Exhibit a.(10)(f)
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MINNESOTA LIFE SUPPLEMENT TO POLICY CHANGE APPLICATION PART 1
VARIABLE ADJUSTABLE LIFE
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Minnesota Life Insurance Company . Individual Policyowner Services . 400 Robert Street North . St. Paul, Minnesota 55101-2098
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Policyowner's name (Please Print)
ALLOCATIONS TO SUB-ACCOUNTS AND GUARANTEED PRINCIPAL ACCOUNT
[_] Allocate Net Premiums as indicated in Column A.
[_] Allocate Single Non-Repeating Premium as indicated in Column B
(Note: Billable NRP's use the same allocation as Net Premium).
[_] Allocate Partial Surrender as indicated in Column C.
End date for Monthly Charge Allocation __________________________ (month/year).
Increments of 5%, Minimum is 5%, Each column must total 100%.
A B C
Net Single Partial
Premium NRP Surrender
_____________% _____________% _____________% Growth
_____________% _____________% _____________% Bond
_____________% _____________% _____________% Money Market
_____________% _____________% _____________% Asset Allocation
_____________% _____________% _____________% Mortgage Securities
_____________% _____________% _____________% Index 500
_____________% _____________% _____________% Capital Appreciation
_____________% _____________% _____________% Guaranteed Principal Account
_____________% _____________% _____________% International Stock
_____________% _____________% _____________% Small Company Growth
_____________% _____________% _____________% Value Stock Portfolio
_____________% _____________% _____________% Small Company Value
_____________% _____________% _____________% Global Bond
_____________% _____________% _____________% Index 400 Mid-Cap
_____________% _____________% _____________% Macro-Cap Value
_____________% _____________% _____________% Micro-Cap Growth
_____________% _____________% _____________% Real Estate Securities
_____________% _____________% _____________% Templeton Dev. Mkt /2/
_____________% _____________% _____________% Templeton Asset Strategy Fund--Class 2
_____________% _____________% _____________% Janus Aspen Cap App /o/
_____________% _____________% _____________% Janus Aspen Int Grth /o/
_____________% _____________% _____________% Fidelity VIP Contrafund (R) Portfolio: SC2*
_____________% _____________% _____________% Fidelity VIP Equity-Income Portfolio: SC2*
_____________% _____________% _____________% Fidelity VIP Mid Cap Portfolio: SC /2/*
_____________% _____________% _____________% Franklin Small Cap Fund-Class 2
_____________% _____________% _____________% Warburg Pincus Glo Post Vent /1/
_____________% _____________% _____________% Other ______________________________
_____________% _____________% _____________% Other ______________________________
_____________% _____________% _____________% Other ______________________________
Janus Footnote /o/ = Invests in Aspen Series Service Shares Fidelity Footnote * = Invests in Service Class 2 Shares
F. MHC-48654 Rev. 3-2000 1 of 3
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Policyowner's name (Please Print)
SUB-ACCOUNT TRANSFERS (Minimum transfer lesser of $250 or the account balance.)
Growth $ _________ to _________ Macro-Cap Value $ _________ to _________
Bond $ _________ to _________ Micro-Cap Growth $ _________ to _________
Money Market $ _________ to _________ Real Estate Securities $ _________ to _________
Asset Allocation $ _________ to _________ Templeton Dev. Mkt /2/ $ _________ to _________
Mortgage Securities $ _________ to _________ Templeton Ast St /2/ $ _________ to _________
Index 500 $ _________ to _________ Janus Asp Cap App /o/ $ _________ to _________
Capital Appreciation $ _________ to _________ Janus Asp Int Grth /o/ $ _________ to _________
Guaranteed Principal Account $ _________ to _________ Fidelity VIP Contra* $ _________ to _________
International Stock $ _________ to _________ Fidelity VIP Eq-Inc* $ _________ to _________
Small Company Growth $ _________ to _________ Fidelity VIP Mid Cap* $ _________ to _________
Value Stock $ _________ to _________ Franklin Sm Cap /2/ $ _________ to _________
Small Company Value $ _________ to _________ Warburg Gl Pst-V /1/ $ _________ to _________
Global Bond $ _________ to _________ Other ________________ $ _________ to _________
Index 400 Mid-Cap $ _________ to _________ Other ________________ $ _________ to _________
SYSTEMATIC TRANSFER (Dollar Cost Averaging)
[_] Start a Systematic Transfer of funds (Complete Parts A, B, C, & D).
[_] Change the transfer amount (Complete Parts A & B).
[_] Change the frequency (Complete Part C).
[_] Change the transfer date (Complete Part D).
[_] Cancel the Systematic Transfer.
PART A: Transfer Option (Minimum transfer lesser of $250 or the account balance).
Select one of the following:
[_] __________ units from the ________________________Account. (Units must be a positive whole number.)
[_] __________ from the ______________________________Account. (Must be a positive whole number.)
PART B: Transfer Allocation (Increments of 1%, Minimum is 1%, Must total 100%.)
Note: Indicate dollar amounts only if transferring a dollar amount from Part A.
Allocate the amount transferred as follows:
Dollar Amount or Percent Dollar Amount or Percent
$___________ ______ % Growth $___________ ______ % Macro-Cap Value
$___________ ______ % Bond $___________ ______ % Micro-Cap Growth
$___________ ______ % Money Market $___________ ______ % Real Estate Securities
$___________ ______ % Asset Allocation $___________ ______ % Templeton Dev. Mkt /2/
$___________ ______ % Mortgage Securities $___________ ______ % Templeton Ast St /2/
$___________ ______ % Index 500 $___________ ______ % Janus Asp Cap App /o/
$___________ ______ % Capital Appreciation $___________ ______ % Janus Asp Int Grth /o/
$___________ ______ % Guaranteed Principal Account $___________ ______ % Fidelity VIP Contra*
$___________ ______ % International Stock $___________ ______ % Fidelity VIP Eq-Inc*
$___________ ______ % Small Company Growth $___________ ______ % Fidelity VIP Mid Cap*
$___________ ______ % Value Stock $___________ ______ % Franklin Sm Cap /2/
$___________ ______ % Small Company Value $___________ ______ % Warburg Gl Pst-V /1/
$___________ ______ % Global Bond $___________ ______ % Other _____________
$___________ ______ % Index 400 Mid-Cap $___________ ______ % Other _____________
PART C: Frequency
[_] Monthly [_] Quarterly [_] Semi-annually [_] Annually
PART D: Transfer Date (10th or 20th only)
[_] 10th [_] 20th Starting ____________(Month and Year) Ending____________(Month and Year)
Janus Footnote /o/ = Invests in Aspen Series Service Shares Fidelity Footnote * = Invests in Service Class 2 Shares
F. MHC-48654-2 Rev. 3-2000 2 of 3
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Policyowner's name (Please Print)
INVESTMENT SUITABILITY -- TO BE COMPLETED BY POLICYOWNER
NASD rules require inquiry concerning the financial condition of individuals applying for variable policies. The
Policyowner must supply such information so that an informed judgment may be made as to the suitability of the
investment for the Policyowner.
1. Employer____________________________________________________ Address________________________________________________________
Occupation_____________________________________________________________________________ Years Employed______________________
2. Are you an employee of Minnesota Life or a subsidiary? [_] Yes [_] No
3. Are you a spouse or dependent child of an employee of Minnesota Life or a subsidiary? [_] Yes [_] No
4. Are you an employee of a NASD firm? [_] Yes [_] No
5. Are you of legal age in the state of your mailing address? [_] Yes [_] No
6. Dependents: [_] Spouse [_] Children How many?________________________ Ages________________________________________
7. Approximate: Annual Income $__________________ Assets $__________________ Debt $_______________ Tax Bracket_____________%
Please indicate spouse's income if it should be considered in determining suitability. $____________________________________
8. Who will be primarily responsible for paying the premium? __________________________________________________________________
9. Face amount of life insurance in force $___________________
10. Asset Breakdown:
Savings $__________________________ Balanced/Total Return Funds $__________________________
Insurance Cash Values $__________________________ Stock Funds $__________________________
Real Estate $__________________________ Bond Funds $__________________________
Business Interests $__________________________ Individual Stocks $__________________________
Retirement Funds $__________________________ Individual Bonds $__________________________
Other __________________ $__________________________
11. Ranking of Investment Objectives (Rank 1-5, in order of importance; 1 is "most important")
_______________ Capital Preservation/Conservative Income ______________ Growth
_______________ Current Income ______________ Aggressive Growth
_______________ Total Return/Conservative Growth
12. Risk Tolerance (Check one):
[_] Low Risk [_] Moderate Risk [_]High Risk
13. Did you receive the current Variable Adjustable Life and the Funds Prospectuses for the
product you are applying for? [_] Yes [_] No
14. The Fund Prospectuses refer to a Statement of Additional Information. Please indicate below if you would like to
request the Statement of Additional Information for the following funds:
[_] Advantus [_] Templeton [_] Janus [_] Fidelity [_] Warburg
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For Registered Principal Use Only
Suitability Accepted by Registered Principal ______________________________________________________________ Date_________________
F. MHC-48654-4 Rev. 3-2000 3 of 3