Exhibit 26(e)(2)
APPLICATION PART 3
AGREEMENTS AND AUTHORIZATIONS
INDIVIDUAL LIFE INSURANCE
MINNESOTA LIFE
MINNESOTA LIFE INSURANCE COMPANY - A Securian Company
Life New Business . 000 Xxxxxx Xxxxxx Xxxxx . St. Xxxx,
Minnesota 55101-2098
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Proposed insured name (last, first, middle)
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AGREEMENTS: 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
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 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
this application. IF SUCH CONDITIONS ARE MET, THE INSURANCE WILL TAKE EFFECT AS
OF THE EARLIER OF THE POLICY DATE SPECIFIED IN THE POLICY OR THE DATE THE
POLICY IS DELIVERED TO ME; 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 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 AND DECREASES DEPENDING ON THE INVESTMENT RESULTS.
THERE IS NO MINIMUM ACTUAL CASH VALUE FOR THE POLICY VALUES INVESTED IN THESE
SUB-ACCOUNTS.
AUTHORIZATION: I authorize any physician, medical practitioner, hospital,
clinic or other health care provider, pharmacy, pharmacy benefits manager,
insurance or reinsuring company, consumer reporting agency, the Medical
Information Bureau, Inc. (MIB), or employer which has any records or knowledge
of my physical or mental health, and/or the physical or mental health of each
minor child listed as the Proposed Insured, to give all such information and
any other non-medical information relating to such persons to Minnesota Life
Insurance Company 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 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 Life Insurance Company 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, support staff, licensed representatives, and firms of Minnesota Life
Insurance Company. I authorize Minnesota Life Insurance Company 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-four months from the date
it is signed. I may revoke this authorization at any time by sending a written
request addressed to the 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 or to the extent that Minnesota
Life Insurance Company has a legal right to contest a claim under an insurance
policy or to contest the policy itself.
I understand that I, or my legal representative, 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 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 Your Privacy Is Important To Us notice.
I understand that a copy of this entire application, including Part 2, will be
attached to the policy and delivered to the policyowner.
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.
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Proposed insured signature Date City State
X
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Owner signature (if other than proposed insured) Date City State
(give title if signed on behalf of a business)
X
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Parent/conservator/guardian signature (juvenile Date City State
applications)
X
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IS REPLACEMENT OF EXISTING LIFE INSURANCE, ANNUITY OR MUTUAL FUND INVOLVED IN
THIS APPLICATION? [ ] YES[ ] NO
I believe that the information provided by this applicant is true and accurate.
I certify I have accurately recorded all information given by the Proposed
Insured(s).
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Licensed representative signature Date
X
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ICC12-59536 1-2012
