EXHIBIT 27(e)4
POLICY CHANGE APPLICATION PART 3 (UNDERWRITING)
Agreements and Authorizations
MINNESOTA LIFE
MINNESOTA LIFE INSURANCE COMPANY - Policyowner Services
000 Xxxxxx Xxxxxx Xxxxx - Xx. Xxxx, Xxxxxxxxx 00000-0000
Insured Name (last, first, middle)
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 agree
that they will become part of this application and any coverage issued on it. I
understand that the policy will be contestable, as to representations in this
application, from the date of reinstatement or reissue, for the time period
stated in the incontestable provision of the policy. The insurance applied for
will not take effect unless and until the policy is reissued and delivered and
the full first premium is paid while the health of the Insured remains as stated
in this Policy Change Application, as provided in the Life Receipt and Temporary
Insurance Agreement.
VARIABLE ADJUSTABLE 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 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, 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 non-medical information
relating to such persons to Minnesota Life 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 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 Life. I authorize Minnesota Life 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 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 Life Consumer Privacy Notice
(Notice Regarding Consumer Reports and Notice Regarding Medical Information
Bureau, Inc.).
FRAUD WARNING: Any person who, with intent to defraud or knowing that he/she is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
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Insured Signature Date City State
X
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Owner Signature (If other than Date City State
Insured) (Give title if signed
on behalf of a business)
X
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Assignee Signature (Give title Date City State
if signed on behalf of a
business)
X
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Irrevocable Beneficiary Date City State
Signature (Give title if signed
on behalf of a business)
X
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Parent/Conservator/Guardian Date City State
Signature (Juvenile
Applications)
X
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I believe that the information provided by this applicant is true and accurate. I certify I have
accurately recorded all information given by the Insured(s).
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Licensed Representative Signature Date
X
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F. 59534 8-2003
