EX-99.24.B.5.A 5 d834430dex9924b5a.htm EX-99.24.B.5.A EX-99.24.B.5.A

Exhibit (24)(b)(5)(a)

MultiOption Annuities

Individual Variable Annuity Application

Minnesota Life Insurance Company - a Securian Financial company

Annuity Services • A1-9999 • 400 Robert Street North, St. Paul, MN 55101-2098 1-800-362-3141 • Fax 651-665-7942 • securian.com

1.

Contract Type

 

 

 

 

 

 

Guide B

Extra

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Plan Type

 

 

 

 

 

 

 

 

 

 

Traditional IRA - Tax year

Non-Qualified

 

 

 

 

Roth IRA - Tax year

 

*Inherited 1035 Exchange - Relationship

 

 

 

 

 

 

 

 

 

 

SEP IRA - Tax year

 

Under the

(state) UTMA/UGMA

 

 

 

 

 

 

 

 

 

 

*Inherited IRA - Relationship

 

 

 

 

 

 

* If an Inherited plan type is selected, please provide the deceased's date of death:

For UTMA/UGMA enter custodian's information here.

For TRUSTS:

Only provide the title of the trust. Do not include the name of the trustee.

3. Owner

Individual name (first, middle initial, last, suffix) trust title, or entity

 

 

 

 

 

 

 

 

 

 

Male

Female

Entity

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth or date of trust

 

Tax I.D. (SSN or TIN)

 

 

 

 

 

 

 

 

 

US citizen:

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Physical address (no PO Boxes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if different than physical address)

 

City

State Zip code

 

 

 

 

 

 

 

 

 

 

 

 

Email address

 

 

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

Cell

Landline

4. Joint Owner (if applicable)

 

Individual name (first, middle initial, last, suffix)

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

 

Tax I.D. (SSN)

 

Relationship to owner

US citizen:

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical address (no PO Boxes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if different than physical address)

 

City

State Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email address

 

 

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell

Landline

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IAN000064

 

Securian Financial is the marketing name for Minnesota Life Insurance Company. Insurance products are issued by Minnesota Life Insurance Company.

 

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Complete only if the primary annuitant is not the same as owner.

For UTMA/UGMA enter minor's information here.

5. Annuitant

Individual name (first, middle initial, last, suffix)

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

Date of birth

Tax I.D. (SSN)

Relationship to owner

Yes

No

 

 

 

 

 

US citizen:

 

 

 

 

 

 

 

 

Physical address (no PO Boxes)

City

State

Zip code

 

 

 

 

 

Mailing address (if different than physical address)

Email address

City

State

Zip code

 

 

 

 

 

Telephone number

 

 

 

 

 

 

Cell

 

Landline

Complete only if the joint annuitant is not the same as the joint owner.

If IRA and selecting a Joint Living Benefit Rider, do not list Joint Annuitant. Instead, list spouse as sole beneficiary.

6.Joint Annuitant (if applicable)

Individual name (first, middle initial, last, suffix)

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

Date of birth

Tax I.D. (SSN)

Relationship to owner

Yes

No

 

 

 

 

 

US citizen:

 

 

 

 

 

 

 

 

Physical address (no PO Boxes)

City

 

 

 

State

Zip code

 

 

 

 

 

 

 

 

 

 

Mailing address (if different than physical address)

 

City

State

Zip code

 

 

 

 

 

 

 

 

 

Email address

 

Telephone number

 

 

 

 

 

 

 

 

 

 

Cell

Landline

Primary beneficiary designations must total 100%.

Contingent beneficiary designations must total 100%.

For TRUSTS:

Only provide the title of the trust. Do not include the name of the trustee.

7.Beneficiary(ies) **Unless otherwise indicated, all designated beneficiaries will be considered primary beneficiaries with equal shares.**

Name

 

 

Male

Female

Entity

 

 

 

 

 

 

 

 

 

 

 

Date of birth or date of trust

 

Tax I.D. (SSN or TIN)

 

 

 

 

 

 

 

 

 

 

 

Relationship to owner

 

Type of beneficiary

Percentage

 

 

Primary

Contingent

 

 

 

%

Address

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

 

Email address

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

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Name

 

 

Male

Female

Entity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth or date of trust

 

Tax I.D. (SSN or TIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to owner

 

Type of beneficiary

Percentage

 

 

 

Primary

Contingent

 

 

 

%

 

Address

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

 

 

 

Email address

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

Male

Female

Entity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth or date of trust

 

Tax I.D. (SSN or TIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to owner

 

Type of beneficiary

Percentage

 

 

 

Primary

Contingent

 

 

 

%

 

Address

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

 

 

 

Email address

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

Male

Female

Entity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth or date of trust

 

Tax I.D. (SSN or TIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to owner

 

Type of beneficiary

Percentage

 

 

 

Primary

Contingent

 

 

 

%

 

Address

 

City

 

 

State

Zip code

 

 

 

 

 

 

 

 

 

 

Email address

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Special Instructions

 

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Issue age min/max:

Ascend

45/80

Core Flex

45/80

Horizon

45/80

Value

35/80

Plus 90

0/80

If selecting a joint option on a qualified plan, the spouse must be the sole primary beneficiary.

9.Optional Living Benefit Riders (additional charges apply - see Prospectus)

Please choose only one from the rider list below:

GLWB riders (not available with a death benefit rider):

MyPath Ascend 2.0 - Single

MyPath Ascend 2.0 - Joint

MyPath Ascend 2.0 - Joint 50

MyPath Horizon - Single

MyPath Horizon - Joint

MyPath Horizon - Joint 50

GLWB riders (available with a death benefit rider):

MyPath Core Flex - Single

MyPath Core Flex - Joint

MyPath Value - Single

MyPath Value - Joint

GMAB riders:

SureTrack Plus 90 (not available with a death benefit rider)

Issue age max:

 

MyPath HA

70

PDB II

75

HAV II

75

EEB II

75

PPDB

70

10. Optional Death Benefit Riders (additional charges apply - see Prospectus)

If you are electing either the MyPath Core Flex or MyPath Value rider and wish to elect an optional death benefit under the rider, you may select the option below:

MyPath Highest Anniversary Death Benefit**

**The corresponding single or joint Death Benefit rider will be added to your contract based _ on the rider chosen.

If you are NOT electing a rider from the Optional Living Benefit Riders section, and wish to elect an optional death benefit rider(s), you may choose from the options below:

Note: Premier Protector is not available with MultiOption Extra.

Premier Protector is not available in the states of IL, MA, MO, VA, WA.

Premier II Death Benefit (PDB II)

Highest Anniversary Value II Death Benefit (HAV II)

Estate Enhancement Benefit II (EEB II)

Premier Protector Death Benefit (PPDB)*

*To elect the Premier Protector Death Benefit, both Owner(s) and Annuitant(s) must be able to answer "No" to both of the following questions:

Yes

No

Are you currently residing in a nursing home or skilled nursing facility?

Yes

No

Are you currently unable to perform, without assistance, one or more of

 

 

the activities of daily living (bathing, continence, dressing, toileting,

 

 

eating, and transferring)?

 

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If yes, a state replacement form must be signed and dated with the same date as the application in most states.

11. Statement Regarding Existing Policies or Annuity Contracts

 

 

 

Do you have any existing life insurance or annuity contracts?

 

Yes

No

Will the contract applied for replace or change an existing life insurance

 

 

or annuity contract? If yes, complete the section below.

 

Yes

No

 

 

 

 

 

 

Company Name

Life/

 

Policy/Contract

Year

 

Annuity

 

Number

Issued

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minimum purchase payment is $10,000.

12. Purchase Payment Method

 

Approximate amount $

Purchase Payment submitted via:

Make checks payable to Minnesota Life.

Check with Application (Note: cashier's checks and/or starter checks will not be accepted.)

Client initiated Rollover

Direct Transfer/Rollover

1035 Exchange

Non-Qualified Transfer

13. Notice to Applicant

Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

14. Electronic Prospectus Authorization

Yes

No If "Yes" is selected, please provide the owner's email address on page one.

I would like to receive electronic copies of the variable annuity and/or variable life insurance prospectus(es), privacy policies, underlying fund company prospectus(es) and supplements, underlying fund semiannual and annual reports and supplements rather than paper copies. I understand I will receive a communication directing me to the Minnesota Life internet website address where the documents will be available, be notified when new, updated prospectuses, privacy policies, reports and supplements for contracts become available, and continue to receive my statements in the mail. I understand and acknowledge that I have the ability to access the internet and will need Adobe Acrobat Reader in order to view the documents, am responsible for any subscription fees an internet service provider might charge for internet access, (Minnesota Life does not charge a fee for electronic delivery), may request specific documents in paper form at any time without revoking this consent, and can revoke this consent at any time by calling Minnesota Life's Service Center at 1-800-362-3141 or writing to the address PO Box 64628, St. Paul, MN 55164-0628. If I need to correct or change my email address, I will contact Minnesota Life at the previously stated telephone number or mailing address. I also understand that Minnesota Life will rely on my signature as consent to receive all of the above mentioned disclosure documents for all Minnesota Life products currently owned and any purchased in the future, until this consent is revoked.

 

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15. Owner Signatures

I understand that Minnesota Life is not acting as a fiduciary or otherwise providing me with investment advice.

I acknowledge that I have received and understand the current prospectus. I understand that all payments and values provided by this contract, when based upon the investment experience of a variable annuity account, are variable, may increase or decrease and are not guaranteed as to dollar amount.

If I am an active duty member of the United States Armed Forces (including active duty military reserve personnel), I confirm that this application was not solicited and/or signed on a military base or installation, and I have received from the registered representative the Active Duty Military Personnel Required Disclosure (form F72467) required by Section 10 of the Military Personnel Financial Services Protection Act.

I/we represent that the statements and answers in this application are full, complete, and true to the best of my/our knowledge and belief. I/we agree that they are to be considered the basis of any contract issued to me/us. I/we have read and agree with the applicable statements. The representative left me/us the original or a copy of the written or printed communications used in this presentation.

Contract owner's signatureSigned in (state) Date

X

Joint contract owner's signature

 

Signed in (state) Date

X

 

 

 

 

16. To Be Completed By Representative/Agent

Yes No

Do you have offices in or conduct business in the state of New York?

Yes No N/A If yes, I certify I comply with the Minnesota Life Sales Activities Requirements for _ Financial Professionals Who Have Offices in or Conduct Business in New York.

By signing this form, I certify that:

1.The applicant's Statement Regarding Existing Policies or Annuity Contracts has been answered correctly to the best of my knowledge and belief.

2.The applicant's statement as to whether or not an existing life insurance policy or annuity contract is being replaced is true and accurate to the best of my knowledge and belief.

3.No written sales materials were used other than those furnished by the Home Office.

4.I have provided the Owner with all appropriate disclosures including the Variable Buyer's Guide as applicable.

5.If this application involved funds being allocated to/from an IRA or qualified plan - my recommendation was in compliance with ERISA and DOL regulations, including the appropriate prohibited transaction exemption(s).

6.I believe the information provided by this client is true and accurate to the best of my knowledge and belief.

Please only select one option.

Compensation Options:

 

 

 

 

 

Guide B

 

 

 

 

Extra

 

 

 

 

 

 

 

 

A

B

C

D

E

U

U/T

L

 

 

 

 

 

 

 

 

 

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All representatives/ agents involved in this sale must sign this application.

Representative/ agent split must total 100%

Representative/agent name (print)Representative/agent code

 

 

 

 

 

 

 

 

%

Representative/agent signature

 

Representative/agent email

Representative/agent telephone

X

 

 

 

 

 

 

 

 

Representative/agent name (print)

 

 

Representative/agent code

 

 

 

 

 

 

 

%

Representative/agent signature

 

Representative/agent email

Representative/agent telephone

X

 

 

 

 

 

 

 

 

Representative/agent name (print)

 

 

Representative/agent code

 

 

 

 

 

 

 

%

Representative/agent signature

 

Representative/agent email

Representative/agent telephone

X

17.To Be Completed By Broker - Dealer (if applicable)

Broker - dealer name

Signature of authorized dealerDate

X

Principal signatureDate

X

Special note

 

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