Exhibit
4(ii)


 


	Application	[	CUNA
    MUTUAL GROUP]


 


	[CUNA
    Mutual Group ZoneChoiceTM  Annuity]	MEMBERS
    Life Insurance Company
	Single
    Premium Deferred Variable Annuity with Index-Linked Interest Options	[2000
    Heritage Way  • Waverly, IA 50677]


 


	1	 Plan
    Option[s]


 


[Check
one plan option.] [☐][ CUNA
Mutual Group ZoneChoiceTM 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.


 


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	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
	 	 	 	 	 
	 	$	 	 	 
	 	 	 	 	 
	 	$	 	 	 
	 	 	 	 	 
	 	$	 	 	 
	 	 	 	 	 
	 	$	 	 	 


 


	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%]
	%	[S&P
    500 Index with 6-Year Interest Term and -10% Buffer]
	%	[Barclays
    Risk Balanced Index with 6-Year Interest Term and -10% Buffer]
	 	100%	Total	 



 





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	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
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 
	 	 	 	 	 


 


	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


 





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	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.] 


[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.]


[Virginia:]
[Any person who, with
the intent to defraud or knowing that s/he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may have violated the 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.


 





	 
	 
	 
	 
	 
	 
	 
	 
	 
	 
	 
	 
	 
	 




 


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	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.]






	●	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



 


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	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)]




 


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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)


 


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