding Medical
Information Bureau, Inc.)
Proposed Insured X Date signed
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City State
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Signature of Applicant (if other than Proposed Insured)
Give title if signed on behalf of a buinsess
X
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D.O.B. of Applicant
(if other than Proposed Insured)
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Witness/Registered Representative (licensed resident agent)
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Signature of Parent, Conservator or Guardian (on juvenile applications)
X
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