Attached files
Exhibit 4(ii)
[LOGO OF CUNA MUTUAL
GROUP| CUNA MUTUAL GROUP] SINGLE PREMIUM DEFERRED MODIFIED
MEMBERS LIFE INSURANCE COMPANY GUARANTEED INDEX ANNUITY APPLICATION
[2000 Heritage Way o Waverly, IA 50677]
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1 PLAN OPTIONS REQUIRED. CHECK ONE INITIAL INDEX PERIOD IN
SECTION 1A. COMPLETE ALLOCATIONS IN SECTION
1B. ALLOCATIONS MUST BE IN WHOLE (1%)
INCREMENTS AND TOTAL 100%. REBALANCING OF
ALLOCATIONS OCCURS ON CONTRACT ANNIVERSARY.
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[MEMBERS(R) MARKET ZONE ANNUITY]
A. INITIAL INDEX PERIOD [o 5-year o 7-year o 10-year]
B. RISK CONTROL ACCOUNT ALLOCATION ___% [Secure Account] ___% [Growth Account]
[ALASKA AND ARIZONA: UPON WRITTEN REQUEST, WE WILL PROVIDE WITHIN A REASONABLE
TIME REASONABLE FACTUAL INFORMATION REGARDING THE BENEFITS AND PROVISIONS OF THE
CONTRACT TO YOU. IF FOR ANY REASON YOU DECIDE NOT TO KEEP YOUR CONTRACT, RETURN
IT TO US WITHIN 30 DAYS AFTER YOU RECEIVE IT FOR A REFUND OF THE AMOUNT PAID.
YOU MAY RETURN IT TO MEMBERS LIFE INSURANCE COMPANY AT THE ADDRESS SHOWN ABOVE,
OR TO THE AGENT WHO SOLD IT TO YOU. FOR ALASKA RESIDENTS "WITHIN A REASONABLE
TIME" MEANS WITHIN 10 DAYS OF RECEIPT OF YOUR WRITTEN REQUEST.]
[STATE VARIATIONS]
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2 PARTIES TO THE CONTRACT REQUIRED. ALL PARTIES MUST BE AGE 85 OR
YOUNGER ON CONTRACT ISSUE DATE. MUST COMPLETE
SECTION 2A. OWNER WILL BE THE ANNUITANT
UNLESS A DIFFERENT ANNUITANT IS NAMED IN
SECTION 2B. TO NAME A JOINT OWNER, COMPLETE
SECTION 2C. TO NAME MORE PARTIES TO THE
CONTRACT, USE SECTION 9.
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A. OWNER
COMPLETE THIS BOX FOR A NATURAL PERSON OWNER.
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NAME ____________________________________________ GENDER o Male o Female
FIRST MI LAST
DATE OF BIRTH ________ U.S. CITIZEN o Yes o No
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COMPLETE THIS BOX FOR A TRUST OR CREDIT UNION OWNER. THIS IS ONLY ALLOWED
FOR NON-QUALIFIED PLAN TYPES (EXCEPT NON-QUALIFIED BENEFICIARY). FOR A
TRUST OWNER, INCLUDE A COPY OF THE TRUST DOCUMENT PAGES SHOWING TRUST NAME,
TRUST DATE, TRUSTEE NAME(S), INVESTMENT AUTHORITY AND SIGNATURE(S), OR
COMPLETE [FORM 1919(CML), TRUSTEE CERTIFICATION OF INSURANCE/ANNUITY
POWERS].
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Name _______________________________________________________________________
TRUST OR CREDIT UNION
DATE OF TRUST ________ PERSON AUTHORIZED TO RECEIVE CORRESPONDENCE ____
TRUSTEE(S)/AUTHORIZED OFFICER(S) ___________________________________________
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ALL OWNERS MUST COMPLETE THIS BOX.
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SOCIAL SECURITY OR EMPLOYER ID NUMBER __________ DAYTIME PHONE ___________
MAILING ADDRESS ________________________________ [EMAIL __________________]
CITY ___________________________________________ STATE ________ ZIP _____
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B. ANNUITANT (IF OTHER THAN OWNER) COMPLETE THIS BOX ONLY IF ANNUITANT IS OTHER
THAN THE OWNER NAMED IN SECTION 1A.
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NAME ____________________________________________ GENDER o Male o Female
FIRST MI LAST
DATE OF BIRTH ________ RELATIONSHIP TO
OWNER(S) U.S. CITIZEN o Yes o No
SOCIAL SECURITY NUMBER _________________________ DAYTIME PHONE ___________
MAILING ADDRESS ________________________________ [EMAIL __________________]
CITY ___________________________________________ STATE ________ ZIP _____
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C. JOINT OWNER MUST BE A NATURAL PERSON. THIS IS ONLY ALLOWED FOR NON-QUALIFIED
PLAN TYPES (EXCEPT NON-QUALIFIED BENEFICIARY).
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NAME ____________________________________________ GENDER o Male o Female
FIRST MI LAST
DATE OF BIRTH ________ U.S. CITIZEN o Yes o No
SOCIAL SECURITY NUMBER _________________________ DAYTIME PHONE ___________
MAILING ADDRESS ________________________________ [EMAIL __________________]
CITY ___________________________________________ STATE ________ ZIP _____
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SPDMGIAAPP-2012 PAGE 1 DOC CODE 02
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3 PLAN TYPE AND PURCHASE PAYMENT REQUIRED. COMPLETE ALL SECTIONS. MAKE ALL
CHECKS PAYABLE TO MEMBERS LIFE INSURANCE
COMPANY.
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A. PURCHASE PAYMENT MINIMUM IS $5,000. MAXIMUM CANNOT EXCEED $1,000,000 WITHOUT
PRIOR APPROVAL.
SUBMITTED WITH APPLICATION $ ___________ ESTIMATED TOTAL AMOUNT $ ___________
BY CHECK OR DRAFT FROM ALL
SOURCES
B. PLAN TYPE AND PAYMENT CLASSIFICATION SELECT ONLY ONE PLAN TYPE AND COMPLETE
THE ROW FOR THAT TYPE. [FOR SEP IRA, COMPLETE [FORM 5305-SEP]. FOR
BENEFICIARY IRA, COMPLETE [FORMS CLS-520, CLS-521 AND CLS-381]. FOR
NON-QUALIFIED BENEFICIARY, COMPLETE [FORMS CLS-522, CLS-523 AND CLS-524].
ONLY CREDIT UNION-OWNED 457 PLANS ARE ALLOWED. FOR IRAS, CURRENT AND PRIOR
YEAR CONTRIBUTIONS WILL BE BASED ON SIGNED DATE OF APPLICATION.]
PLAN TYPE PAYMENT CLASSIFICATION
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o Non-qualified $ ______________ $ ______________
NON-1035 1035 EXCHANGE
EXCHANGE
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o Non-qualified $ ______________
Beneficiary 1035 EXCHANGE
(Stretch)
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o Traditional IRA
$ ______________ $ ______________ $ ______________ $ ______________
ROLLOVER TRANSFER CURRENT YEAR PRIOR YEAR
CONTRIBUTION CONTRIBUTION
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o Roth IRA $ ______________ $ ______________ $ ______________ $ ______________ $ _______________
ROLLOVER TRANSFER CURRENT YEAR PRIOR YEAR ROTH CONVERSION
CONTRIBUTION CONTRIBUTION
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o SEP IRA $ ______________ $ ______________ $ ______________ $ ______________
ROLLOVER TRANSFER CURRENT YEAR PRIOR YEAR
CONTRIBUTION CONTRIBUTION
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o Beneficiary IRA $ ______________ $ ______________
(Stretch) ROLLOVER TRANSFER
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o 457(b) $ ______________ $ ______________
ROLLOVER TRANSFER
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o 457(f) $ ______________ $ ______________
ROLLOVER TRANSFER
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[STATE VARIATIONS]
c. SOURCE OF PAYMENTS COMPLETE ONE LINE FOR EACH PAYMENT. FOR 401(K) PLAN
TYPES, LIST ROTH 401(K) AMOUNTS SEPARATELY FROM REGULAR 401(K) AMOUNTS.
CONTRACT WILL BE ISSUED ONLY AFTER ALL SOURCES ARE RECEIVED.
SOURCE/COMPANY NAME ESTIMATED AMOUNT EXISTING PLAN TYPE
__________________________________ $ _____________________ _____________________
__________________________________ $ _____________________ _____________________
__________________________________ $ _____________________ _____________________
__________________________________ $ _____________________ _____________________
__________________________________ $ _____________________ _____________________
SPDMGIAAPP-2012 PAGE 2 DOC CODE 02
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4 REPLACEMENT REQUIRED. ANSWER BOTH QUESTIONS AND COMPLETE
AS APPROPRIATE.
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o Yes o No Do you have any existing life insurance policies or annuity
contracts with MEMBERS Life Insurance Company or any other
company? If yes, a completed Important Notice: Replacement of
Life Insurance or Annuities must accompany this application if
required by your state.
o Yes o No Will this contract replace, discontinue or change any existing
life insurance policies or annuity contracts with MEMBERS Life
Insurance Company or any other company? If yes, a completed
Replacement Form must accompany this application if required
by your state.
COMPANY NAME OF POLICY/CONTRACT BEING REPLACED POLICY/CONTRACT NUMBER
___________________________________________________ ___________________________
___________________________________________________ ___________________________
___________________________________________________ ___________________________
___________________________________________________ ___________________________
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5 BENEFICIARY REQUIRED. LIST EACH BENEFICIARY AND CHECK
WHETHER PRIMARY OR CONTINGENT. DO NOT
INCLUDE FRACTIONS OR PERCENTS FOR EVEN
DISTRIBUTION OF PROCEEDS. IF TYPE IS NOT
CHECKED, WE WILL ASSUME PRIMARY. TO LIST
MORE USE A SEPARATE SIGNED AND DATED PAPER.
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THE OWNER HAS THE RIGHT TO PREDETERMINE HOW A BENEFICIARY WILL RECEIVE THE
DEATH BENEFIT BY COMPLETING [FORM 40RESTRICT, BENEFICIARY DESIGNATION WITH
RESTRICTED PAYOUT OPTIONS].
FOR INDIVIDUAL BENEFICIARIES:
o Primary _____________________________________________ ________________________________________
o Contingent NAME ADDRESS
_________________________________ _____________________________ _____________________
RELATIONSHIP SOCIAL SECURITY NUMBER DATE OF BIRTH
o Primary _____________________________________________ ________________________________________
o Contingent NAME ADDRESS
_________________________________ _____________________________ _____________________
RELATIONSHIP SOCIAL SECURITY NUMBER DATE OF BIRTH
o Primary _____________________________________________ ________________________________________
o Contingent NAME ADDRESS
_________________________________ _____________________________ _____________________
RELATIONSHIP SOCIAL SECURITY NUMBER DATE OF BIRTH
o Primary _____________________________________________ ________________________________________
o Contingent NAME ADDRESS
_________________________________ _____________________________ _____________________
RELATIONSHIP SOCIAL SECURITY NUMBER DATE OF BIRTH
FOR TRUST BENEFICIARIES:
o Primary _____________________________________________ ________________________________________
o Contingent NAME OF TRUST ADDRESS
________________________________________________________________ _____________________
TRUSTEE NAME(S) DATE OF TRUST
SPDMGIAAPP-2012 PAGE 3 DOC CODE 02
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6 ELECTRONIC AUTHORIZATION OPTIONAL. SEE [FORM CLS-56.
PHONE/FAX/INTERNET AUTHORIZATION] FOR
DETAILS ON WHAT TRANSACTIONS MAY BE
AUTHORIZED.
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I understand that I will automatically have phone/fax/internet authorization
unless the following box is marked:
o I do NOT want this authorization.
I understand that the registered representative/agent/insurance producer
assigned to my contract will automatically have phone/fax/internet
authorization unless the following box is marked:
o I do NOT want the registered representative/agent/insurance producer
assigned to my contract to have this authorization.
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7 EMAIL CONSENT OPTIONAL. THIS CONSENT ALLOWS YOU TO RECEIVE
THE PROSPECTUS AND OTHER REGULATORY
DOCUMENTS ELECTRONICALLY VIA EMAIL. THIS
REDUCES ENVIRONMENTAL WASTE AND THE VOLUME
OF MAIL YOU RECEIVE.
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I DO want to receive my regulatory documents, including the prospectus,
statement of additional information, annual and semi-annual reports, and proxy
statements via email, and I understand and agree:
o This consent will be in effect until I revoke it.
o While at certain times the Company may still choose to deliver paper copies,
I can receive paper copies at any time by calling MEMBERS Life Insurance
Company at [1.800.798.6600].
o I may be charged by a third party vendor for the access to the internet
necessary to obtain the documents and/or download Adobe Reader software, but
I will not be charged by MEMBERS Life Insurance Company.
o I must have access to computer equipment and software that can access a
website and read documents formatted for Adobe Reader. Adobe Reader software
can be downloaded for no charge at www.adobe.com.
You must provide a valid email address to participate in electronic delivery
of your regulatory documents. You will receive an email confirmation of your
consent. The consent process will be complete only when you reply to that
email as instructed.
OWNER EMAIL __________________________________________________________________
JOINT OWNER EMAIL (IF DIFFERENT THAN OWNER EMAIL) ____________________________
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8 FRAUD WARNING REQUIRED. REFER TO WARNING FOR YOUR STATE
BELOW.
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[ALABAMA:] [Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to
restitution, fines or confinement in prison, or any combination thereof.]
[COLORADO:] [It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant
for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado division of insurance within the department
of regulatory agencies.]
[DISTRICT OF COLUMBIA:] [WARNING: It is a crime to provide false or
misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.]
[MAINE:] [See section 10. The fraud warning that applies to you appears
directly above your signature.]
[MARYLAND:] [Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.]
[NEW JERSEY:] [Any person who includes any false or misleading information on
an application for an insurance policy is subject to criminal and civil
penalties.]
[OHIO:] [Any person who, with intent to defraud or knowing that he 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.]
[PENNSYLVANIA:] [Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or a
statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person
to criminal and civil penalties.]
ALL OTHER STATES: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND
SUBJECT TO FINES AND CONFINEMENT IN PRISON, AND DENIAL OF INSURANCE BENEFITS,
DEPENDING ON STATE LAW.
[STATE VARIATIONS]
SPDMGIAAPP-2012 PAGE 4 DOC CODE 02
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9 SPECIAL INSTRUCTIONS OPTIONAL. PLEASE PRINT CLEARLY.
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_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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10 AGREEMENT REQUIRED. READ AND HAVE ALL PARTIES TO THE
CONTRACT NAMED IN SECTION 2 SIGN BELOW.
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o I have read the application and represent that all statements and answers,
as they pertain to me, are true and complete to the best of my knowledge and
belief and are the basis for any contract issued by MEMBERS Life Insurance
Company; and I understand that no information will be considered to have
been given to MEMBERS Life Insurance Company unless it is stated in this
application.
o I understand that no registered representative/agent/insurance producer is
authorized to make, void, waive or change any conditions or provisions of
the application or contract.
o The USA Patriot Act requires all financial institutions, including insurance
companies, to verify the identity of their customers. I understand that
providing my name, address, date of birth and taxpayer identification number
allows MEMBERS Life Insurance Company to verify my identity. This
verification process may include the use of third party sources to verify
the information I provided.
o I understand the contract I have applied for is suitable for me based on my
investment objective, financial situation and needs. In addition, if this
contract will replace, change or modify an existing contract, I hereby
confirm my belief that replacing my existing contract is suitable, and I
have considered product features, fees and charges.
o I understand that MEMBERS Life Insurance Company will have no liability
until a contract is issued, delivered and accepted by me.
o I understand my contract will not be issued until the index purchase date
following receipt of my application by MEMBERS Life Insurance Company in
good order. No interest will be credited to my purchase payment prior to the
contract issue date.
o I UNDERSTAND WHILE CONTRACT VALUES MAY BE AFFECTED BY AN EXTERNAL INDEX, THE
CONTRACT DOES NOT DIRECTLY PARTICIPATE IN ANY STOCK OR EQUITY INVESTMENT.
CONTRACT VALUES ARE NOT GUARANTEES, PROMISES OR WARRANTIES.
o I understand the surrender charge schedule begins when the purchase payment
is credited to my contract and runs for the number of years selected as my
Initial Index Period in section 1a.
o I have received a copy of the [MEMBERS(R) Market Zone Annuity] Disclosure.
o I ACKNOWLEDGE RECEIPT OF A CURRENT PROSPECTUS FOR THIS ANNUITY, AND
UNDERSTAND THAT BECAUSE OF THE MARKET VALUE ADJUSTMENT PROVISION OF THIS
CONTRACT, THE AMOUNT I RECEIVE UPON WITHDRAWAL MAY VARY FROM THE STATED
CONTRACT VALUE.
o I request a Statement of Additional Information.
[MAINE:] [ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND SUBJECT TO FINES AND
CONFINEMENT IN PRISON, AND DENIAL OF INSURANCE BENEFITS, DEPENDING ON STATE
LAW.] [STATE VARIATIONS]
SIGNED AT: _________________ __________ SIGNED ON: __________________________
CITY STATE DATE
________________________________________ _____________________________________
SIGNATURE OF OWNER/TRUSTEE/AUTHORIZED SIGNATURE OF JOINT OWNER (IF NAMED
OFFICER NAMED IN SECTION 2A IN SECTION 2C)
________________________________________
SIGNATURE OF ANNUITANT (IF OTHER THAN
THE OWNER IS NAMED IN SECTION 2B)
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11 HOME OFFICE ONLY FOR ADMINISTRATIVE PURPOSES ONLY. NOT TO BE
USED FOR ANY CHANGE THAT REQUIRES THE
OWNER'S AGREEMENT IN WRITING.
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SPDMGIAAPP-2012 PAGE 5 DOC CODE 02
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12 REGISTERED REPRESENTATIVE REQUIRED. TO BE COMPLETED BY THE REGISTERED
SECTION REPRESENTATIVE/AGENT/INSURANCE PRODUCER.
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A. For replacement information, answer both questions and complete as
appropriate.
To the best of your knowledge:
o Yes o No Does the applicant have any existing life insurance policies or
annuity contracts with MEMBERS Life Insurance Company or any
other company? If yes, a completed Important Notice:
Replacement of Life Insurance or Annuities must accompany this
application if required by the state.
o Yes o No Will this contract replace, discontinue or change any existing
life insurance policies or annuity contracts with MEMBERS Life
Insurance Company or any other company? If yes, a completed
Replacement Form must accompany this application if required by
the state.
If yes, I confirm:
a. This replacement meets the standards for replacement
sales identified in MEMBERS Life Insurance Company's
Statement Regarding the Acceptability of Life and
Annuity Replacement Sales.
b. The following sales materials were used: ________________
If no sales materials were used, state "None."
B. o Yes o No Have you reviewed the owner's identity documents in accordance
with the USA Patriot Act and recorded all necessary information
as follows?
1. If owner is a natural person: o Driver's License o Passport o Green Card o Other Photo ID ____________
LIST TYPE
Card No. ____________________ Expiration Date ______________ Country/State of Issue ____________________
2. If owner is a trust or credit union:
County/State Where Formed _________________________________ Date Formed _________________________________
3. If there is a joint owner: o Driver's License o Passport o Green Card o Other Photo ID ____________
LIST TYPE
Card No. ____________________ Expiration Date ______________ Country/State of Issue ____________________
C. If the applicant is an active duty member of the United States Armed Forces
(including active duty military reserve personnel), I certify I have
completed the proper disclosure if this application was solicited and/or
signed on a military base or installation.
D. If sales materials were used, I certify that I have used only approved sales
materials in connection with this sale and that copies of all sales
materials used were left with the applicant.
E. I have explained to the owner(s) how the annuity will meet their current
financial needs and objectives.
F. I certify that I have reviewed this application and have determined that its
proposed purchase is suitable as required under law based on information
provided by the owner(s), as applicable, including information that is
reasonably appropriate to determine the suitability of my recommendation.
G. I certify that I have also considered the liquidity needs of the owner(s),
along with risk tolerance and investment time horizon; I have followed my
broker/dealer's suitability guidelines in the recommendation of this
annuity; and I acknowledge that this application is subject to review for
suitability by my broker/dealer.
H. I am FINRA-registered and state-licensed for registered annuity contracts in
all required jurisdictions.
I. I certify that I have truly and accurately recorded the information provided
by the applicant.
[J. I select the following compensation option:
If no option is selected, then option 1 will apply. o 1 (T000) o 2 (T025)]
I UNDERSTAND THAT WHEN I SIGN THIS APPLICATION, I AM AGREEING TO ALL THE TERMS
AND CONDITIONS APPLICABLE TO ME AS A REGISTERED REPRESENTATIVE.
SIGNATURE _______________________________________________________ Date _________________________________________
SIGNATURE OF REGISTERED REPRESENTATIVE
REP ID __________________________________ REP NAME _________________________________________________
5-DIGIT REP NUMBER PRINT FULL NAME
REP PHONE __________________________________ REP EMAIL _________________________________________________
BEST NUMBER TO CALL PRINT EMAIL
CREDIT UNION ID __________________________________ CREDIT UNION NAME _________________________________________
8-DIGIT CU NUMBER (IF APPLICABLE) PRINT NAME OF CU (IF APPLICABLE)
BROKER/DEALER ID __________________________________ BROKER/DEALER NAME _________________________________________
B/D NUMBER PRINT NAME OF B/D (IF OTHER THAN CBSI)
General Agent ID __________________________________ GENERAL AGENT NAME _________________________________________
GA NUMBER (IF APPLICABLE) PRINT NAME OF GA (IF APPLICABLE)
SPDMGIAAPP-2012 PAGE 6 DOC CODE 0
