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Exhibit a.(10)(g)
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MINNESOTA LIFE POLICY CHANGE APPLICATION PART 1
NO UNDERWRITING REQUIRED
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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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POLICY NUMBER(S) INSURED'S BIRTHPLACE (State or Country if outside US)
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INSURED'S NAME INSURED'S SOCIAL SECURITY NUMBER
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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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LIFE INSURANCE (ALL PRODUCTS)
FACE/PREMIUM ADJUSTMENTS
[_] Change face amount to $ ___________________
[_] Change annual premium amount to $ __________________
Premiums payable: [_] Annual [_] Semi-annual [_] Quarterly
[_] Monthly Automatic Payment Plan #______________ [_] Direct Monthly
[_] 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.)
Please note: Face amount will be reduced.
[_] Cost of Living alternate exercise.
[_] Face Amount Increase Agreement/AIO/AIOW exercise.
[_] Alternate option _________________________ (attach proof).
[_] Eliminate policy loan (if available). (Complete Withholding Election on Page 2.)
Please note: Face amount will be reduced. 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 rollover or conversion 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.
F. MHC-44097 Rev. 9-1999
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LIFE INSURANCE (CONTINUED)
BENEFIT AND AGREEMENT ADJUSTMENTS (Select only those available for the particular product.)
[_] Maintain same total annual premium [_] Change total annual premium accordingly
Decrease New
Add Remove Amount Amount
Accidental Death Benefit....................... [_] [_] $__________
Additional Insured Agreement .................. [_] [_] $__________
Additional Term Protection .................... [_]
Adjustable Survivorship Life Agreement......... [_] [_] $__________ Designated Life _________
Automatic Premium Loan......................... [_] [_]
Business Continuation Rider ................... [_] [_] $__________ Designated Life _________
Cost of Living Agreement ...................... [_]
Face Amount Increase Agreement ................ [_] [_] $__________
Family Term - Children's Agreement ............ [_] [_] $__________
Family Term - Spouse Agreement................. [_] [_] $__________
Guaranteed Protection Waiver................... [_]
Inflation Agreement ........................... [_]
Policy Enhancement Rider ...................... [_] [_] __________% (Indicate a whole number
between 3 - 10%)
Waiver of Premium Agreement.................... [_]
Other__________________________________________ [_] [_]
OTHER ADJUSTMENTS
[_] Change Death Benefit Option to Cash.
[_] Change dividend option to: _______________________
WITHHOLDING FOR TAX PURPOSES - Required Information for all partial surrenders and loan eliminations
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 any 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)
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Year Policy Business/ Pending? Will it be
Issued Amount Type of Coverage Full Company Name Number(s) Personal Yes No Replaced?
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DISABILITY AND OVERHEAD EXPENSE INSURANCE
PRE-DI '90 SERIES ADJUSTMENTS
New Benefit Waiting
Decrease Risk Remove Amount Period Period
Base............................................... [_] $_____________ __________ __________
Additional Disability Monthly Income Agreement..... [_] [_] $_____________ __________ __________
Additional Disability Monthly Income Agreement..... [_] [_] $_____________ __________ __________
Additional Disability Monthly Income Agreement..... [_] [_] $_____________ __________ __________
Guaranteed Future Insurability Agreement........... [_]
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.......... [_]
DI '90 SERIES
PLAN OF COVERAGE CHANGES (Policy required - complete Lost Policy Declaration if policy is lost)
[_] Change DI '90 series policy Plan of Coverage to: (Indicate A or B Below)
A. [_] Disability Income B. [_] Disability Income
Insurance Policy Insurance Policy Plus
(all occupation classes) (Class *P, 1*, *S, 1 only)
BENEFIT AND AGREEMENT ADJUSTMENTS
New Benefit Waiting
Decrease Remove Amount Period Period
Base............................................... [_] $_____________ __________ __________
Additional Disability Monthly Income Agreement..... [_] [_] $_____________ __________ __________
Additional Disability Monthly Income Agreement..... [_] [_] $_____________ __________ __________
Additional Disability Monthly Income Agreement..... [_] [_] $_____________ __________ __________
Supplementary Income Benefit....................... [_] [_] $_____________ __________
Social Security Agreement.......................... [_] [_] $_____________ __________
Inflation Protection Agreement..................... [_] [_] [_] 4% [_] 6%
Guaranteed Increase Agreement...................... [_]
Guaranteed Increase Agreement Plus................. [_]
Future Income Protection Agreement................. [_]
ADJUSTMENTS - ALL SERIES
[_] Add Discount (Choose one selection from the following:)
[_] Association Discount #____________________________
[_] Employer/Employee #_______________________________ (Include F. 37443)
[_] Professional Group Discount_______________________
Name of Group
[_] 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 #_______________________
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ALL PRODUCTS
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 issued, 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 new 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
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.
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.
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DATE SIGNED CITY STATE [_] CHANGE SERVICE AGENT (print name/code, only if policy(ies)
is being reassigned)
NAME CODE
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OWNER (List title if signed on behalf of corporation) OWNER'S TELEPHONE NUMBER
X ( ) -
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INSURED AGENCY CODE
X
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ASSIGNEE (List title if signed on behalf of corporation) AGENT CODE %
X X
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IRREVOCABLE BENEFICIARY AGENT CODE %
X X
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F. MHC-44097-4 Rev. 9-1999
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