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Exhibit a.(10)(e)
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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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Proposed Insureds 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).
End date for Monthly Charge Allocation_______________________________ (month/year)
(Increments of 5%,Minimum is 5%,Each column must total 100%.)
A B
Net Single
Premium NRP
_____________% _____________% 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 Developing Markets Securities Fund - Class 2
_____________% _____________% Templeton Asset Strategy Fund - Class 2
_____________% _____________% Janus Aspen Series Capital Appreciation Portfolio- Srv Sh(degree)
_____________% _____________% Janus Aspen Series International Growth Portfolio- Srv Sh(degree)
_____________% _____________% Fidelity VIP Contrafund(R)Portfolio:SC2*
_____________% _____________% Fidelity VIP Equity-Income Portfolio:SC2*
_____________% _____________% Fidelity VIP Mid Cap Portfolio:SC2*
_____________% _____________% Franklin Small Cap Fund - Class 2
_____________% _____________% Warburg Pincus Global Post-Venture Capital Portfolio
_____________% _____________% Other____________________________________________________
_____________% _____________% Other____________________________________________________
_____________% _____________% Other____________________________________________________
Janus Footnote /o/ = Invests in Aspen Service Shares Fidelity Footnote * = Invests in Series Class 2 Shares
F.MHC-48653 Rev.3-2000 1 of 3
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Proposed Insureds Name (Please Print)
SYSTEMATIC TRANSFER (Dollar Cost Averaging)
[_] Start a Systematic Transfer of funds (complete each the following sections).
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.)
Transfer Allocation (Increments of 1%,Minimum is 1%,Must total 100%.)
Note: Indicate dollar amounts only if transfer amount is indicated above as a dollar amount.
Allocate the amount transferred as follows:
Dollar Amount or Percent
$___________________ ____________________ % 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 Developing Markets Securities Fund - Class 2
$___________________ ____________________ % Templeton Asset Strategy Fund - Class 2
$___________________ ____________________ % Janus Aspen Series Capital Appreciation Portfolio - Srv Sh /o/
$___________________ ____________________ % Janus Aspen Series International Growth Portfolio - Srv Sh /o/
$___________________ ____________________ % Fidelity VIP Contrafund(R)Portfolio:SC2*
$___________________ ____________________ % Fidelity VIP Equity-Income Portfolio:SC2*
$___________________ ____________________ % Fidelity VIP Mid Cap Portfolio:SC2*
$___________________ ____________________ % Franklin Small Cap Fund - Class /2/
$___________________ ____________________ % Warburg Pincus Global Post-Venture Capital Portfolio
$___________________ ____________________ % Other_______________________________________________
$___________________ ____________________ % Other_______________________________________________
$___________________ ____________________ % Other_______________________________________________
Frequency
[_] Monthly [_] Quarterly [_] Semi-annually [_] Annually
Transfer Date (10th or 20th only)
[_] 10th [_] 20th Starting ___________(Month & Year) Ending__________________(Month & Year)
Janus Footnote /o/ = Invests in Aspen Service Shares Fidelity Footnote * = Invests in Series Class 2 Shares
F.MHC-48653-2 Rev.3-2000 2 of 3
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Proposed Insureds 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 proposed
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___________%
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 Fund $____________________
Business Interests $____________________ Individual Stock $____________________
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-48653-3 Rev.3-2000 3 of 3
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