Form of Application-Amendment. (Form No. 2020-VAILAPPAMEND)

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

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 ZoneChoiceTM Annuity
		●	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

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.

	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