AUTHORIZATION TO COLLECT AND DISCLOSE PERSONAL OR PRIVILEGED INFORMATION

(We are required to obtain this authorization from you pursuant to Minnesota Statute 72A.501.)

I, the undersigned, hereby authorize the agent named above, if any, and/or the underwriting department of the insurance company named
above to collect credit-related and other information about me from the following types of organizations:
       • Credit bureaus
       • Other organizations providing personal or privileged information

I understand this information will be used for the purpose of making underwriting decisions in connection with the insurance for which I have applied, sought reinstatement or requested a change in benefits. These decisions may include determinations to grant or deny me
coverage and/or the rates I will be charged.

I understand that this temporary authorization will expire as soon as one of the folllowing occurs:
• The above-named company makes the underwriting decision(s) in question, or
• One year elapses after the date I sign this authorization