EXHIBIT 26(E)(3)
POLICY CHANGE APPLICATION PART 3 (UNDERWRITING)
AGREEMENTS AND AUTHORIZATIONS
INDIVIDUAL LIFE INSURANCE
[LOGO]
MINNESOTA LIFE INSURANCE COMPANY - A Securian Company
Individual Life Policy Administration . 000 Xxxxxx Xxxxxx Xxxxx . St. Xxxx, Minnesota 55101-2098
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 answers, to the best of my knowledge
and belief, as stated in this Policy Change Application remain true and
complete. However, if premium is paid with this Policy Change Application,
coverage may be provided under the Life Receipt and Temporary Insurance
Agreement.
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 MIB, Inc., 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, Inc. 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,
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 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, 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 and may
be guilty of a criminal offense and subject to penalties under state law.
[ ] Change Service Representative (Print name/code Representative name Firm/rep code
only if policy is being reassigned)
Insured signature Date City State
X
Owner signature (if other than Insured) Date City State
(give title if signed on behalf of a business)
X
Assignee signature (give title if signed on behalf of a Date City State
business)
X
Irrevocable beneficiary signature (give title if signed on Date City State
behalf of a business)
X
Parent/conservator/guardian signature (juvenile Date City State
applications)
X
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 insured(s).
Licensed representative signature Firm/rep code Date
X
F59534 Rev 2-2014
