Form of Application-Amendment. (Form No. 2020-VAILAPPAMEND)
EX-4.III 10 g170483_ex4iii.htm FORM OF APPLICATION-AMENDMENT
Exhibit 4(iii)
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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: | ||||
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2020-APPAMEND
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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
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