Amendment to Annuity Application between MEMBERS Life Insurance Company and Policyholder

Summary

This document is an amendment to an existing annuity application and contract between MEMBERS Life Insurance Company and the policyholder(s). It updates or clarifies key contract details, such as plan options, annuity type, ownership, and purchase payment allocation. The amendment becomes effective as of the contract's issue date and requires signatures from the owner, joint owner, and, if applicable, the annuitant(s). The parties confirm that the information provided is accurate and complete as of the signing date.

EX-4.III 10 g170483_ex4iii.htm FORM OF APPLICATION-AMENDMENT

Exhibit 4(iii)

[]

MEMBERS Life Insurance Company

[2000 Heritage Way, Waverly, Iowa 50677]

Phone: [800 ###-###-####]

[http://www.cunamutual.com]

AMENDMENT TO ANNUITY APPLICATION

IMPORTANT INFORMATION REGARDING YOUR CONTRACT COVERAGE

Owner:

[John Doe]

[Contract Number:

[123456789]]

[Joint Owner:

[Jane Doe]

]

[Annuitant (if other than Owner):

[James Doe]

]

[Joint Annuitant (if other than Joint Owner):

[Jimmy Doe]

]

Date of Original Application:

[October 1, 2020]

I understand and agree that the application [and contract issued on the basis of the application] is amended as follows:

Plan Option
The Plan Option is [____________].
	●	CUNA Mutual Group ZoneChoice^TMAnnuity
	●	Other – see Explanation of Variables


Owner and Annuitant
	●	The gender of the above named [Owner] is [male].
	●	The date of birth of the above named [Owner] is [January 15, 1956].
	●	The [Joint Annuitant] of this contract is [Jane Doe].
	●	Other – see Explanation of Variables.


Annuity Type
The Annuity Type is [___________].
	●	Non-qualified;
	●	Non-qualified stretch
	●	Traditional IRA;
	●	Roth IRA;
	●	Simplified Employee Pension (SEP) IRA;
	●	Inherited IRA – Traditional;
	●	Inherited IRA - Roth
	●	Other – see Explanation of Variables


Purchase Payment Allocation
The purchase payment is allocated as follows:
	●	[Percentage] [to Allocation Option]
	●	Other – see Explanation of Variables

	Incomplete Information

	I hereby verify that [______________] of the application is as stated below:
		------- Dictation Area --------

2020-APPAMEND

Signatures

This amendment is effective as of the issue date of the contract to which it is attached. I agree that the representations in this Amendment are true and complete to the best of my knowledge and belief on the date signed.

Date signed:
	(month, day and year)

	Signature of Owner


	Signature of Joint Owner


	[Louisiana:] [The Annuitant must agree to the representations in this Amendment when they are not the Owner or Joint Owner.]

	Signature of Annuitant (if other than Owner)

	Signature of Joint Annuitant (if other than Joint Owner)

MEMBERS Life Insurance Company



	President

2020-APPAMEND