Document:

Exhibit
4(i)

 

	[ ]	

         

	MEMBERS
    Life Insurance Company [2000
                                         Heritage Way, Waverly, Iowa 50677]

Phone:
[800.798.5500]

[http://www.cunamutual.com]

	SINGLE
    PREMIUM DEFERRED 

    VARIABLE ANNUITY CONTRACT WITH 

    INDEX-LINKED INTEREST OPTIONS

  

CONTRACT
NUMBER: [123456789]

 

READ
YOUR CONTRACT CAREFULLY. This is a legal contract between the Owner and MEMBERS Life Insurance Company, and hereafter will
be referred to as the contract. 

 

This
contract is issued to the Owner in consideration of the application and the Purchase Payment. MEMBERS Life Insurance Company will
pay the benefits of this contract, subject to its terms and conditions, which will never be less than the amount required by the
state law in which the contract is delivered.

 

THE
VALUES PROVIDED BY THIS CONTRACT ARE NOT GUARANTEED AS TO A FIXED DOLLAR AMOUNT.

 

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.

  

THE
CONTRACT VALUE MAY BE SUBJECT TO AN INTEREST ADJUSTMENT AND AN EQUITY ADJUSTMENT. ANY ADJUSTMENT IS IN ADDITION TO ANY SCHEDULED
SURRENDER CHARGE. 

 

THE
DEATH BENEFIT IS NOT SUBJECT TO A SURRENDER CHARGE.

  

The
Purchase Payment is held in a non-unitized insulated Separate Account. Assets in the Separate Account are not chargeable with
liabilities arising out of any other business that we conduct. General Account assets are also available to meet guarantees under
this contract as well as our other general obligations.

 

Signed
for MEMBERS Life Insurance Company on the Contract Issue Date.

 

	 	 	 		 	
	 	 
	President	Secretary

	 	 
	RIGHT
    TO EXAMINE THIS CONTRACT. If for any reason you decide not to keep this contract, you have [10]
    days from the date you receive it ([30] days if this
    is a replacement contract) to return it or notify us in writing that you do not want to keep it. You may return it to either
    our Administrative Office or to the agent who sold it to you. We will then consider it void from the beginning and pay you
    a refund within 7 days after receiving your written notice or the returned contract. The amount of the refund will be either
    the Contract Value, or the greater of Contract Value or Purchase Payment less withdrawals, as required by state law.

   

SINGLE
PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT WITH INDEX-LINKED INTEREST OPTIONS 

Income
Payments Starting on the Income Payout Date 

Death
Benefit Payable at Death Prior to the Income Payout Date 

Non-Participating

 

2020-VAIL

 

     

     

    

 

CONTRACT
GUIDE AND INDEX 

 

	DATA PAGE	 
	 	 
	DEFINITIONS	[3]
	 	 
	PARTIES TO THE CONTRACT	[5]
	 	 
	GENERAL INFORMATION	[6]
	 	 
	CHANGE OF OWNER, ANNUITANT AND BENEFICIARY	[7]
	 	 
	PURCHASE PAYMENT AND ALLOCATION OPTIONS	[7]
	 	 
	CONTRACT VALUE	[8]
	 	 
	SURRENDER VALUE AND WITHDRAWALS	[9]
	 	 
	DEATH BENEFIT OPTIONS	[10]
	 	 
	INCOME PAYMENTS, INCOME PAYOUT PERIODS AND
    INCOME PAYOUT OPTIONS	[11]
	 	 
	RIDERS, AMENDMENTS AND ENDORSEMENTS, IF ANY;
    AND A COPY OF ANY APPLICATION	 
	 	 

 

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DEFINITIONS 

 

Accumulation
Period. The period of time that begins on the Contract Issue Date stated on the Data Page and ends on the Income Payout Date
or the date this contract is terminated if earlier.

  

Adjusted
Index Return. The Index Return for the current Interest Term adjusted for the Crediting Strategy. See Contract Value section.

 

Administrative
Office. MEMBERS Life Insurance Company, [2000 Heritage Way, Waverly, lowa 50677].

 

Allocation
Option Maturity Date. The last day of an Allocation Option Period. A new Allocation Option Period will begin on the Allocation
Option Maturity Date. The initial Allocation Option Maturity Date is shown on the Data Page.

 

Allocation
Option Period. The period of time that begins on an Allocation Option Start Date and ends on an Allocation Option Maturity
Date. The Allocation Option Period is used in calculating the Interest Adjustment and is shown on the Data Page. The Allocation
Option Period is shown on the Data Page.

 

Allocation
Option Start Date. The first day of an Allocation Option Period. The initial Allocation Option Start Date is shown on the
Data Page.

 

Allocation
Options. All available options under this contract for allocating your Purchase Payment and Contract Value. The initial Allocation
Options are shown on the Data Page. 

 

Annual
Free Withdrawal Amount: The amount that can be withdrawn each Contract Year without incurring a Surrender Charge. See Surrender
Value and Withdrawals section.

 

Authorized
Request. A signed and dated request that is in Good Order. A request to transfer value, change a party to the contract, change
the Income Payout Date, or request a partial withdrawal or full surrender of the contract must be signed by all Owners. An Authorized
Request may also include a phone, fax or electronic request for specific transactions.

 

Business
Day. Any day that the New York Stock Exchange is open for trading. All requests for transactions that are received at our
Administrative Office in Good Order on any Business Day prior to market close, generally 4 P.M. Eastern Time, will be processed
as of the end of that Business Day. Any transactions required as of a date that does not fall on a Business Day will be processed
on the next Business Day.

 

Contract
Anniversary. The same day and month as the Contract Issue Date for each year the contract remains in force.

 

Contract
Issue Date. The day your contract is issued. This date will be used to determine Contract Years and Contract Anniversaries.
The Contract Issue Date is shown on the Data Page.

 

Contract
Value. The total value of your contract during the Accumulation Period. All values are calculated as of the end of a Business
Day.

 

Contract
Year. Any twelve-month period beginning on the Contract Issue Date or Contract Anniversary and ending one day before the next
Contract Anniversary.

 

Crediting
Base. The amount used to calculate the Risk Control Account Value. It is equal to the amount allocated to a Risk Control Account
at the start of the Interest Term, reduced proportionally for any withdrawals.

 

Crediting
Strategy. The method by which interest is calculated for an Allocation Option during the Interest Term. The Crediting Strategy
for an Allocation Option is shown on the Data Page.

 

Declared
Rate Account. An Allocation Option under the contract that is part of our Separate Account and is credited a declared rate
of interest.

 

Death
Benefit. The amount the Beneficiary is entitled to upon the death of an Owner who is a natural person or the death of an Annuitant
if the Owner is a non-natural person. See Death Benefit Options section.

  

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Equity
Adjustment. An adjustment made to the Crediting Base to calculate the Contract Value for a Risk Control Account on any day
other than the first and last Business Day of an Interest Term. See Contract Value section.

 

General
Account. All the Company’s assets other than the assets in the Separate Account and all other insulated separate accounts
maintained by the Company.

 

Good
Order. Receipt in our Administrative Office of all information, documents, instructions and/or payment we require to process
requests or transactions for the contract. To be in Good Order, instructions must be sufficiently clear so that we do not need
to exercise any discretion to follow such instructions.

 

Income
Payout Date. The date the first income payment is paid from the contract to the Owner. The anticipated Income Payout Date
is shown on the Data Page. See Income Payments, Income Payout Periods, and Income Payout Options section.

 

Index,
Indices. The applicable Index for each Risk Control Account Allocation Option available on the Contract Issue Date is shown
on the Data Page.

 

Indexed
Interest Buffer. The maximum loss for an Interest Term that will not result in a negative Adjusted Index Return. The Indexed
Interest Buffer for a Risk Control Account with this Crediting Strategy is shown on the Data Page.

 

Indexed
Interest Cap. The maximum gain for an Interest Term for determining the Adjusted Index Return. The Initial Indexed Interest
Cap for a Risk Control Account Value with this Crediting Strategy is shown on the Data Page.

 

Indexed
Interest Floor. The maximum loss for an Interest Term for determining the Adjusted Index Return. The available Indexed Interest
Floors for a Risk Control Account with this Crediting Strategy are shown on the Data Page.

  

Indexed
Interest Participation Rate. The percentage applied to an Index Return that is greater than zero for the Interest Term to
determine the Adjusted Index Return. The Initial Indexed Interest Participation Rate for a Risk Control Account with this Crediting
Strategy is shown on the Data Page.

 

Index
Return. The percentage change in the Index from the beginning of the Interest Term to the end of the Interest Term. See Contract
Value section.

 

Index
Value. The value for the associated Index as of the end of a Business Day.

 

Interest
Adjustment. The amount of an adjustment (increase or decrease) that may be applied to a partial withdrawal, a full surrender
of the contract, the Death Benefit, or the Contract Value applied to an income payout option. The Interest Adjustment calculation
is shown in the Contract Value section.

 

Interest
Adjustment Indices. The Indices used to determine the interest rates used to calculate the Interest Adjustment. They are shown
on the Data Page.

 

Interest
Rate. The effective annual rate credited to the Declared Rate Account. The Initial Minimum Interest Rate is shown on the Data
Page. We may declare a new Interest Rate for each subsequent Interest Term and will notify you of the new Interest Rate at least
two weeks in advance of the start of an Interest Term. The Interest Rate will never be less than the Minimum Interest Rate shown
on the Data Page.

 

Interest
Term. The period for which interest is calculated for an Allocation Option. The Interest Term may vary by Allocation Option.
Interest Terms will start and end on a Contract Anniversary, unless such term has a duration of less than one Contract Year. Interest
Terms for the available Allocation Options are shown on the Data Page.

 

IRC.
The Internal Revenue Code of 1986, as amended.

 

Payout
Period. The period of time that begins on the Income Payout Date; and continues until we make the last payment as provided
by the income payout option chosen.

 

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Proof
Of Death. May consist of a certified copy of the death record, a certified copy of a court decree reciting a finding of death
or other similar proof.

 

Purchase
Payment. The amount paid to us, by or on behalf of an Owner, that is used to establish the annuity on the Contract Issue Date.
We do not allow any additional Purchase Payments under the contract after the initial Purchase Payment.

 

Required
Minimum Distributions. The required minimum distribution (RMD) defined by section 401(a)(9) of the  IRC for this contract
and as determined by us. RMDs only apply to tax-qualified contracts.

 

Risk
Control Account. An Allocation Option to which we credit interest based in part on the performance of a reference Index, subject
to the Crediting Strategy.

 

Risk
Control Account Value. The value of the contract in a Risk Control Account. See Contract Value section.

 

Separate
Account. A non-registered Separate Account in which we hold reserves for our guarantees under the contract. The assets in
the Separate Account shall not be chargeable with liabilities arising out of any other business that we conduct. Our General Account
assets are also available to meet the guarantees under the contract and our other general obligations. We have the right to transfer
to our General Account any assets of the Separate Account that are in excess of required reserves and other liabilities under
the contract. The income, gains and losses, realized or unrealized, from the assets allocated to the Separate Account, will be
credited to or charged against the Separate Account, without regard to our other income, gains, or losses.

  

Spouse.
The person to whom you are legally married. The term Spouse includes the person with whom you have entered into a legally
sanctioned marriage that grants you the rights, responsibilities, and obligations married couples have in accordance with applicable
state laws. Individuals who do not meet the definition of Spouse may have adverse tax consequences when exercising provisions
under this contract and any attached endorsements or riders. Additionally, individuals in other arrangements that are not recognized
as marriage under the relevant state law will not be treated as married or as Spouses as defined in this contract for federal
tax purposes. Consult with a tax advisor for more information on this subject and before exercising benefits under the contract
and any attached endorsements or riders.

 

Surrender
Charge. The charge associated with surrendering either some or all of the Contract Value. The Surrender Charge schedule is
stated on the Data Page and is expressed as a percentage of the Contract Value withdrawn.

 

Surrender
Value. The amount you are entitled to receive if you elect to surrender this contract during the Accumulation Period. See
Surrender Value and Withdrawals section.

 

Valuation
Period. The period beginning at the close of one Business Day and continuing to the close of the next succeeding Business
Day.

 

PARTIES
TO THE CONTRACT

 

Company.
MEMBERS Life Insurance Company. Also referred to as “we”, “our” and “us”.

 

Owner
(Joint Owner). The person(s) or entity who own(s) this contract and has (have) all rights under this contract. Unless owned
by a non-natural person, the Owner is also the person(s) whose death determines the Death Benefit. Joint Owners are not allowed
on qualified contracts or contracts owned by a non-natural person. The maximum number of Owners is two. The consent of both Joint
Owners is needed to complete an Authorized Request. The Owner is also referred to as “you” or “your”.

 

Annuitant
(Joint Annuitant). The person(s) whose life (or lives) determines the income payment amount payable under the contract. If
the Owner is a non-natural person, the Annuitant(s) is also the person(s) whose death determines the Death Benefit.

 

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Beneficiary.
The person(s) or entity named by the Owner to receive proceeds payable upon the death of the first Owner or the first Annuitant
if the Owner is a non-natural person. Prior to the Income Payout Date, if no Beneficiary survives the Owner, the proceeds will
be paid to the Owner’s estate. If there are Joint Owners and we are unable to determine that one of the Joint Owners predeceased
the other, it will be assumed that the Joint Owners died simultaneously. In this instance the Death Benefit will be divided equally
among the Joint Owners’ estates. If there is more than one Beneficiary, each Beneficiary will receive an equal share unless
otherwise specified by the Owner. If Joint Owners have been designated, the surviving Joint Owner will be treated as the sole
primary Beneficiary and any other designated Beneficiary will be treated as a contingent Beneficiary.

 

Irrevocable
Beneficiary. A Beneficiary who must consent to being changed or removed as a Beneficiary.

 

GENERAL
INFORMATION 

 

Entire
Contract. The contract form, Data Page, any attached riders and/or endorsements, and any application attached will form the
entire contract between you and us. 

 

Incontestability.
This contract is incontestable from its Contract Issue Date. The statements contained in the application (in the absence of
fraud) are considered representations and not warranties. 

 

Misstatement
of Age or Gender. If an Annuitant’s date of birth has been misstated, we will adjust the anticipated Income Payout Date
and the income payments under this contract to be equal to the payout amount the Contract Value would have purchased based on
the Annuitant’s correct date of birth. If an Annuitant’s gender has been misstated and the Life Income Rate Type is
based on gender (see the Data Page), we will adjust the income payments under this contract to be equal to the payout amount the
Contract Value would have purchased based on the Annuitant’s correct gender. Any underpayment will be added to the next
payment. Any overpayment will be subtracted from future payments. No interest will be credited or charged to any underpayment
or overpayment adjustments.

 

Proof
of Survival. If any payment required by this contract depends on a living Annuitant, Owner, or Beneficiary, we may require
satisfactory proof of that person's survival prior to making such payment.

 

Annual
Reports. We will send you a report, without charge, at least annually which provides information about your contract required
by any applicable law. You may request additional reports without charge at any time. The reports provided will provide current
information as of a date not more than four months prior to the date of mailing.

 

The
report will include at least the following information: 

		a)	The
                                         beginning and end dates for the current report period;

		b)	The
                                         Contract Value at the beginning and end of the current report period;

		c)	The
                                         amounts that have been credited and debited to your Contract Value during the current
                                         report period, identified by the type of activity the amount represents;

		d)	The
                                         Death Benefit at the end of the current report period; and

		e)	The
                                         Surrender Value at the end of the current report period.

 

Deferral
of Payment. Subject to obtaining prior approval in writing by the state insurance commissioner, we may defer payment of your
Authorized Request for a partial withdrawal or full surrender for a period not exceeding six months. We will credit interest on
deferred amounts as required by state law. The Company will not defer payment of Death Benefits.

  

Applicable
Law. The provisions of this contract conform with the minimum requirements of the state in which the contract is delivered
(“state of issue”). The laws of the state of issue control over any conflicting laws of any other state in which the
Owner may live on or after the Contract Issue Date. The Contract is intended to be treated as an annuity contract under federal
and state tax laws. The Company will amend this contract as required to maintain compliance with applicable insurance and tax
laws.

 

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CHANGE
OF OWNER, ANNUITANT AND BENEFICIARY

  

Change
of Owner. The Owner may request to change ownership at any time after the Contract Issue Date by Authorized Request. Unless
otherwise specified by the Owner, such change will take effect as of the date the Authorized Request was signed. We are not liable
for any payment we make or action we take before we receive the Authorized Request. A change of Owner request may be refused in
a non-discriminatory manner in order to comply with any applicable laws or regulations in effect at the time of the request.

 

Change
of Annuitant. If the Owner is a natural person, the Annuitant can be changed at any time before the Income Payout Date by
Authorized Request. A request to change the Annuitant must be received by us at least 30 days before the Income Payout Date. Unless
otherwise specified by the Owner, such change will take effect as of the date the Authorized Request was signed. We are not liable
for any payment we make or action we take before we receive the Authorized Request. If the Annuitant is changed, the anticipated
Income Payout Date will not change. The Annuitant cannot be changed on or after the Income Payout Date for any reason. If the
Owner is a non-natural person, the Annuitant cannot be changed.

 

Change
of Beneficiary. The Beneficiary can be changed by Authorized Request but requires the consent of any Irrevocable Beneficiary.
Unless otherwise specified by the Owner, such change will take effect as of the date the Authorized Request was signed. We are
not liable for any payment we make or action we take before we receive the Authorized Request.

 

Assignment.
Assignment of your contract is not allowed.

 

PURCHASE
PAYMENT AND ALLOCATION OPTIONS 

 

Purchase
Payment Allocation. On the Contract Issue Date, your Purchase Payment will be allocated to the Allocation Options based on
the instructions specified on your application. Your allocation instructions on the Contract Issue Date are shown on the Data
Page.

 

Transfers.
An Allocation Option is available on the Contract Issue Date and thereafter at the end of the Interest Term until the length
of time before the Payout Date is less than the duration of the Interest Term. For example, an Interest Term of one year is available
on the Contract Issue Date and every Contract Anniversary thereafter; whereas an Interest Term of six years is available on the
Contract Issue Date and every 6th Contract Anniversary thereafter unless there is less than six years until the Payout Date.

 

At
the end of the Interest Term for an Allocation Option, you may elect to transfer the value to any available Allocation Option
or a different Indexed Interest Floor as of the start of the next Interest Term via transfer instructions by Authorized Request.
Only one Indexed Interest Floor for a given Allocation Option can be elected at any given time.

 

New
transfer instructions by Authorized Request will supersede any prior transfer instructions for a given Allocation Option. If we
do not receive transfer instructions by Authorized Request at least one Business Day prior to the end of the current Interest
Term, we will apply the value of the Allocation Option to a new Interest Term of the same Allocation Option with the same Indexed
Interest Floor, if applicable. If the same Allocation Option is not available, we will apply the value to the Declared Rate Account
with the shortest Interest Term.

 

Changes
to Crediting Strategy Components. We may declare a new Indexed Interest Cap and Indexed Interest Participation Rate for each
subsequent Interest Term and will notify you of the new Indexed Interest Cap and Indexed Interest Participation Rate at least
two weeks in advance of the start of an Interest Term. The Indexed Interest Cap and Indexed Interest Participation Rate will never
be less than the minimum rates shown on the Data Page. The Indexed Interest Floors and Indexed Interest Buffer for an Allocation
Option will not change during the life of your Contract unless the Allocation Option is discontinued.

 

Addition
or Discontinuation of an Allocation Option. We may offer additional Allocation Options, which include offering an additional
Index, Crediting Strategy, or Interest Term. We may also discontinue an Allocation Option, effective as of the end of an Interest
Term. We will notify you of the addition or discontinuation of an Allocation Option. Such a change will be subject to any applicable
regulatory approval that may be required. Any change we make will be on a non-discriminatory basis.

 

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Discontinuation
or Substantial Change to an Index. If publication of the Index associated with a given Risk Control Account is discontinued
or the calculation of the Index is materially changed during an Interest Term, we will substitute a suitable Index that will be
used for the remainder of the Interest Term and notify you of the change in advance. Such a change will be subject to any applicable
regulatory approval that may be required. Any change we make will be on a non-discriminatory basis.

 

Notification
will be in your annual report unless timing of any such change would cause us to send a separate notification prior to your Contract
Anniversary.

 

CONTRACT
VALUE 

 

Contract
Value during the Accumulation Period. Your Contract Value on your Contract Issue Date is equal to the Purchase Payment. On
any other day during the Accumulation Period, the Contract Value is equal to the account value in all Allocation Options. The
calculation of account value varies by Allocation Option.

 

Declared
Rate Account Value. The Declared Rate Account Value is equal to: 

		a)	The
                                         amount applied to the Declared Rate Account at the start of the current Interest Term;
                                         minus

		b)	Any
                                         withdrawals (including any Surrender Charge and Interest Adjustment); plus

		c)	The
                                         interest earned.

 

The
Equity Adjustment does not apply to Contract Value in the Declared Rate Account. 

 

Risk
Control Account Value. The Risk Control Account Value is calculated separately for each Risk Control Account and varies based
on the Business Day it is calculated:  

 

		•	On
                                         the first Business Day of an Interest Term, the Risk Control Account Value is equal to
                                         the Crediting Base.

		•	On
                                         the last Business Day of an Interest Term, the Risk Control Account Value is equal to
                                         the Crediting Base multiplied by the sum of one plus the Adjusted Index Return.

		•	On
                                         every other Business Day, the Risk Control Account Value is equal to the Crediting Base
                                         plus the Equity Adjustment.

 

Crediting
Base. The Crediting Base is equal to the amount allocated to a Risk Control Account at the start of the Interest Term, reduced
proportionally for any withdrawals.

 

A
withdrawal will proportionally reduce the Crediting Base by the ratio of the withdrawal to the Risk Control Account Value immediately
prior to the withdrawal. Withdrawals include any applicable Surrender Charge and Interest Adjustment.

 

Index
Return and Adjusted Index Return. The Index Return and Adjusted Index Return are calculated to determine the interest credited
to a Risk Control Account. The Index Return and Adjusted Index Return are calculated separately for each Risk Control Account.

 

The
Index Return is the percentage change in the Index from the beginning of the Interest Term to the end of the Interest Term. The
Index Return is calculated using the following formula:

 

Index
Return = A / B – 1, where:

A
= Index Value on the last day of the Interest Term 

B
= Index Value on the first day of the Interest Term

 

If
the first or last day of the Interest Term does not fall on a Business Day, the Index Value for the next Business Day will be
used.

  

The
Adjusted Index Return is the Index Return for the current Interest Term adjusted for the Crediting Strategy. The calculation of
the Adjusted Index Return varies based on the Crediting Strategy and is shown on the Data Page.

 

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Equity
Adjustment. The Equity Adjustment is calculated at the end of each Business Day except the first and last day of an Interest
Term. The Equity Adjustment may change each Business Day and the change may be positive or negative.

 

The
Equity Adjustment reflects the change in value of derivative instruments that hedge market risks associated with the Risk Control
Accounts. The value is determined using an option pricing formula. It is calculated separately for each Risk Control Account and
varies based on the Crediting Strategy. The Equity Adjustment calculation is on file with the insurance supervisory official in
the jurisdiction in which this contract is issued.

 

Interest
Adjustment. The Interest Adjustment reflects the change in value of the investments that support the guarantees under this
contract upon withdrawal during the Allocation Option Period. A withdrawal, including a partial withdrawal, a full surrender of
the contract, the Death Benefit, or the Contract Value applied to an income payout option, may be adjusted (increased or decreased)
for the Interest Adjustment. The Interest Adjustment is calculated separately for each Allocation Option.

 

On
any given Business Day, the Interest Adjustment is calculated by multiplying the amount withdrawn by the sum of the Interest Adjustment
factor (IAF) minus one (i.e. IAF – 1), where IAF is equal to the following formula:

 

IAF
= ((1 + I + K)/(1 + J + L))^N, where:

  

I
= The applicable rate for Interest Adjustment Index 1 as of the Allocation Option Start Date for a maturity consistent with the
Allocation Option Period. 

J
= The applicable rate for Interest Adjustment Index 1 as of the date of withdrawal for a maturity consistent with the remaining
number of years (whole and partial) in the Allocation Option Period. 

K
= The applicable rate for Interest Adjustment Index 2 as of the Allocation Option Start Date. 

L
= The applicable rate for Interest Adjustment Index 2 as of the date of withdrawal. 

N
= The number of years (whole and partial) from the date of withdrawal until the Allocation Option Maturity Date.

 

If
there is no corresponding length of the Interest Adjustment Index 1, then the linear interpolation of the Index with maturities
closest to N will be used to determine I and J.

 

There
is no Interest Adjustment on the Allocation Option Maturity Date.

 

The
Interest Adjustment Indices are shown on the Data Page. If an Interest Adjustment Index is discontinued, or if the publication
of any component of an Interest Adjustment Index is discontinued, or if the calculation of an Interest Adjustment Index is changed
substantially, we may substitute for the discontinued or substantially changed Index subject to any applicable regulatory approval
that may be required. Before a substitute Index is used, we will notify you of the substitution. Any change we make will be on
a non-discriminatory basis.

  

SURRENDER
VALUE AND WITHDRAWALS

 

Partial
Withdrawals. You may make partial withdrawals during the Accumulation Period by Authorized Request. The partial withdrawal
will be processed the Business Day it is received. Unless you instruct us otherwise, withdrawals will be taken proportionally
from the Contract Value in each Allocation Option. Any applicable Surrender Charge, Equity Adjustment, and Interest Adjustment
will affect the amount available for a withdrawal.

 

If
a partial withdrawal would cause the Surrender Value to be less than the minimum Surrender Value remaining after any partial withdrawal
amount shown on the Data Page, we will treat your request as a full surrender.

 

Annual
Free Withdrawal Amount. The Annual Free Withdrawal Amount is the amount that can be withdrawn without incurring a Surrender
Charge in a Contract Year. The Annual Free Withdrawal Amount in the first Contract Year is 10% of the Purchase Payment less any
withdrawal taken in that Contract Year. The Annual Free Withdrawal Amount in subsequent Contract Years is equal to 10% of the
Contract Value as of the last Contract Anniversary less any withdrawals taken in the current Contract Year. Any unused Annual
Free Withdrawal Amount will not carry over to the next Contract Year.

 

Surrender
Value. You have the right to surrender this contract at any time during the Accumulation Period or on the Payout Date by Authorized
Request. If you surrender this contract, you will be paid the Surrender Value, as of the Business Day we received your Authorized
Request. We may require that the contract be returned to our Administrative Office prior to making payment of the Surrender Value.

 

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The
Surrender Value is equal to: 

		a)	Your
                                         Contract Value at the end of the Valuation Period in which we receive your Authorized
                                         Request, including any applicable Equity Adjustment; minus

		b)	Any
                                         applicable Surrender Charge; adjusted for 
	 	c)	Any
                                         applicable Interest Adjustment.

 

Upon
payment of the Surrender Value, this contract is terminated, and we have no further obligation under this contract.

 

Amounts
Not Subject to Surrender Charge. A Surrender Charge will not be incurred in the following situations: 

		•	The
                                         Annual Free Withdrawal Amount;

		•	Required
                                         Minimum Distributions that are withdrawn under an automatic withdrawal program provided
                                         by us;

		•	Death
                                         Benefit proceeds;

		•	Withdrawals
                                         on an Allocation Option Maturity Date;

		•	Amounts
                                         withdrawn after the Surrender Charge period; and

		•	Amounts
                                         applied to an income payout option.

 

An
Authorized Request to withdraw on an Allocation Option Maturity Date must be received at least one Business Day prior to the Allocation
Option Maturity Date.

 

DEATH
BENEFIT OPTIONS

  

Notwithstanding
any provision to this contract to the contrary, any benefits required to be paid under this contract will be paid in a manner
that satisfies the requirements of section 72(s) of the IRC.

  

Death
of Owner During Accumulation Period. If an Owner who is a natural person dies during the Accumulation Period, the Beneficiary
is entitled to the Death Benefit. If there is a Joint Owner, the Death Benefit will be available when the first Joint Owner dies.
If there is a surviving Owner, the surviving Joint Owner will be treated as the sole primary Beneficiary. Any other Beneficiary
will be treated as a contingent Beneficiary.

 

The
following Death Benefit options are available:

 

Option
A: If the sole primary Beneficiary is the surviving Spouse of the deceased Owner, the surviving Spouse may elect to continue
the contract as the new Owner. This benefit may only be exercised one time. An individual who does not meet the definition of
Spouse may not be able to continue the contract for that person’s lifetime. That individual must receive the proceeds of
the contract and any attached endorsements or riders within the time period specified in section 72(s) of the IRC.

  

Option
B: If the Beneficiary is a natural person, the Death Benefit proceeds will be applied in accordance with section 72(s) of
the IRC under one of the income payout options. The income payments must be made for the Beneficiary’s life or a period
not extending beyond the Beneficiary’s life expectancy. Payments must commence within one year of the date of the Owner’s
death.

 

Option
C: A Beneficiary may receive the Death Benefit proceeds in a single lump sum at any time within five years after the date
of the Owner’s death.

 

Unless
Option A is elected, or payments under Option B commence within one year of the date of the Owner’s Death, the entire interest
in the contract will be paid under Option C.

 

Death
of Annuitant During Accumulation Period. If an Annuitant who is not an Owner dies during the Accumulation Period and the Owner
is a natural person, the following will occur: 

		a)	If
                                         there is a surviving Joint Annuitant, the surviving Joint Annuitant will become the Annuitant.

		b)	If
                                         there is no Joint Annuitant, the Owner(s) will become the Annuitant(s).

 

2020-VAIL

 

    10 

     

    

 

When
the Owner is a non-natural person, and an Annuitant dies during the Accumulation Period the following will occur: 

		a)	The
                                         death of any Annuitant will be treated as the death of the Owner and Death Benefit proceeds
                                         must be distributed in accordance with the Death Benefit Options B or C.

		b)	Unless
                                         payments under Option B commence within one year of the date of the Owner’s death,
                                         the entire interest in the contract will be paid in accordance with Option C.

  

Payment
of Death Benefit Proceeds. The Death Benefit proceeds are payable upon our receipt of Proof Of Death (Owner’s death
or Annuitant’s death if the Owner is a non-natural person), and proof of each Beneficiary’s interest, which includes
the required documentation and proper instructions from each Beneficiary. So far as permitted by law, the Death Benefit proceeds
will not be subject to any claim of the Beneficiary's creditors. The contract is terminated upon payment of the Death Benefit
proceeds. 

 

Death
Benefit Proceeds Amount. The amount that will be paid as Death Benefit proceeds during the Accumulation Period is equal to
the greater of: 

		a)	The
                                         current Contract Value on the date Death Benefit proceeds are payable, including any
                                         applicable Equity Adjustment and Interest Adjustment; or

		b)	The
                                         Purchase Payment adjusted for withdrawals.

 

Withdrawals
will proportionally reduce the Purchase Payment by the ratio of the withdrawal to the Contract Value immediately prior to the
withdrawal. Withdrawals include deductions for any applicable Surrender Charge and Interest Adjustment.

  

If
an Owner is added or changed, except in the case of spousal continuation, the amount that will be paid upon the death of the new
Owner is equal to the Contract Value on the date Death Benefit proceeds are payable, including any applicable Equity Adjustment
and Interest Adjustment. There is no impact on the Death Benefit if an Owner is removed.

  

The
Death Benefit amount will not be less than the amount required by state law in which the contract was delivered. The Death Benefit
proceeds include any interest paid on the Death Benefit proceeds as required by state law. Interest, if any, will be calculated
at the rate and for the time period required by state law. A Surrender Charge will not apply to Death Benefit proceeds.

  

Spousal
Continuation. If the sole primary Beneficiary is the surviving Spouse of the deceased Owner, the surviving Spouse may elect
to continue the contract at the current Contract Value. In this event, the surviving Spouse will assume ownership of the contract.
This benefit may only be exercised one time.

 

Death
of Owner After the Income Payout Date. If an Owner dies on or after the Income Payout Date, the Beneficiary will receive any
remaining income payments. 

 

Death
of Annuitant After the Income Payout Date. If all Annuitants die before all of the guaranteed income payments have been made,
remaining guaranteed income payments will be treated as the Death Benefit and will be distributed in one of the following two
ways: 

		a)	Income
                                         payments will be continued during the remainder of the guaranteed period certain to the
                                         Owner; or

		b)	The
                                         present value of the remaining income payments computed at the interest rate used to
                                         create the income payout option in effect will be paid to the Owner.

  

If
all Annuitants die and there are no remaining guaranteed income payments, the contract is terminated, and we have no further obligation
under the contract. 

 

INCOME
PAYMENTS, INCOME PAYOUT PERIODS AND INCOME PAYOUT OPTIONS 

 

Income
Payments. A series of payments made by us during an income payout period, based on the income payout option you select. For
life options, income payments are based on the Annuitant’s gender and adjusted age.

 

For
installment options, income payments are based on the selected duration of payments. The first income payment will be paid as
of the Income Payout Date.

 

2020-VAIL

 

    11 

     

    

 

Income
Payments Frequency. You may choose to receive income payments monthly, quarterly, semi-annually or annually for installment
options. If you choose a life income payout option, your payments will be received monthly. 

 

Minimum
Income Payment Amount. If the Contract Value is less than $2,500, we may make a lump sum payment equal to the Contract Value
in lieu of income payments. For installment options, if the amount of the income payment would be less than $20, we may reduce
the frequency of payments to an interval which will result in the payment being at least $20, but with a frequency of no less
than annually.

 

Income
Payout Period. The period of time that:

		a)	Begins
                                         on the Income Payout Date; and

		b)	Continues
                                         until we make the last payment as provided by the income payout option chosen.

  

On
the first day of this period, the Contract Value, including any applicable Equity Adjustment and Interest Adjustment, will be
applied to the income payout option selected. If an income payout option is not selected, the default income payout options will
be as follows unless otherwise required under the Internal Revenue Code:

		a)	Life
                                         Income Option with a 10-year guaranteed period certain for contracts with one Annuitant;
                                         and

		b)	Joint
                                         & Survivor Life Income Option with a 10-year guaranteed period certain for contracts
                                         with two Annuitants.

 

The
Annuitant and Owner cannot be changed after the Income Payout Date for any reason. Surrender Charges, Interest Adjustments, and
Equity Adjustments do not apply to income payments during the income payout period. 

 

Income
Payout Date. The anticipated Income Payout Date is the first Contract Anniversary after the oldest Annuitant’s 95th
birthday. Even if the Annuitant is changed, the Income Payout Date will not change unless you request a different date by
Authorized Request. Requests for changing the Income Payout Date must meet the criteria below: 

		a)	The
                                         request is made while the Owner is living;

		b)	The
                                         request is received at our Administrative Office at least 30 days before the anticipated
                                         Income Payout Date;

		c)	The
                                         requested Income Payout Date is at least two years after the Contract Issue Date; and

		d)	The
                                         requested Income Payout Date is no later than the anticipated Income Payout Date.

  

Income
Payout Options. There are different ways to receive income payments. We call these income payout options. Three income payout
options are described below. The income payout options described may not be available in all states at all times. Other income
payout options may be available with our consent.

  

The
income option tables for the income payout options are shown on the Data Page. The amount of each income payment is guaranteed
by us. Higher current rates may be applicable on the Income Payout Date. You may contact us at our Administrative Office for a
quote of the current rates. The amount of any income payment at the time it starts will never be less than that which would have
been provided by applying the Surrender Value to purchase a single premium immediate annuity at the purchase rates then offered
by us to the same class of Annuitants. 

 

Option
1 – Installment Option. You can elect to receive payments for any number of years between 10 and 30. The income payments
are guaranteed for the chosen number of years.

  

Option
2 – Life Income Option – Guaranteed Period Certain. We will pay monthly income payments for as long as the Annuitant
lives and at least for as long as the guaranteed period certain chosen. 

 

The
guaranteed period certain choices are: 

		a)	0
                                         years (life income only);

		b)	5
                                         years;

		c)	10
                                         years;

		d)	15
                                         years; or 

		e)	20
                                         years.

 

Option
3 – Joint and Survivor Life Income Option – 10-Year Guaranteed Period Certain. We will pay monthly income payments
for as long as either of the Annuitants is living and at least for 10 years. 

 

Income
payment(s) will be made to the Beneficiary if there is no surviving Owner. If there is no surviving Owner or Beneficiary, income
payment(s) will be made to the Owner’s estate.

 

2020-VAIL

 

    12 

     

    

 

 

SINGLE
PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT WITH INDEX-LINKED INTEREST OPTIONS 

Income
Payments Starting on the Income Payout Date 

Death
Benefit Payable at Death Prior to the Income Payout Date 

Non-Participating

 

MEMBERS
Life Insurance Company

[2000
Heritage Way, Waverly, Iowa 50677]

[Phone:
800.798.5500]

 

2020-VAIL

 

    13Exhibit
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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    CODE 02

 

     

    	 

    

 

	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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Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00319-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00319-of-00352.parquet"}]]