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

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 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

 

 

 

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