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MINNESOTA MUTUAL ANNUITY APPLICATION
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The Minnesota Mutual Life Insurance Company - Annuity Services - 000 Xxxxxx Xxxxxx Xxxxx - Xx. Xxxx, Xxxxxxxxx 00000-0000
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For Group, Flexible Contributions, Deferred Annuity under Group 403(b) Contracts issued to the Church of the Nazarene, Board of
Pensions and Benefits USA and for a Group Variable Annuity Contract issued to the Church of the Nazarene Tax Sheltered Annuity Plan
Trust.
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A. PARTICIPANT (PLEASE PRINT)
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FULL NAME OF PARTICIPANT (EMPLOYEE) DATE OF BIRTH AGE SEX
/ / M / / F
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ADDRESS TAXPAYER I.D. (SOCIAL SECURITY NUMBER OR EIN)
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CITY, STATE, ZIP CODE OCCUPATION DISTRICT AFFILIATION (IF ANY)
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B. SPOUSE (IF APPLICABLE)
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SPOUSE'S NAME DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
/ / M / / F
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C. BENEFICIARY
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CLASS* NAME RELATIONSHIP DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
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/ / M / / F
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/ / M / / F
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D. ANNUITANT'S EMPLOYER
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NAME ADDRESS CITY, STATE, ZIP CODE
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E. OPTION TYPE (PLEASE CHECK ONLY ONE BOX) F. PURCHASE PAYMENT ACCOUNT ALLOCATION (USE FOR OPTION D OR E)
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/ / Option A - Flexible Benefit Options Account Option D Option E
/ / Option B - Limited Benefit Options Account ___N/A__ ________% General (Not available for OPTION D)
/ / Option D - Group Variable Annuity Account ________% ________% Advantus Growth
with a purchase payment account allocation ________% ________% Advantus Money Market
/ / Option E - TSA Limited Benefit Group Variable ________% ________% Vanguard Long Term Corporate
Annuity Account with a purchase payment ________% ________% Vanguard Wellington
account allocation ________% ________% Advantus Index 500
________% ________% Fidelity Contrafund
PLEASE COMPLETE DISCLOSURE FORM ON THE ________% ________% Xxxxxxx International
REVERSE SIDE IF YOU CHOOSE OPTION D OR E. ________% ________% Janus Twenty
-------------------------------------------------- ________% ________% Advantus Asset Allocation
The prospectuses for the Group Variable Annuity
Account and the Advantus Series Fund Inc., each __________ __________
refer to a Statement of Additional Information. TOTAL 100% TOTAL 100%
Would you like us to send you a copy?
/ / Yes / / No
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G. SPECIAL INSTRUCTIONS OR REMARKS
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H. SIGNATURES
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I represent that the statements and answers in this application are full, complete and true to the best of my knowledge.
I agree that they are to be considered the basis of any contract issued to me.
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SIGNATURE OF PARTICIPANT EMPLOYER
X
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SIGNED AT (city, state) DATE EMPLOYER SIGNATURE (Treasurer or Secretary of Board) DATE
X
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TO BE COMPLETED BY AUTHORIZED REPRESENTATIVE
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To the best of my knowledge this contract / / will / / will not replace or change an existing insurance or annuity contract.
I certify that a current prospectus was delivered. No written sales materials were used other than those furnished by the
Home Office. I have determined this to be a suitable investment based on my knowledge of the participant's investment objectives
and financial circumstances.
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REPRESENTATIVE NAME (Print) REPRESENTATIVE SIGNATURE AGENCY CODE AGENT CODE
X 2064 422
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THIS APPLICATION BECOMES EFFECTIVE ONLY UPON ITS ACCEPTANCE BY ASCEND FINANCIAL SERVICES, INC.
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ACCEPTED BY DATE CASE NUMBER CERTIFICATE NUMBER
2856424 -
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97-9422 12-1997 FOR OPTION D AND E, ALSO COMPLETE REVERSE SIDE
GROUP VARIABLE ANNUITY ACCOUNT DISCLOSURE
(MUST BE COMPLETED FOR OPTION D AND OPTION E - GROUP VARIABLE ANNUITY APPLICATION)
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I. INVESTMENT SUMMARY
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1. Are you or your spouse an employee or employed by an NASD firm? / / YES / / NO
2. Dependents: / / Spouse / / Children Ages ________________
3. How was account acquired? / / Unsolicited / / Solicited
4. Current Approximate: Annual Income $_____________ Assets $_____________ Debt $_____________ Tax Bracket _____________%
5. Other investments: (Exclusive of personal residence, automobile and this investment.)
$_____________ Savings $_____________ Balanced/Total Return Funds
$_____________ Insurance Cash Value $_____________ Stock Funds
$_____________ Real Estate $_____________ Bond Funds
$_____________ Business Interests $_____________ Individual Stocks
$_____________ Retirement Funds $_____________ Individual Bonds
$_____________ Other _________________
6. Ranking of Investment Objectives 7. Ranking of Investment Objectives
(Rank 1-5 in order of importance): (Rank 1-5 in order of importance):
THIS INVESTMENT TOTAL PORTFOLIO (ALL INVESTMENTS)
___ Conservative Income/Capital Preservation ___ Conservative Income/Capital Preservation
___ Current Income ___ Current Income
___ Conservative Growth/Total Return ___ Conservative Growth/Total Return
___ Growth ___ Growth
___ Aggressive Growth ___ Aggressive Growth
8. Risk tolerance of current investment 9. Risk tolerance of total portfolio
(Please select only one): (Please select only one):
/ / Low Risk / / Moderate Risk / / High Risk / / Low Risk / / Moderate Risk / / High Risk
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J. PARTICIPANT SIGNATURE
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- I understand that the provisions of Section 403(b)(11) of the Internal Revenue Code restrict the timing of distributions
from the tax sheltered annuity contracts such as that described in this application. Distributions are restricted to
certain stated events such as: attained at age 59-1/2, separation from service, disability, death or hardship. I understand that
the restrictions do not alter my contractual ability to transfer the accumulation values among the sub-accounts available under
the contract or to exchange my TSA contract for another, provided that the transaction meets the requirements of the Code and
that any required agreements, including those requiring the consent of the employer are executed prior to the transfer.
- I have received and had an opportunity to read a current copy of the Group Variable Annuity Account and the Advantus Series
Fund Inc., Prospectuses for this investment prior to investing.
- I have been informed of all charges and expenses associated with this investment.
- I realize that this may be a long-term investment which should be held for a number of years. Surrendering in the short term
may result in a loss.
- I am aware there is no assurance that the initial objective(s) of this investment will be achieved. Thus, when I ultimately
surrender the investment, I may receive more or less than the amount I invested.
- I realize that the element of risk is inherent in any investment - what varies is the degree of risk. Generally, the greater
the expected return, the greater the risk I must be willing to assume.
- Given my personal circumstances, this is a suitable investment.
I believe the information on this form is true and accurate to the best of my knowledge. I have read and agree with the
above statements.
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SIGNATURE OF PARTICIPANT DATE
X
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- If more than one beneficiary is specified, indicate the class of each. All living Class 1 beneficiaries receive an equal share
of the death proceeds. If no Class 1 beneficiaries are living, all living Class 2 beneficiaries receive an equal share and so on.
Class 1 beneficiaries are considered the primary beneficiaries.
Class 2 beneficiaries and so on, are considered the contingent beneficiaries.
