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MINNESOTA LIFE VARIABLE ANNUITY APPLICATION
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The Minnesota Life Insurance Company - Annuity Services - 000 Xxxxxx Xxxxxx Xxxxx - Xx. Xxxx, Xxxxxxxxx 00000-0000
Toll Free 0-000-000-0000
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OWNER (PLEASE PRINT) ANNUITANT (IF OTHER THAN OWNER)
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NAME NAME
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XXXXXXX XXXXXXX
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XXXX, XXXXX, XXX XXXX, XXXXX, XXX
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DATE OF BIRTH SEX TAXPAYER I.D. (Soc Sec # or EIN) DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
/ /M / /F / /M / /F
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JOINT OWNER (OPTIONAL - MUST BE SPOUSE OF OWNER) JOINT ANNUITANT (OPTIONAL - MUST BE SPOUSE OF ANNUITANT)
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NAME NAME
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DATE OF BIRTH SEX SOCIAL SECURITY NUMBER DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
/ /M / /F / /M / /F
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BENEFICIARY
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CLASS NAME RELATIONSHIP DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
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/ /M / /F
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/ /M / /F
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ANNUITANT'S EMPLOYER (IF NOT SELF EMPLOYED)
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NAME ADDRESS CITY, STATE, ZIP
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TYPE OF PLAN (PLEASE CHECK ONLY ONE BOX) PURCHASE PAYMENT ACCOUNT ALLOCATION
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/ / Non-Qualified $____________
/ / Under the ____ (state) Uniform Transfers To Minor Act ______% General (Not available for MultiOption Select)
/ / Individual Retirement Annuity (XXX) for tax year ________ ______% Maturing Government Bond - 2002
/ / XXX Rollover $____________ ______% Maturing Government Bond - 2006
/ / XXX Transfer from existing XXX $____________ ______% Maturing Government Bond - 2010
/ / Xxxx XXX for tax year _____________ ______% Growth
/ / Simplified Employee Pension (SEP) ______% Bond
/ / SIMPLE ______% Money Market
/ / Tax Sheltered Annuity (IRC Section 403(b)) ______% Asset Allocation
Annual Earned Income $____________ ______% Mortgage Securities
/ / Qualified Retirement Plan (IRC Section 401) ______% Index 500
/ / Employee Funded / / Employer Funded ______% Capital Appreciation
/ / Public Employee Deferred Compensation (IRC Section 457) ______% International Stock
/ / Non-Qualified Deferred Compensation ______% Small Company
/ / Other ___________________ ______% Value Stock
----------------------------------------------------------------- ______% Small Company Value
TYPE OF CONTRACT AND AMOUNT OF PAYMENT ______% Global Bond
----------------------------------------------------------------- ______% Index 400 Mid-Cap
/ / MultiOption Select Flexible Payment Deferred Variable Annuity ______% Xxxxxxxxx Developing Markets
of $______ per ______ OR $______ as a single payment ______% Macro-Cap Value
/ / MultiOption Flexible Payment Deferred Variable Annuity ______% Micro-Cap Growth
of $______ per ______ OR $______ as a single payment ______% Real Estate Securities
/ / MultiOption Single Payment Deferred Variable Annuity __________
of $_________________ ($5,000 Minimum) TOTAL 100%
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The prospectuses for the Variable Annuity Account, Advantus
Series Fund and Xxxxxxxxx Developing Markets Fund each refer
to a Statement of Additional Information. Would you like us to
send you a copy? / / Yes / / No
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PAYMENT METHOD
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/ / APP (Automatic Payment Plan) commencing on Month _____________ Day _________
/ / Enclosed APP Authorization form and voided check
/ / Xxxx employer commencing on Month ____ and continuing Add to existing case# ______________
/ / Annually (1) / / Semi-Annually (2) / / Quarterly (4)
/ / Monthly (12) / / Semi-Monthly (24) / / Bi-Weekly (26)
Individual billing, commencing on the 1st day of Month ________ and continuing / / Quarterly / / Semi-Annually / / Annually
MHC-84-9093 Rev. 7-1998
- I have received and had an opportunity to read a current copy of the
Variable Annuity Account Prospectus and the current prospectuses for the
Advantus Series Fund and Xxxxxxxxx Developing Markets Fund for this
investment prior to investing.
- I have been informed of all charges and expenses associated with this
investment.
- I realize that this may be a long-term investment which should be held
for a number of years. Due in part to the sales charges involved,
selling or surrendering in the short term may result in a loss.
- I am aware there is no assurance that the initial objective/s of this
investment will be achieved. Thus, when I ultimately sell or surrender the
investment, I may receive more or less than the amount I invested.
- I realize that the element of risk is inherent in any investment - what
varies is the degree of risk. Generally, the greater the expected return,
the greater risk I must be willing to assume.
- I will only make payment by check payable to the entity listed on the
application or in the prospectus and never payable directly to a
representative or an entity to which the representative may gain access to
my funds. I will not loan to nor borrow from a representative any monies
or securities.
- Given my personal circumstances, this is a suitable investment.
- Financial data should be updated approximately every two years as
investment activity warrants.
IMPORTANT INSTRUCTIONS
1. COMPLETE ALL ITEMS OF THE APPLICATION
2. IF YOU ARE REQUESTING: PLEASE SUBMIT:
Automatic Payment Plan (APP) - APP Authorization F. 25744.2
- Voided check
Direct Rollover (client initiated distribution) - Transfer/Rollover/1035 Exchange F. 52258 (send to
existing institution)
Immediate Annuity Contract - Annuity Service Request F. 35264
(includes W-4P. If Deferred Compensation, submit W-4)
- Proof of age for annuitant(s) if a life contingency option
is selected (copy of driver's license or birth certificate)
MultiOption Annuity Exchange - Exchange Authorization F. 35079
MultiOption Select Annuity Exchange - MOA Select Exchange Authorization F. 51459
Qualified Retirement Plan - Employee Benefit Plan Disclosure Statement F. 23273
Replacement of another life insurance or - Appropriate replacement forms as required by the
annuity contract state of jurisdiction
SEP contract - Completed IRS form 5305-SEP or
- Prototype Request and Document Services
Agreement and service fee
SIMPLE - Completed 5304 SIMPLE or Adoption Agreement
Systematic Dollar Cost Averaging - Annuity Service Request F. 35264
Systematic Withdrawal - Annuity Service Request F. 35264
Traditional XXX to Xxxx Internal Exchange - Xxxx Exchange F. 52223
Transfer (available for use with transfers - Transfer/Rollover/1035 Exchange F. 52258
from TSA to TSA or XXX/Xxxx/SEP to
XXX/Xxxx/SEP only)
TSA contract - TSA Withdrawal Disclosure F. 38754
- Salary Modification Agreement F. 23251
Calculation worksheet if the contribution is to exceed
maximum exclusion allowance
1035 Exchange (non-qualified) - Transfer/Rollover/1035 Exchange F. 52258
- Original contract
3. IF YOU ARE REPLACING A MUTUAL FUND, VARIABLE, OR - Switch Form F. 51821
FIXED PRODUCT FOR AN ANNUITY:
If more than one beneficiary is specified, indicate the class of each. All
living Class 1 beneficiaries receive an equal share of the death proceeds. If
no Class 1 beneficiaries are living, Class 2 beneficiaries receive an equal
share and so on.
Class 1 beneficiaries are considered the primary beneficiaries.
Class 2 beneficiaries and so on, are considered the contingent beneficiaries.
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REPLACEMENT
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Will this contract applied for replace or change an existing contract? / / Yes / / No
If yes please provide: COMPANY NAME __________________________________ CONTRACT NUMBER(S) ______________________
Have you completed a State Replacement Form (where required)? (Based on jurisdiction, not state of residence)
/ / Not Required / / Enclosed
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SPECIAL INSTRUCTIONS OR REMARKS
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INVESTMENT SUMMARY
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1. Are you an employee of Minnesota Mutual or a subsidiary? / / Yes / / No
2. Are you a spouse or dependent child of an employee of Minnesota Mutual or a subsidiary? / / Yes / / No
3. Are you or your spouse an employee or employed by an NASD firm? / / Yes / / No
4. Dependents: / / Spouse / / Children Ages ____________________
5. How was account acquired? / / Known Personally / / Unsolicited / / Solicited / / Referred By __________________________
6. Current Approximate: Annual Income $___________________ Assets $__________________ Debt $_________________ Tax Bracket _______%
7. Other Investments: (Exclusive of personal residence, automobile and this investment.)
Savings $____________________ Balanced/Total Return Funds $____________________
Insurance Cash Values $____________________ Stock Funds $____________________
Real Estate $____________________ Bond Funds $____________________
Business Interests $____________________ Individual Stocks $____________________
Retirement Funds $____________________ Individual Bonds $____________________
Other________________ $____________________
8. Ranking of Investment 9. Ranking of Investment
Objectives (Rank 1 - 5 in order of importance): Objectives (Rank 1 - 5 in order of importance):
CURRENT INVESTMENT TOTAL PORTFOLIO
________ Conservative Income/Capital Preservation ________ Conservative Income/Capital Preservation
________ Current Income ________ Current Income
________ Conservative Growth/Total Return ________ Conservative Growth/Total Return
________ Growth ________ Growth
________ Aggressive Growth ________ Aggressive Growth
10. Risk tolerance of current investment (Please select only 11. Risk tolerance of total portfolio (Please select only one):
one):
/ / Low Risk / / Moderate Risk / / High Risk / / Low Risk / / Moderate Risk / / High Risk
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OWNER/ANNUITANT SIGNATURES
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- I represent that the statements and answers in this application are full, complete and true to the best of my knowledge. I
agree that they are to be considered the basis of any contract issued to me.
- I ACKNOWLEDGE RECEIPT OF A CURRENT VARIABLE ANNUITY ACCOUNT PROSPECTUS AND THE CURRENT
PROSPECTUSES FOR THE ADVANTUS SERIES FUND AND XXXXXXXXX DEVELOPING MARKETS FUND. I UNDERSTAND
THAT ALL PAYMENTS AND VALUES OF ANY CONTRACT ISSUED, WHEN BASED UPON THE INVESTMENT EXPERIENCE OF
A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT.
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SIGNED AT (CITY, STATE) DATE SIGNATURE OF OWNER SIGNATURE OF ANNUITANT
X X
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AMOUNT REMITTED WITH APPLICATION SIGNATURE OF JOINT OWNER SIGNATURE OF JOINT ANNUITANT
$ X X
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TO BE COMPLETED BY REPRESENTATIVE
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To the best of my knowledge this contract / /will / /will not replace or change an existing insurance or annuity contract. I certify
that a current prospectus was delivered. No written sales materials were used other than those furnished by the Home Office.
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REPRESENTATIVE NAME (PRINT) REPRESENTATIVE SIGNATURE AGENCY CODE AGENT CODE
X %
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X %
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TO BE COMPLETED BY DEALER
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DEALER NAME DATE SIGNATURE OF AUTHORIZED DEALER
X
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THIS APPLICATION BECOMES EFFECTIVE ONLY UPON ITS ACCEPTANCE BY ASCEND FINANCIAL SERVICES, INC.
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ACCEPTED BY DATE CONTRACT NUMBER CASE NUMBER
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