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Exhibit A. (10)(c)
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MINNESOTALIFE POLICY CHANGE APPLICATION PART 1
UNDERWRITING REQUIRED
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<S> <C> <C> <C> <C>
Minnesota Life Insurance Company . Individual Policyowner Services . 400 Robert Street North . St. Paul, Minnesota 55101-2098
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ALL APPLICATIONS - PERSONAL INFORMATION
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<S> <C>
POLICY NUMBER(S) INSURED'S BIRTHPLACE (State or Country if outside U.S.)
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INSURED'S NAME INSURED'S SOCIAL SECURITY NUMBER
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INSURED'S ADDRESS (Street, City, & Zip code.) INSURED'S DRIVER'S LICENSE NUMBER
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INSURED'S OCCUPATION INSURED'S INCOME
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OWNER'S NAME OWNER'S SOCIAL SECURITY/TAX I.D. NUMBER
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OWNER'S ADDRESS (Street, City, State, & Zip code.) [ ] Check if new address and you want our records to reflect this.
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EFFECTIVE DATE [ ] Current AMOUNT SUBMITTED: MAKE CHECKS PAYABLE TO MINNESOTA LIFE. POLICY SENT
OF CHANGE [ ] Other (Indicate month and reason) $ [ ] Receipt given [ ] Yes [ ] No
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<CAPTION>
LIFE INSURANCE (ALL PRODUCTS)
FACE/PREMIUM ADJUSTMENTS
<S> <C> <C> <C> <C>
[ ] Change face amount to: $ ___________________
[ ] Change annual premium amount to: $ ____________
Premiums payable: [ ] Annual [ ] Semi-annual [ ] Quarterly
[ ] Monthly Automatic Payment Plan #______________ [ ] Direct Monthly (if available)
[ ] List Bill Plan #_____________ [ ] Payroll Deduction Plan #____________
[ ] Change plan of insurance to: _________________________________________
[ ] Credit a Non-Repeating Premium of: $ _________________($500 minimum required)
[ ] Increase face by Non-Repeating Premium amount. [ ] Do not increase face by Non-Repeating Premium amount.
[ ] All or part of the Non-Repeating premium is the result of surrendering or borrowing the cash value of another policy(ies).
[ ] Start a billable Non-Repeating Premium: Annual total $ ____________________
($600.00 Minimum annual total with a $2,400.00 minimum annual base premium.)
Frequency: [ ] Annual [ ] Semi-annual [ ] Quarterly [ ] APP Monthly
[ ] Partial Surrender of: $ ____________________ (Complete Withholding Election on page 2.)
[ ] Maintain same face amount. [ ] Reduce face amount.
[ ] Eliminate policy loan (if available). (Complete Withholding Election on Page 2.)
[ ] Maintain same face amount. [ ] Reduce face amount.
Please note: Dividend additions and accumulations will be surrendered first.
PRODUCT ADJUSTMENTS (Policy required - if policy is lost, complete Lost Policy Declaration.)
Automatic Premium Loan Provision (APL), is automatically added at conversion or rollover unless indicated here.
[ ] Omit APL
[ ] Convert term insurance at attained age to:
[ ] Variable Adjustable Life [ ] Adjustable Life [ ] Variable Adjustable Life Horizon
Partial conversion: [ ] Retain balance [ ] Surrender balance
[ ] Conversion of term agreement: Name:_______________________________________________________________________________________
[ ] Rollover at attained age to:
[ ] Variable Adjustable Life (loans will be eliminated.) [ ] Adjustable Life
Please note: Waiver will be a separate premium charge. Loan interest rate will be 8%.
[ ] Combine policies and rollover at attained age to:
[ ] Variable Adjustable Life (loans will be eliminated.) [ ] Adjustable Life
Please note: Waiver will be a separate premium charge. Loan interest rate will be 8%. Policies must have same beneficiary
and owner. Complete F. 17092-2a, Request to Change Beneficiary Name and/or Ownership, if needed.
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F.MHC-44096 Rev. 9-1999
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LIFE INSURANCE(Continued)
BENEFIT AND AGREEMENT ADJUSTMENTS (Select only those available for the
particular product.)
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<S> <C> <C>
[ ] Maintain same total annual premium. [ ] Change total annual premium accordingly.
<CAPTION>
Change New
Add Remove Amount Amount
<S> <C> <C> <C> <C>
Accidental Death Benefit ........................ [ ] [ ] [ ] $ _________
Additional Insured Agreement .................... [ ] [ ] [ ] $ _________ (Complete Family Term Agreement)
Additional Term Protection ...................... [ ]
Adjustable Survivorship Life Agreement .......... [ ] [ ] [ ] $ _________ Designated Life __________________________
(To add, attach application for Designated
Life.)
Automatic Premium Loan .......................... [ ] [ ]
Business Continuation Rider ..................... [ ] [ ] [ ] $ _________ Designated Life __________________________
(To add, attach application for Designated
Life.)
Cost of Living Agreement ........................ [ ] [ ]
Face Amount Increase Agreement .................. [ ] [ ] [ ] $ _________
Family Term-Children's Agreement ................ [ ] [ ] [ ] $ _________ (Complete Family Term Agreement)
Family Term-Spouse Agreement .................... [ ] [ ] [ ] $ _________ (Complete Family Term Agreement)
Guaranteed Protection Waiver .................... [ ] [ ]
Inflation Agreement ............................. [ ] [ ]
Policy Enhancement Rider ........................ [ ] [ ] [ ] _________% (Indicate whole number between
3 - 10%.)
Waiver of Premium Agreement ..................... [ ] [ ]
Other ___________________________________________ [ ] [ ] [ ] $ _________
<CAPTION>
OTHER ADJUSTMENTS
<S> <C> <C> <C>
[ ] Change Death Benefit Option to: [ ] Cash [ ] Protection (Default is cash if none selected.)
[ ] Remove/reconsider rating:
[ ] Maintain same total annual premium. [ ] Reduce total annual premium accordingly.
[ ] Change dividend option to: __________________
[ ] Reinstate
I understand that this application may be attached to and considered part of the policy to which it applies. Also I understand
that this policy will be contestable, as to representations in this application, from the date of reinstatement
for the time period stated in the incontestable provision of the policy.
WITHHOLDING FOR TAX PURPOSES - Required information for all partial surrenders and loan elimination's.
Social Security Number or Tax I.D. of owner: ______________________________________________________________________________________
(If a correct number is not provided, the IRS requires us to withhold 31% of any gain, irrespective of the withholding election.)
Withholding election if reissue results in a taxable gain (Withholding is automatic if no election is made).
[ ] Yes, I elect withholding. [ ] No, I do not elect withholding.
REPLACEMENT
Has there been or will there be a lapse, surrender, loan, withdrawal or other change to an existing life insurance or annuity as a
result of, or in anticipation of this application? [ ] Yes [ ] No
If yes, please indicate which coverage will be replaced in the box below and submit replacement forms where required.
LIFE INSURANCE IN FORCE AND PENDING (Complete for face increase and/or replacement requests.)
Do you have any life insurance in force or pending? [ ] Yes [ ] No (If yes, indicate below.)
<CAPTION>
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Year Amount Type of Coverage Full Company Name Policy Business/ Pending? Will it be
Issued Number(s) Personal Yes No Replaced?
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
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DISABILITY AND OVERHEAD EXPENSE INSURANCE
PRE-DI '90 SERIES ADJUSTMENTS
NOTE: . Any increases to Pre-Dl '90 policies must be done as an exchange to the
DI '90 series by completing the lower half of this page.
. GFIA and AMIO exercises must be added to an existing DI '90 series
policy or submitted as a new application.
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<CAPTION>
New Benefit Waiting
Decrease Risk Remove Amount Period Period
<S> <C> <C> <C> <C> <C>
Base ................................................. [ ] $______ ______ ______
Additional Disability Monthly Income Agreement ....... [ ] [ ] $______ ______ ______
Additional Disability Monthly Income Agreement ....... [ ] [ ] $______ ______ ______
Additional Disability Monthly Income Agreement ....... [ ] [ ] $______ ______ ______
Guaranteed Future Insurability Agreement ............. [ ] [ ] RETAIN
Supplementary Income Benefit ......................... [ ] [ ] $______
Social Security Agreement ............................ [ ] [ ]
Proportionate Benefit Agreement ...................... [ ]
Additional Monthly Income Option ..................... [ ]
Monthly Income Benefit Escalator ..................... [ ] [ ] 4% [ ] 6%
Monthly Income Benefit Escalator ..................... [ ] [ ] 4% [ ] 6% [ ] 8% [ ] 10%
OVERHEAD EXPENSE POLICIES ONLY:
Base ................................................. [ ] $______ ______ ______
Cost of Living Agreement ............................. [ ]
Replacement Expense Agreement ........................ [ ]
Transitional Disability Benefit Agreement ............ [ ]
<CAPTION>
DI '90 SERIES
PRODUCT ADJUSTMENTS (Policy required--if policy lost, complete Lost Policy Declaration)
<S> <C> <C>
[ ] Exchange Pre-Dl '90 Level Rate policy(ies) to DI-'90 Level Rate. (Indicate Plan of Coverage below.)
[ ] Exchange Pre-Dl '90 Step Rate policy(ies) to DI '90 Annual Renewable Disability Income (ARDI).
(Indicate Plan of Coverage below.)
[ ] Change Pre-DI '90 Step Rate or DI '90 ARDI policy(ies) to DI '90 Level Rate Policy. (Indicate Plan of Coverage below.)
Premiums will be calculated at attained age.
[ ] Change DI '90 Series policy Plan of Coverage. (Indicate Plan of Coverage below.)
PLAN OF COVERAGE (Indicate one section--A or B.)
A.[ ] Disability Income B.[ ] Disability Income
Insurance Policy Insurance Policy Plus
(all occupation classes). (class *P, 1*, *S, 1 only).
<CAPTION>
BENEFIT AND AGREEMENT ADJUSTMENTS
New Benefit Waiting
Add Change Renew Remove Amount Period Period
<S> <C> <C> <C> <C> <C> <C> <C>
Base .................................................... [ ] $______ ______ ______
Additional Disability Monthly Income Agreement* ......... [ ] [ ] [ ] $______ ______ ______
Additional Disability Monthly Income Agreement* ......... [ ] [ ] [ ] $______ ______ ______
Additional Disability Monthly Income Agreement* ......... [ ] [ ] [ ] $______ ______ ______
Supplementary Income Benefit (365) ...................... [ ] [ ] [ ] $______ ______ ______
Social Security Agreement ............................... [ ] [ ] [ ] $______ ______ ______
Inflation Protection Agreement .......................... [ ] [ ] [ ] [ ] 4% [ ] 6%
Guaranteed Increase Agreement ........................... [ ] [ ]
Guaranteed Increase Agreement Plus ...................... [ ] [ ]
Future Income Protection Agreement ...................... [ ] [ ] (Increase [ ] $________aggregate
only)
* [ ] Check here if this is a GFIA/FIPA/AMIO exercise. From policy # ______________________________________
</TABLE>
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DISABILITY AND OVERHEAD EXPENSE INSURANCE (CONTINUED)
ADJUSTMENTS - ALL SERIES
[ ] Remove/Reconsider
[ ] Rating [ ] Exclusion Rider
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<S> <C> <C>
[ ] Add Discount (Choose one selection from A., and/or select B.)
A. [ ] Association Discount # ________________ B. [ ] Income Documentation
[ ] Employer/Employee Discount # __________ (Include F. 37443) Discount (For 1994 Rates only.
[ ] Professional Group Discount # _________ Complete income section
and submit appropriate
income documentation.)
[ ] Reinstate
I understand that this application may be attached to and considered part of the policy to which it applies. Also I
understand that this policy will be contestable, as to representations in this application, from the date of reinstatement
for the time period stated in the incontestable provision of the policy.
[ ] Change contract to level rate.
[ ] Change dividend option to: [ ] Reduce premiums [ ] Accumulate [ ] Cash
[ ] Change premium payment frequency to:
[ ] Annual [ ] Semi-annual [ ] Quarterly [ ] Direct Monthly (must meet requirements)
[ ] Automatic Payment Plan # _______________________________ [ ] Payroll Deduction/List Bill #_____________________________
REPLACEMENT - COMPLETE FOR ALL INCREASES IN RISK
Will you drop any existing disability, overhead expense, or any other accident and sickness insurance when this coverage
is issued? [ ] Yes [ ] No
If yes, I agree upon accepting this policy to drop the coverage indicated below. Note: please submit replacement forms
where required.
DISABILITY AND OVERHEAD EXPENSE IN FORCE OR PENDING (If none, insert "None.")
Do you have any disability insurance in force or pending? [ ] Yes [ ] No
If yes, complete below.
List Disability with all companies including Group, Pension or Retirement Plans, Salary Continuation Plans, Association
Plans, Credit Insurance Plans, Overhead Expense Plans, and any other Disability or Health Coverage. Also include
coverage for which the Insured will become eligible in the next five years after a qualifying period of employment has been met.
<CAPTION>
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Paid To Policy Benefit Elimination Pending? Will it be
Date Amount Type Company Number(s) Period Period Yes No Replaced?
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
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</TABLE>
OCCUPATION
A. Change Occupational Class to: [ ] *P [ ] 1* [ ] *S [ ] 1 [ ] 2
[ ] 3 _______________________________________________________________________
B.Occupational title and/or professional designation:___________________________
Nature of business:_____________________________________________________________
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<CAPTION>
OCCUPATIONAL DETAILS (Provide description of daily job activities and percentage spent on each.)
<S> <C> <C>
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Duties Percentage
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A. Number of years employed by current employer?________________________________
B. How many hours does Insured work per week on an average?_____________________
C. How many full-time employees report to Insured?______________________________
D. Does Insured have any part-time or full-time jobs other than the above?
[ ] Yes [ ] No____________________________________________________________
If yes, provide full details____________________________________________________
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DISABILITY AND OVERHEAD EXPENSE INSURANCE (CONTINUED)
INCOME
Fill in amounts that are (or will be) shown on the Insured's individual and/or
business income tax forms and supporting schedules. Note: Do not list income
that is not reported to the IRS. Explain any significant fluctuations between
years in Remarks. Ask for third party income verification on all disability
applications. Complete sections A-G:
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<CAPTION>
Current Year Last Year Two Calendar
Years ago
<S> <C> <C> <C>
A. EARNED INCOME (Fill in all which apply.) ____________ ____________ ____________
1. Non-owner Employee's salary, bonus, and profit sharing
(Form W-2). ____________ ____________ ____________
2. a. Owner of Regular or S Corporation's salary and bonus
(Form W-2). ____________ ____________ ____________
b. Owner's share of after tax corporate profits or losses
(after expenses) provided the Insured has significant
ownership and is active in the corporation (Form 1120 or
1120S). If losses, indicate with parentheses. ____________ ____________ ____________
c. Pension plan or other contributions that would
cease if the Insured became disabled. ____________ ____________ ____________
3. Sole Proprietor net income, after expenses (Form 1040
Schedule C). ____________ ____________ ____________
4. Share of partnership net income, after expenses
(Insured's Schedule K-1 or Form 1040 Schedule E). ____________ ____________ ____________
5. Other earned income (describe in Remarks). ____________ ____________ ____________
6. Total earned Income. ____________ ____________ ____________
B. UNEARNED INCOME - This includes capital gains, interest,
dividends, tax exempt unearned income, income from other
investments, net rental income, pensions, annuities, and alimony.
Itemize in Remarks if exceeding 15% of earned income or
$125,000. ____________ ____________ ____________
C. NET WORTH is the Insured's net worth, exclusive of primary residence, greater than
$4,000,000? [ ] Yes [ ] No
If yes, itemize the net worth in Remarks.
D. Premiums will be paid by: [ ] Insured
[ ] Employer - Will any portion of the premium be included in your
taxable income? [ ] Yes [ ] No
If yes, provide details in Remarks.
[ ] Other (Indicate name and address in Remarks.)
(NOTE: Individual paid Issue and Participation limits should be used for those Insureds who are owners in a Sole
Proprietorship, Partnership, or S Corporation. Employer paid Issue and Participation limits can be used for
Owners of a Regular Corporation when the Corporation is paying the premium and for Non-Owner Employees
when the Employer is paying the premium.)
E. Is the Insured self-employed, including any partial ownership? [ ] Yes [ ] No
(If yes, answer questions F. and G.)
F. For tax purposes the Insured's business is set up as a/an:
[ ] Sole Proprietorship [ ] Partnership [ ] Regular Corporation [ ] S Corporation
G. What is the Insured's ownership? ____%
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REMARKS:________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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ALL PRODUCTS (Complete for all requests.)
Special activities and other insurance activity(Provide details in space
provided to all yes answers.)
<TABLE>
<S> <C> <C>
A. Do you plan to change jobs within the next 12 months? [ ] Yes [ ] No
(If yes, please advise of the industry, company, and location to which you
are planning to go. If you do not know the specifics yet but are
contemplating such a change, please provide as many details as you can.)
_____________________________________________________________________________
B. Do you plan to travel or reside outside of the U.S. in the next three years? [ ] Yes [ ] No
If yes, please provide the country(ies) and city(ies) you will be visiting or
moving to and whether this is for business or pleasure.______________________
How long will you be there? ___________How frequently will you be visiting if
more than once? _____________
C. Have you, within the last five years, or do you plan in the next six months, [ ] Yes [ ] No
to pilot a plane?
(If yes, complete the Aviation Statement F. MHC-4883.)
D. Have you, within the last five years, or do you plan in the next six months,
to engage in sky diving, organized vehicle racing, mountain/rock climbing,
hang gliding, underwater diving, bungee jumping, or other activity requiring
special equipment and/or training. [ ] Yes [ ] No
(If yes, complete Avocation Statement F. MHC-11393.)
E. Have you, within the last five years, been declined, modified, rated, or been
issued a rider for life or disability insurance? [ ] Yes [ ] No
F. Within the last year have you missed any work due to illness or injury? [ ] Yes [ ] No
G. Are you in the Armed Forces, National Guard, or Reserves? [ ] Yes [ ] No
(If yes, complete Military Statement F. MHC-4883.)
H. Have you applied elsewhere for insurance within the last six months? [ ] Yes [ ] No
DRIVING AND CONVICTION HISTORY (Provide details in Additional Information.)
A. In the last five years, have you been charged with a driving while intoxicated
violation, had your driver's license restricted or revoked, or been cited with
a moving violation? [ ] Yes [ ] No
B. Except for traffic violations, have you ever been convicted of a felony? [ ] Yes [ ] No
</TABLE>
NON-SMOKER STATEMENT
[ ] Add non-smoker designation.
I do not currently smoke any cigarettes, nor have I smoked cigarettes for
the past 12 months. (If tobacco other than cigarettes is used, list type
____________________ and frequency_______________________.) I understand
that a material misrepresentation, including but not limited to statements
regarding my smoking status, may result in the cancellation of insurance
and nonpayment of any claim.
LOST POLICY DECLARATION
[ ] I am not able to find the policy(ies) listed on page 1. I agree that when
the duplicate policy(ies) is provided to me, the original policy(ies) will
be void. I also agree that if the original policy(ies) is found, it will be
returned to the Company immediately.
[ ] Provide duplicate policy. [ ] Provide certificate.
[ ] Rollover/conversion/exchange - provide duplicate policy.
[ ] Payment of fee for duplicate or new policy:
[ ] Fee is attached. [ ] Take fee from policy cash value.
[ ] See "Additional Information" for fee payment instructions.
ADDITIONAL INFORMATION
HOME OFFICE ENDORSEMENTS
Home Office Corrections or Additions - Acceptance of the policy shall ratify
changes entered here by the Company. Not to be used in CA (for disability
insurance only), IA, IL, KS, KY, MD, MI, MN, MO, NH, NJ, OR, PA, TX, WI, or WV
for changes unless agreed to in writing.
