Exhibit 10(d)
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POLICY CHANGE APPLICATION PART 3
MINNESOTA LIFE AGREEMENTS, CERTIFICATION AND AUTHORIZATION
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Minnesota Life Insurance Company . Individual Policyowner Services .
400 Robert Street North . St. Paul, Minnesota 55101-2098
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Insured's Name (Last, First, Middle Name)
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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 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 Part 1 and Part 2 of the Policy Change Application, as
provided in the Receipt and Temporary Life Insurance Agreement and the
Conditional Health Receipt.
VARIABLE ADJUSTABLE LIFE:
I also agree that if this application is for a Variable Adjustable Life Policy,
that Minnesota Life, 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 REISSUED 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 REISSUED 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 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, sickle cell disease, 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
Medical Information Bureau, 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 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 a valid as
the Original.
I acknowledge that I have been given Minnesota Life's Consumer Privacy Notice.
(Notice Regarding Consumer Reports and Notice Regarding Medical Information
Bureau, Inc.)
Any person who, with intent to defraud or knowing that he or 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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DATE SIGNED CITY STATE
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INSURED
X
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OWNER (If other than insured, list title if signed on behalf of corporation)
X
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ASSIGNEE (List title if signed on behalf of corporation)
X
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IRREVOCABLE BENEFICIARY
X
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PARENT/CONSERVATOR/GUARDIAN
X
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[_] CHANGE SERVICE AGENT (Print name/code only if policy(ies) is being
reassigned)
AGENT CODE
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AGENCY CODE
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OWNER'S TELEPHONE NUMBER
( ) -
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WITNESS/REGISTERED REPRESENTATIVE (Licensed agent where required) CODE %
X
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AGENT CODE %
X
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AGENT CODE %
X
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F.MHC-44098 10-1998