Document:

Exhibit
4(iii)

 

[] 

MEMBERS
Life Insurance Company 

[2000
Heritage Way, Waverly, Iowa 50677]

Phone:
[800.798.5500]

[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

 

    1 

     

    

 

	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

 

    2Exhibit
4(iv)

 

	 	 DATA
    PAGE 	CONTRACT
    NUMBER: [123456789]

 

GENERAL
INFORMATION

 

	Owner(s)	Contract Issue Date
	[John
    Doe]	[October
    1, 2020]
	 	 
	Annuitant(s)	Annuitant(s) Issue Age(s)
	[John
    Doe]	[35]	 

  

Endorsements/Riders
Attached:

	 	Nursing
                             Home or Hospital/Terminal Illness Withdrawal Privilege Endorsement

Individual
Retirement Annuity Endorsement

Roth
Individual Retirement Annuity Endorsement

Post
Death Annuity Exchange Endorsement

	 

 

Purchase
Payment: $[10,000.00]

 

SURRENDER
CHARGE SCHEDULE

 

	 	Contract
    Year		1	2	3	4	5	6	7+	 
	Surrender
    Charge %	9%	9%	8%	7%	6%	5%	0%

 

 

WITHDRAWALS

 

Partial
Withdrawal Information:

 

Minimum
Partial Withdrawal Amount: $[100]

Minimum
Surrender Value Remaining After Any Partial Withdrawal: $[2,000]

 

NOTE:
If a partial withdrawal would cause the Surrender Value to be less than the minimum shown above, we will treat your request as
a full surrender.

 

INITIAL
ALLOCATION OPTIONS

 

	Initial
    Allocation Option Start Date:	[October
    10, 2020]
	Initial
    Allocation Option Maturity Date:	[October
    10, 2026]
	Allocation
    Option Period:	[6
    Years]

 

Risk
Control Accounts:

 

	 	[Crediting
        Strategy: Indexed Interest Floor and Indexed Interest
        Cap

        Available
        Indexed Interest Floors: 0%, -1%, -2%, -3%, -4%, -5%, -6%, -7%, -8%, -9%, -10%]
	 
	 	 	 	 	 	 	 	 
	Index	Interest	Minimum
    Indexed	 	Initial	 	Initial
    Indexed	Initial
    Indexed Interest
	 	Term	Interest
    Cap	Allocation	Interest
    Floor	Cap
	 	 	 	 	 	 	 	 	 
	[S&P
    500 Index]	[1-Year]	[1.00%]	 	[50%]	 	[-5%]	[10%]
	 	 	 	 	 	 	 	 	 
	[Barclays
    Risk	[1-Year]	[1.00%]	 	[10%]	 	[-5%]	[10%]
	Balanced
    Index]	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 

 

    1 

     

    

 

 

DATA
PAGE continued

 

 

	 	[Crediting
    Strategy: Indexed Interest Buffer and Indexed Interest Participation
    Rate]	 
	 	 	 	 	 	 	 	 
	Index	Interest	Minimum
    Indexed	 	Initial	 	Indexed	Initial
    Indexed Interest
	 	Term	Participation
    Rate	Allocation	Interest
    Buffer	Participation
    Rate
	 	 	 	 	 	 	 	 	 
	[S&P
    500 Index]	[6-Year]	[10.00%]	 	[0%]	 	[-10%]	[100%]
	 	 	 	 	 	 	 	 	 
	[Barclays
    Risk	[6-Year]	[10.00%]	 	[30%]	 	[-10%]	[100%]
	Balanced
    Index]	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 

 

[Additional
Risk Control Accounts]

 

Declared
Rate Account:

Crediting
Strategy: Interest Rate

 

	 	Interest	Initial
    Minimum	 	Initial	 	Initial
    Interest	  
	Term	Interest
    Rate*	Allocation	Rate
	 	 	 	 	 	 	 
	[1-Year]	[1.00%]	 	[10%]	 	[3.00%]
	 	 	 	 	 	 	 

 

[Applicable
Index Disclosure Wording will print here, if required.]

 

*The
Minimum Interest Rate will be calculated each calendar quarter (on each January 1, April 1, July 1, and October 1). The Minimum
Interest Rate will be determined on each Allocation Option Start Date based on the calendar quarter in which the Allocation Option
Start Date falls and will apply for the Allocation Option Period.

 

The
Minimum Interest Rate will never be less than the lessor of: 

		a)	3%;
                                         or

		b)	The
                                         interest rate determined as follows:

		1)	The
                                         average of the three applicable monthly five-year Constant Maturity Treasury (CMT) rates
                                         reported by the Federal Reserve, as described below, and rounded to the nearest 0.05%;

		2)	Minus
                                         1.25%; and

		3)	Subject
                                         to a minimum interest rate of [1.00%].

 

The
three monthly five-year Constant Maturity Treasury rates used in the calculation above are as follows: 

		●	The
                                         prior September, October, and November monthly five-year CMT rates will be used to determine
                                         the first quarter interest rate that is effective each January 1;

		●	The
                                         prior December, January, and February monthly five-year CMT rates will be used to determine
                                         the second quarter interest rate that is effective each April 1;

		●	The
                                         prior March, April, and May monthly five-year CMT rates will be used to determine the
                                         third quarter interest rate that is effective each July 1; and

		●	The
                                         prior June, July, and August monthly five-year CMT rates will be used to determine the
                                         fourth quarter interest rate that is effective each October 1.

 

    2 

     

    

 

DATA
PAGE continued

 

 

ADJUSTED
INDEX RETURN

 

	 	[The
    Adjusted Index Return for the Indexed Interest Floor and Indexed Interest Cap Crediting Strategy is calculated as follows: 	
	 	 	 
	 	●	If the Index Return is positive or zero, the
    Adjusted Index Return equals the lessor of the Index Return or the Indexed Interest Cap.
	 	●	If the Index Return is negative, the Adjusted
    Index Return equals the greater of the Index Return or the Indexed Interest Floor.]
	 	 	 
	[The
    Adjusted Index Return for the Indexed Interest Buffer and Indexed Interest Participation Rate Crediting Strategy is calculated
    as follows:
	 	●	If the Index Return is positive, the Adjusted
    Index Return equals the Index Return multiplied by the Indexed Interest Participation Rate.
	 	●	If the Index Return is between zero and the Indexed
    Interest Buffer, the Adjusted Index Return equals zero.
	 	●	If the Index Return is less than the Indexed
    Interest Buffer, the Adjusted Index Return equals the Index Return minus the Indexed Interest Buffer.]

 

INTEREST
ADJUSTMENT

 

Interest
Adjustment Indices:

Interest
Adjustment Index 1: [Constant Maturity Treasury]

Interest
Adjustment Index 2: [ICE BofA 1-10 Year US Corporate Constrained Index]

 

[Applicable
Index Disclosure Wording will print here, if required.]

 

INCOME
PAYOUT INFORMATION

 

	Anticipated
    Payout Date	 	Anticipated
    Income Option	 
	[10/01/2080]	 	 	 	[Monthly
    Payments - Life Income Option
	 	 	 	 	with
    a 10-Year Guaranteed Period Certain]
	Life
    Income Rate Type	 	 	 	 
	[Based
    on Gender]	 	 	 
	 	 	 	 
	Mortality
    Table	 	Income
    Payout Option Rate	 
	[Annuity
    2000 with Mortality Improvement]	[1.00%]	 	 

 

Income
Option Tables: 

The
following monthly income payment tables show values per $1,000 applied to the Income Payout Option and are based on the Life Income
Rate Type, Income Payout Option Rate, and Mortality Table.

 

Rates
for years payable and guaranteed periods certain not shown, if allowed by us, will be calculated on an actuarially equivalent
basis and will be available upon request.

 

The
Annuitant’s adjusted age is determined by [taking the Annuitant’s age as of the date
of the first payment minus five years, and then subtracting two additional years for each five full years elapsed between January
1, 2013 and the Income Payout Date].

 

    3 

     

    

 

DATA
PAGE continued

 

 

Option
1 – Installment Option Rates – First Payment Due at Beginning of Period.

	Number
    of Years	 
	 	Payable	Payment	 
	  	    	10	8.75	 
	15	5.98
	20	4.59
	25	3.76
	30	3.21

 

Option
2 – Life Income Option Rates – Guaranteed Period Certain – First Payment Due at Beginning of Period.

 

	 	Life
    Income Rate Type: Based on Gender	 	 	 	 	 	 
	 	Years	Adjusted
    Age – Male
	 	Certain	55	60	65	70	75	80	85	90	95
	0	3.22	3.69	4.32	5.19	6.37	8.02	10.34	13.63	18.28
	5	3.22	3.68	4.30	5.13	6.22	7.65	9.45	11.52	13.69
	10	3.20	3.64	4.21	4.92	5.77	6.69	7.55	8.21	8.61
	15	3.16	3.56	4.04	4.57	5.10	5.53	5.81	5.94	5.98
	20	3.09	3.43	3.79	4.12	4.37	4.52	4.58	4.59	4.59
	 	 	 	 	 	 	 	 	 	 	 	 
	 	Years	Adjusted
    Age – Female
	 	Certain	55	60	65	70	75	80	85	90	95
	0	3.01	3.43	3.99	4.77	5.89	7.53	9.98	13.52	18.17
	5	3.01	3.42	3.98	4.73	5.80	7.28	9.24	11.47	13.59
	10	3.00	3.40	3.93	4.62	5.50	6.52	7.49	8.19	8.59
	15	2.98	3.35	3.82	4.38	4.98	5.48	5.80	5.94	5.98
	20	2.94	3.27	3.65	4.03	4.33	4.51	4.58	4.59	4.59
	 	 	 	 	 	 	 	 	 	 
	Life
    Income Rate Type: Unisex
	Years	Adjusted
    Age - Unisex
	Certain	55	60	65	70	75	80	85	90	95
	 	 	 	 	 	 	 	 	 	 
	0	3.05	3.48	4.06	4.85	5.98	7.63	10.05	13.54	18.19 
	5	3.05	3.47	4.04	4.81	5.88	7.35	9.28	11.48	13.61 
	10	3.04	3.45	3.98	4.68	5.55	6.55	7.50	8.20	8.59 
	15	3.01	3.40	3.87	4.42	5.00	5.49	5.80	5.94	5.98 
	20	2.97	3.30	3.68	4.05	4.34	4.51	4.58	4.59	4.59 

 

 

    4 

     

    

 

DATA
PAGE continued

 

 

Option
3 – Life Income Option Rates – Joint and Survivor – 10 Year Guaranteed Period Certain – First Payment
Due at Beginning of Period.

 

		Life
    Income Rate Type: Based on Gender	 
	Adjusted	 	 	 	 	Adjusted
    Age – Female	 	 	 
	Age
    -	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	Male	55	60	65	70	75 	80  	85    	90    	95    
	55	2.66	2.81	2.94	3.04	3.11	3.15	3.18	3.19	3.19
	60	2.77	2.98	3.18	3.35	3.47	3.56	3.60	3.63	3.64
	65	2.86	3.13	3.40	3.66	3.88	4.04	4.13	4.18	4.20
	70	2.92	3.24	3.59	3.97	4.31	4.59	4.77	4.87	4.91
	75	2.95	3.31	3.74	4.22	4.72	5.16	5.48	5.66	5.74
	80	2.98	3.36	3.83	4.40	5.05	5.68	6.18	6.49	6.63
	85	2.99	3.38	3.88	4.52	5.28	6.09	6.78	7.23	7.46
	90	2.99	3.39	3.91	4.58	5.42	6.35	7.20	7.78	8.09
	95	3.00	3.40	3.92	4.61	5.48	6.48	7.42	8.08	8.46
	 

        Life
        Income Rate Type: Unisex
	 	 	 	 	 	 
	Adjusted	 	Adjusted
    Age - Unisex
	Age
    -	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	Unisex	 	55	60	65	70	75	80	85	90	95
	55	 	2.63	2.76	2.86	2.93	2.98	3.01	3.03	3.03	3.04
	60	 	2.76	2.95	3.11	3.24	3.34	3.39	3.43	3.44	3.45
	65	 	2.86	3.11	3.36	3.58	3.75	3.87	3.93	3.96	3.98
	70	 	2.93	3.24	3.58	3.91	4.21	4.43	4.57	4.64	4.67
	75	 	2.98	3.34	3.75	4.21	4.66	5.05	5.31	5.46	5.53
	80	 	3.01	3.39	3.87	4.43	5.05	5.64	6.10	6.37	6.51
	85	 	3.03	3.43	3.93	4.57	5.31	6.10	6.76	7.19	7.42
	90	 	3.03	3.44	3.96	4.64	5.46	6.37	7.19	7.77	8.08
	95	 	3.04	3.45	3.98	4.67	5.53	6.51	7.42	8.08	8.44

 

 

 

    5

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