Form of Application (effective May, 2023). (Form No. 2020-VAILAPP)

EX-4.IIB 2 g189533_ex4iib.htm FORM OF APPLICATION

Exhibit 4(ii)(b)

 

 

 

Application

[TruStage™ ZoneChoice Annuity]
Single Premium Deferred Variable Annuity with Index-Linked Interest Options [2000 Heritage Way  ▪ Waverly, IA 50677]
1  Plan Option[s]

[Check one plan option.] [☐][TruStage™ ZoneChoice Annuity]

2  Owner and Annuitant

Section 2A must be completed. The owner will be the annuitant unless an annuitant is named in section 2B. To name a joint owner, complete section 2C. To name more parties to the contract, use section 8. Minimum age on contract issue date is [21]. Maximum age on contract issue date is [85].

A.Owner. Complete this first box for a natural person owner.
Name       Gender  ☐  Male ☐  Female  
  FIRST MI LAST        
Date of Birth       U.S. Citizen  ☐  Yes ☐  No  
               

 

Complete this box if the owner is a non-natural person, such as a trust/entity owner. This is only allowed for a non-qualified annuity type. For a trust owner, submit [form 1920(ML)] and a copy of the trust document or [form 1919(ML)]. For entities other than a trust, complete [form1921(ML)].

Name of Trust/Entity    
Date of Trust/Incorporation    Person Authorized to Receive Correspondence    
Trustee/Authorized Person Name(s)    
     

 

All owners must complete this next box. 

Social Security Number or Employer ID Number   Daytime Phone    ☐  Cell ☐  Other  
Residential Address            
    STREET (CANNOT BE P.O. BOX) CITY  STATE ZIP  
Mailing Address (if different)        
  STREET OR P.O. BOX CITY  STATE ZIP  
Email Address          
           

 

B.Annuitant (if other than Owner). Complete this box only if the annuitant is someone other than the owner named in section 2A.
Name       Gender  ☐  Male ☐  Female  
  FIRST MI LAST        
Date of Birth   Relationship to Owner(s)   U.S. Citizen  ☐  Yes ☐  No  
Social Security Number   Daytime Phone    ☐  Cell ☐  Other  
Residential Address            
    STREET (CANNOT BE P.O. BOX) CITY  STATE ZIP  
Mailing Address (if different)          
  STREET OR P.O. BOX CITY  STATE ZIP  

 

C.Joint Owner. Complete this box to name a joint owner. Must be an individual person. Only allowed for a non-qualified annuity type.
Name       Gender  ☐  Male ☐  Female  
  FIRST MI LAST        
Date of Birth       U.S. Citizen  ☐  Yes ☐  No  
Social Security Number   Daytime Phone    ☐  Cell ☐  Other  
Residential Address            
    STREET (CANNOT BE P.O. BOX) CITY  STATE ZIP  
Mailing Address (if different)          
  STREET OR P.O. BOX CITY  STATE ZIP  
Email Address          
           

 

[Alaska and Arizona:] [Upon written request, we will provide within a reasonable time (within 10 days of your written request) 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 or notify us within 10 days (30 days if you are age 65 or over and reside in Arizona) that you do not want to keep it. We will refund either the Contract Value, or the greater of the Contract Value or Purchase Payment(s) less withdrawals, as required by state law within 7 days of the date of cancellation. You may return it to MEMBERS Life Insurance Company at the address shown above, or to the agent who sold it to you.]

I UNDERSTAND THAT THE VALUES PROVIDED BY THE CONTRACT MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT.

 

 

 

 

3 Annuity Type and Payment Source

 

Complete sections 3A and 3B. [For SEP IRA, complete form 5305-SEP.]

 

A.Annuity Type. Check one annuity type and complete the row for that type. Total your payment classification(s) at the bottom of this section.

 

  ANNUITY TYPE       PAYMENT CLASSIFICATION      
  ☐ Non-qualified                      
  $   $              
    NON-1035
EXCHANGE		   1035 EXCHANGE            
☐ Non-qualified Stretch                    
      $              
        1035 EXCHANGE            
Individual Retirement Annuity(IRA) (check only one) $   $   $   $   $  
☐  Traditional IRA   ROLLOVER   TRANSFER   CURRENT YEAR   PRIOR YEAR   ROTH CONVERSION
☐  Roth IRA           CONTRIBUTION    CONTRIBUTION (AVAILABLE ONLY IF
☐  Simplified Employee                    ROTH IRA BOX IS
Pension (SEP) IRA                   CHECKED) 
Inherited IRA                    
☐  Traditional IRA $   $              
☐  Roth IRA   ROLLOVER   TRANSFER            
                     
  Enter total purchase payment. Enter the total of all amounts above at the right. Minimum is [$5,000] and maximum is [$999,999 ($1,000,000+ requires prior approval)]. Make any checks payable to MEMBERS Life Insurance Company. The purchase payment applied will equal the actual amount received by the Company. $      
           

 

B.Source(s) of Payment. This section must be completed, even if there is only one source of payment. Complete one line for each payment source. (Combining after-tax and tax-deferred dollars from qualified plan rollovers is not permitted; separate applications and contracts are required for both the after-tax dollars (Roth) and tax deferred amounts.) All sources of funds must be received before the contract will be issued.

 

Source/Company Name   Estimated Amount/
Amount If By Check		   Existing Plan Type
         
  $      
         
  $      
         
  $      
         
  $      

 

2020-VAILAPPPage 2DOC CODE 02 0623

 

 

4 Purchase Payment Allocation

 

Complete the section below to allocate your purchase payment. Allocation percentages must total 100%. Use only 1% increments.

 

  Percentage Allocation Option  

 

 

 % [Declared Rate Account with 1-Year Interest Term]

 

 

  [S&P 500 Index with 1-Year Interest Term and Floor
% Select one Floor:
  ☐ 0% ☐ -1% ☐ -2% ☐ -3% ☐ -4% ☐ -5% ☐ -6% ☐ -7% ☐ -8% ☐ -9% ☐ -10%]
  [Barclays Risk Balanced Index with 1-Year Interest Term and Floor
% Select one Floor:
  ☐ 0% ☐ -1% ☐ -2% ☐ -3% ☐ -4% ☐ -5% ☐ -6% ☐ -7% ☐ -8% ☐ -9% ☐ -10%]

%

 

[Dimensional US Small Cap Value Systematic Index with 1-Year Interest Term and Floor

 

Select one Floor: ] 

 

☐ 0% ☐ -1% ☐ -2% ☐ -3% ☐ -4% ☐ -5% ☐ -6% ☐ -7% ☐ -8% ☐ -9% ☐ -10%]

 

% [S&P 500 Index with 1-Year Interest Term and -10% Buffer]
% [Dimensional US Small Cap Value Systematic Index with 1-Year Interest Term and -10% Buffer] 
 % [S&P 500 Index with 6-Year Interest Term and -10% Buffer]
% [Barclays Risk Balanced Index with 6-Year Interest Term and -10% Buffer]
% [Dimensional US Small Cap Value Systematic Index with 6-Year Interest Term and -10% Buffer]
100% Total
   

 

5 Replacement Information

 

Read and answer both questions and complete all information.

 

☐  Yes ☐  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.
☐  Yes ☐  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
         
         
         
         
         
         
         
         

 

2020-VAILAPPPage 3DOC CODE 02 0623

 

6 Beneficiary

 

   
IMPORTANT
INFORMATION

●     List each primary beneficiary and each contingent beneficiary, if any, below. If the type (primary or contingent) is not checked, primary is assumed. Use section 8 or a separate signed and dated sheet of paper to list more beneficiaries. 

●     Death benefit proceeds will be divided equally among the named beneficiaries, unless indicated otherwise. 

●     If a joint owner is named, the surviving joint owner is the automatic primary beneficiary. List each contingent beneficiary, if any, below. 

●     If a non-natural person is named as owner, the non-natural person is typically named as the primary beneficiary. 

   

 

For Individual Beneficiaries:

_____% Share

☐  Primary              
☐  Contingent NAME     ADDRESS  
☐  Irrevocable              
  RELATIONSHIP   DATE OF BIRTH   SOCIAL SECURITY NUMBER   DAYTIME PHONE
               
  EMAIL ADDRESS            

 

_____% Share

☐  Primary              
☐  Contingent NAME     ADDRESS  
☐  Irrevocable              
  RELATIONSHIP   DATE OF BIRTH   SOCIAL SECURITY NUMBER   DAYTIME PHONE
               
  EMAIL ADDRESS            

 

_____% Share

☐  Primary              
☐  Contingent NAME     ADDRESS  
☐  Irrevocable              
  RELATIONSHIP   DATE OF BIRTH   SOCIAL SECURITY NUMBER   DAYTIME PHONE
               
  EMAIL ADDRESS            

 

For Non-Natural Person Beneficiaries:

_____% Share

☐  Primary              
☐  Contingent

NAME OF TRUST / ENTITY

     ADDRESS  
☐  irrevocable              
 

NAME OF TRUSTEE/AUTHORIZED PERSON 

               
  TRUST / INCORPORATION DATE   SSN/EIN   DAYTIME PHONE
2020-VAILAPPPage 4DOC CODE 02 0623

 

 

7 Fraud Warning

 

Refer to the warning for your state below.

 

[Alabama, Arkansas, Louisiana and 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.] 

 

[California: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.]  

 

[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.]  

 

[Florida:] [Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.] 

 

[Maine:] [It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.]  

 

[New Hampshire:] [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 denial of insurance benefits, depending on state law.] 

 

[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.] 

 

[Tennessee:] [It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.] 

 

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

 

[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]

 

8 Special Instructions

 

OPTIONAL. Please print any special instructions below for the administrative office to use when processing your application. You may also use this area to list more parties to the contract not listed in section 2 or additional beneficiaries not listed in section 6.

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
2020-VAILAPPPage 5DOC CODE 02 0623

 

9 Agreement and Signature

 

Read and have all parties to the contract sign below.

 

  ●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.
  ●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.
  ●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 provided.
  ●I am exempt from the Foreign Account Tax Compliance Act (FATCA) and it is not applicable.
  ●I certify, under penalties of perjury, that I am a U.S. person (including a U.S. resident alien) and that the Social Security Number or Employer ID Number is correct.
  ●I acknowledge that 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 policy or contract, I hereby confirm my belief that replacing my existing policy or contract is suitable, and I have considered product features, fees and charges.
  ●I understand that MEMBERS Life Insurance Company will have no liability until a contract is issued, delivered and accepted by me.
  ●I understand my contract will not be issued until the contract issue 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.
  ●I UNDERSTAND THAT THE VALUES PROVIDED BY THIS CONTRACT ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT.
  ●I UNDERSTAND THAT THE CONTRACT VALUE ALLOCATED TO A RISK CONTROL ACCOUNT(S) IS VARIABLE AND IS BASED IN PART ON THE INVESTMENT EXPERIENCE OF EXTERNAL INDICES. IT MAY BE AFFECTED BY THOSE EXTERNAL INDICES, AND AS A RESULT, MAY INCREASE OR DECREASE IN VALUE BASED ON THE INVESTMENT EXPERIENCE OF THE RISK CONTROL ACCOUNT(S), SUBJECT TO THE CREDITING STRATEGY. THE RISK CONTROL ACCOUNTS DO NOT DIRECTLY PARTICIPATE IN ANY STOCK OR EQUITY INVESTMENTS.
  ●I UNDERSTAND THAT THE CONTRACT VALUE MAY BE SUBJECT TO AN INTEREST ADJUSTMENT AND AN EQUITY ADJUSTMENT. ANY ADJUSTMENT IS IN ADDITION TO ANY SCHEDULED SURRENDER CHARGE.
  ●I UNDERSTAND THAT THE DEATH BENEFIT IS NOT SUBJECT TO A SURRENDER CHARGE.
  ●I have received and read a copy of the Annuity Disclosure for this product and I understand it.
{●}[If I am a Connecticut resident, I have received the Connecticut Index-Linked Annuity Disclosure applicable to my Plan Option.]
  ●If I am a Minnesota resident, I have received the Annuity Disclosure, Annuity Disclosure Supplement and the Rate Sheet applicable to my Plan Option.
  ●I understand the Annuitant has no rights of ownership to the contract.
  ●I ACKNOWLEDGE RECEIPT OF A CURRENT PROSPECTUS FOR THIS ANNUITY.

 

[State Variations]

 

Signed at     Signed on  
  STATE [OF RESIDENCE]     DATE
         
SIGNATURE OF OWNER, TRUSTEE(S), AUTHORIZED PERSON(S) NAMED IN SECTION 2A   DATE
     
SIGNATURE OF JOINT OWNER NAMED IN SECTION 2C (IF ANY)   DATE
     
SIGNATURE OF ADDITIONAL TRUSTEE(S)/AUTHORIZED PERSON(S) NAMED IN SECTION 2A   DATE

 

     
 
[Louisiana:] [The Annuitant must consent to the contract being purchased when they are not the Owner or Joint Owner.]
     
SIGNATURE OF ANNUITANT NAMED IN SECTION 2B (IF ANY)   DATE                        
     
SIGNATURE OF JOINT ANNUITANT (IF ANY) NAMED IN SECTION 8   DATE
2020-VAILAPPPage 6DOC CODE 02 0623

 

 

10 Administrative Office

 

FOR ADMINISTRATIVE USE ONLY.  Not to be used for any change that requires the owner’s agreement in writing.

 

 
 
 
 
 
 

 

11 Registered Representative/Agent/Insurance Producer

 

To be completed by the registered representative/agent/insurance producer.

 

A.Answer both questions and complete all information to the best of your knowledge and belief.
☐  Yes ☐  No Does the applicant(s) 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.
☐  Yes ☐  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:
    1. 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.
    2. The following sales materials were used:  
    If no sales materials were used, state “None.”

 

B. ☐  Yes ☐  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: ☐  Driver’s License ☐  Passport   ☐  Green Card ☐  Other Photo ID  
            LIST TYPE 
        Card No.   Expiration Date   Country/State of Issue  

 

    2. If owner is a trust/entity:          
               
        Country/State Where Formed       Date Formed  

 

    3. If there is a joint owner: ☐  Driver’s License ☐  Passport ☐  Green Card ☐  Other Photo ID  
            LIST TYPE
          Card No.   Expiration Date   Country/State of Issue  

 

C.If the applicant(s) 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(s).

 

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(s).

 

E.I have reviewed the owner(s) investment objectives, financial situation and needs and explained how the annuity will meet their current financial needs and objectives.

 

F.I certify that I have reviewed the owner(s) suitability information 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 registered with the Financial Industry Regulatory Authority (FINRA) 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 choose the following compensation option:
               
  [☐ 1(T000.0) ☐  2(T025.2) ☐  3(T035.2) ☐  4(T040.2) ☐  5(T050.2) ☐  6(T060.2)    ☐  7(T100.2)]
2020-VAILAPPPage 7DOC CODE 02 0623

 

I UNDERSTAND THAT WHEN I SIGN THIS APPLICATION, I AM AGREEING TO ALL THE TERMS AND CONDITIONS APPLICABLE TO ME AS A REGISTERED REPRESENTATIVE/AGENT/INSURANCE PRODUCER.

 

Signature     Date  
  SIGNATURE OF REGISTERED REPRESENTATIVE/AGENT/INSURANCE PRODUCER     DATE

 

Rep ID   Rep Name    
    5-DIGIT REP NUMBER   PRINT FULL NAME  
Rep Phone   Rep Email    
    BEST NUMBER TO CALL   PRINT EMAIL  
      [FL License Number    
        FL LICENSE NUMBER (IF APPLICABLE)]  
           
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)

 

2020-VAILAPPPage 8DOC CODE 02 0623