mnlite.com - New Business Amendment

mnlite.com - New Business Amendment Page I of I e isel/1 MIDLAND NATIONAL A Life Insurance Company I New Business Amendment AMENDMENT AND SUPPLEMENT TO APPLICATION FOR INSURANCE. This form must be dated and personally signed in ink by the Proposed Insured, Spouse, Joint Insured, Owner and/or parent, as indicated, in the presence of a witness who must also sign the form in ink. Make the following changes in the application for file or policy number 1502983192-4 on the life (lives) of ANN M RODRIQUEZ. This policy is issued special class for Ann Rodriquez. Planned periodic premium changed to $443.00. It is agreed that this amendment is part of the application and of the policy issued, and it will be binding on any person who will have any interest under the policy. This amendment, and the policy. will not take effect until signed as required below. It is agreed that no coverage is in effect if any changes are made to the above statements on this form. Signed on this 30ranfige day of Witness `Ph ,20 Signature of Proposed Insured if 15 Yea Over Signature of Spouse or Joint Insured Signature of Owner or Parent Copyright 01996.2010 Midland National Life Insurance Company. Sioux Fans. SD. All rights reserved. Imps://vAvw.mnlife.com/info I /PendingBusincss/PBRAmendment.aspx?info=dMI5Oe%21.. 12/9/201 I EFTA01221155