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Exhibit 5a(vii)
[CUNA MUTUAL LIFE
INSURANCE COMPANY (R) LOGO] FLEXIBLE PREMIUM DEFERRED Office Use Only: 02
A Mutual Insurance Company VARIABLE ANNUITY APPLICATION
0000 Xxxxxxxx Xxx - Xxxxxxx, Xxxx 00000
____________________________ _____________________________________________
CONTRACT NO. CREDIT UNION NO. [ ] Check If Not Applicable
REQUIRED
1. ANNUITANT / OWNER Must be no older than age 85 on contract issue date. If
annuitant is under age 18 (age 19 in NE & AL, 21 in MS) an owner must be
named in Section 3a or 3b. Gender: [ ] Male [ ] Female
Name ___________________________________________________________________________ U.S. Citizen: [ ] Yes [ ] No
First Middle Last
Address ________________________________________________________________________ SSN __ __ __-__ __ __-__ __ __
Address ________________________________________________________________________ Date of Birth __ __ __ __ __ __ __ __
Month Day Year
City ________________________________________ State ___________ ZIP __________ Day Phone______________________________
including area code
OPTIONAL
2. CO-ANNUITANT / CO-OWNER NONQUALIFIED ONLY Check one. N/A with Spouse
Benefits in Sections 9 and 10. Must be no older than age 85 on the contract Relationship to
issue date and for b. & c. must be at least age 18 (19 in NE & AL, 21 in Annuitant ________________________
MS).
[ ] A. CO-ANNUITANT Must be spouse of annuitant.
[ ] B. CO-OWNER Gender: [ ] Male [ ] Female
[ ] C. CO-ANNUITANT & CO-OWNER Must be spouse of annuitant. U.S. Citizen: [ ] Yes [ ] No
Name ___________________________________________________________________________ SSN __ __ __-__ __ __-__ __ __
First Middle Last
Address ________________________________________________________________________ Date of Birth __ __ __ __ __ __ __ __
Month Day Year
Address ________________________________________________________________________
City ________________________________________ State ___________ ZIP __________ Day Phone______________________________
including area code
OPTIONAL - COMPLETE ONLY ONE
3A. OWNER-INDIVIDUAL NONQUALIFIED ONLY If other than annuitant/owner. Relationship to
Must be at least age 18 (19 in NE & AL, 21 in MS) and no older than age 85 Annuitant ________________________
on the contract issue date.
Name ___________________________________________________________________________ Gender: [ ] Male [ ] Female
First Middle Last U.S. Citizen: [ ] Yes [ ] No
Address ________________________________________________________________________ SSN __ __ __-__ __ __-__ __ __
Address ________________________________________________________________________ Date of Birth __ __ __ __ __ __ __ __
Month Day Year
City ________________________________________ State ___________ ZIP __________ Day Phone______________________________
including area code
3B. OWNER-TRUST NONQUALIFIED ONLY Include a copy of the page(s) of the trust document which contains trust name, trust date,
trustee name(s), investment authority, and signature(s); or use form 1919(CML) Trustee Certification.
Name of Trust __________________________________________________________________ Gender: [ ] Male [ ] Female
U.S. Citizen: [ ] Yes [ ] No
ATTN ___________________________________________________________________________ SSN __ __ __-__ __ __-__ __ __
OR
Address ________________________________________________________________________ EIN __ __-__ __ __ __ __ __ __
City ________________________________________ State ___________ ZIP __________ Date of Trust __ __ __ __ __ __ __ __
Month Day Year
Trustee Name(s) ________________________________________________________________
3C. OWNER-CREDIT UNION 457(b) AND 457(f) PLANS ONLY
Name of Credit Union ___________________________________________________________ EIN __ __-__ __ __ __ __ __ __
ATTN: __________________________________________________________________________ _________________________________________________
Title of authorized officer signing in section 18.
Address ________________________________________________________________________
City ________________________________________ State ___________ ZIP __________
REQUIRED
4. REPLACEMENT
Do you have any existing life insurance or annuities with our company or any other company? [ ] Yes [ ] No
Will this contract replace, discontinue or change any existing life insurance or annuities with our company or any other
company? [ ] Yes [ ] No If Yes: What Company? ___________________________________________________________________________
What Contract Number?____________________________________________________________________
VAAPP - 2006 0906
Page 1
Office Use Only: 02
REQUIRED
5. PLAN TYPE/TAX QUALIFICATION STATUS Check only one plan type.
[ ] Nonqualified
(Min. Total First Year: $5,000) $_______________ Is this a 1035 Exchange? [ ] Yes [ ] No
[ ] Traditional IRA ROLLOVER TRANSFER CURRENT YR PRIOR YR CONVERSION AMOUNT
[ ] Xxxx XXX AMOUNT AMOUNT CONTRIBUTION CONTRIBUTION AMOUNT FROM TRADITIONAL IRA
[ ] SEP IRA BEING CONVERTED TO XXXX XXX
(Min. Total First
Year: $2,000) $__________ $__________ $__________ $__________ $__________
[ ] Beneficiary IRA ROLLOVER TRANSFER
(Also complete AMOUNT AMOUNT TOTAL INITIAL PURCHASE PAYMENT
forms CLS-520, CLS-521 $_______________
&
CLS-381) Total of dollar amounts in Section 5.
$__________ $__________
(Min. Total First
Year: $2,000)
[ ] 403(b) TSA CONTRIBUTION TRANSFER
AMOUNT AMOUNT
(Min. Total First
Year: $2,000) $__________ $__________
Credit Unions only: CONTRIBUTION TRANSFER
[ ] 457(b) AMOUNT AMOUNT THE INITIAL PURCHASE PAYMENT APPLIED WILL BE
[ ] 457(f) EQUAL TO THE ACTUAL AMOUNT RECEIVED BY CUNA
MUTUAL LIFE INSURANCE COMPANY.
(Min. Total First
Year: $2,000) $__________ $__________ MAKE CHECK PAYABLE TO CUNA MUTUAL LIFE
INSURANCE COMPANY.
OPTIONAL
6. FUTURE PURCHASE PAYMENTS Check only one billing type.
$__________ (Min. $25 per billing for Automatic & List BIll, $100 for Direct Bill)
AUTOMATIC (ACH) Complete Section 7 - Future Payments.
LIST BILL - [ ] Weekly [ ] Bi-weekly [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
For all plan types, complete Employer List Bill Agreement form PA-7, if not already on file. For 403(b) (TSA) plans, also complete
Salary Reduction Agreement form 687A.
DIRECT BILL - [ ] Quarterly [ ] Semiannually [ ]Annually
OPTIONAL
7. AUTOMATIC PAYMENT PLAN AUTHORIZATION (ACH)
[ ] INITIAL PAYMENT: I hereby authorize CUNA Mutual Life Insurance Company and the financial institution named below to retain my
account information and make a debit entry for my initial payment in the amount of $__________.
[ ] FUTURE PAYMENTS: I authorize CUNA Mutual Life Insurance Company and the financial institution named below to retain my account
information and to initiate deductions or credits to my account by electronic funds transfer or paper draft. This authorization
will remain in effect until revoked by me in writing or by telephone.
Frequency: [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
Indicate the amount: $__________ Indicate the ___________ (month) and _____ (day: 1-28 only) this should begin.
(Deductions will occur on the first of the month unless another date is selected.)
I understand I will receive quarterly statements for my variable annuity.
Financial Institution __________________________________ Routing Number ____________________________
Address_________________________________________________ Account Number ____________________________
City ______________________________ State ______________
[ ] Share Draft/Checking (Attach blank voided check.)
Phone Number ___________________________________________ [ ] Share Account/Savings (Only available for accounts
accepting electronic transactions.)
Signature of Account Owner, if other than the Annuitant or Owner_______________________________________________________
OPTIONAL
8. TELEPHONE/FAX/INTERNET AUTHORIZATION See the Telephone/Fax/Internet Authorization for details on what transactions can be
done by telephone/fax/internet.
I understand that I will automatically have telephone/fax/internet authorization unless the following box is marked:
[ ] I do NOT want telephone/fax/internet authorization
I understand that the representative(s) assigned to my contract will automatically have telephone/fax/internet authorization unless
the following box is marked:
[ ] I do NOT want the representative(s) assigned to my contract to have telephone/fax/internet authorization
VAAPP-2006
Page 2
OPTIONAL
9. SPOUSAL CONTINUATION Available at no additional charge. Not available if Beneficiary IRA plan type is chosen in Section 5.
I understand this benefit will be added automatically if:
a. There is a sole annuitant/owner (no one is named in Sections 2 and 3); and
b. The annuitant/owner's spouse is named as the sole primary beneficiary in Section 17.
(A contingent beneficiary(ies) may be named in Section 18)
[ ] I do NOT want Spousal Continuation
OPTIONAL
10. OPTIONAL DEATH BENEFIT(S) Available at an additional charge - see prospectus. Available only if the annuitant is age 75 or
less on the contract issue date.
APPLIES TO DEATH OF ANNUITANT:
[ ] Maximum Anniversary Death Benefit
[ ] 3% Annual Guarantee Death Benefit
[ ] Earnings Enhanced Death Benefit Available only if Maximum Anniversary and/or 3% Annual Guarantee are selected. Not
available if Spouse Beneficiary Death Benefit, below, is selected.
APPLIES TO DEATH OF SPOUSE BENEFICIARY: Not available if Qualified plan type is chosen in Section 5.
[ ] Spouse Beneficiary Death Benefit Spouse Date of Birth _ _ _ _ _ _ _ _ [ ] Male [ ] Female
Month Day Year
Available only if:
a. The Plan Type/Tax Qualification Status is marked Nonqualified in Section 5;
b. The annuitant/owner and their spouse beneficiary are both age 75 or less on the contract issue date;
c. There is a sole annuitant/owner (no one is named in Sections 2 and 3);
d. The annuitant/owner's spouse is named as the sole primary beneficiary in Section 17;
(A contingent beneficiary(ies) may be named in Section 18)
e. The Earnings Enhanced Death Benefit is not applied for; and
f. The annuitant/owner's spouse signs in Section 20.
OPTIONAL
11. OPTIONAL LIVING BENEFIT Available at an additional charge -- see prospectus. Not available if Beneficiary IRA or 403(b) TSA
plan type in Section 5 is chosen. Check only one.
[ ] Guaranteed Minimum Accumulation Benefit [ ] Guaranteed Minimum Withdrawal Benefit
(If co-annuitant or co-annuitant/co-owner is desired, the oldest
spouse must be named annuitant/owner in Seciton 1 and the youngest
spouse must be named in Section 2. The annuitant/owner must be at
least age 45 on the contract issue date.)
USE SECTION 14C FOR PURCHASE PAYMENT ALLOCATIONS, DO NOT USE 14A OR 14B.
OPTIONAL
12. SPECIAL INSTRUCTIONS
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
HOME OFFICE USE ONLY
13. HOME OFFICE USE ONLY
VAAPP-2006
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Office Use Only: 02
REQUIRED - COMPLETE 14A, 14B, OR 14C
SECTION 14 - COMPLETE 14A, 14B, OR 14C -- ONLY ONE
14A. MODEL - PURCHASE PAYMENT ALLOCATION Check one. Preservation Plus Program in Section 16 not available.
CONSERVATIVE: [ ] 7 - 14 Years MODERATE: [ ] 7 - 14 Years AGGRESSIVE: [ ] 7 - 14 Years
[ ] 15+ Years [ ] 15+ Years [ ] 15+ Years
Model Allocation selections automatically include Annual Portfolio Rebalancing.
14B. CUSTOMIZED - PURCHASE PAYMENT ALLOCATION
INVESTMENT OPTIONS DCA FIXED PERIOD(S) TRANSFERS**
------------------------------------------------------------------------------------------ ---------------------------------------
(Whole %; minimum 1% per subaccount or fixed period; minimum: $1,000 per fixed period) (Whole %; minimum 1% per subaccount)
6 1
Month Year
----- -----
_____% Mid Cap Value _____ _____% Mid Cap Value
_____% Large Cap Growth _____ _____% Large Cap Growth
_____% Large Cap Value _____% DCA 6 Month* _____ _____% Large Cap Value
_____% Diversified Income _____% DCA 1 Year* _____ _____% Diversified Income
_____% Bond * COMPLETE THE DCA FIXED PERIOD TRANSFERS SECTION TO THE _____ _____% Bond
_____% Money Market RIGHT. IF NOT COMPLETED, TRANSFERS WILL BE AUTOMATICALLY _____ _____% Money Market
_____% International Stock DISTRIBUTED TO THE MONEY MARKET SUBACCOUNT. _____ _____% International Stock
_____% Mid Cap Growth _____% 1 Year _____ _____% Mid Cap Growth
_____% High Income _____% 3 year _____ _____% High Income
_____% Global Securities _____% 5 Year _____ _____% Global Securities
_____% Conservative Allocation _____% 7 Year _____ _____% Conservative Allocation
_____% Moderate Allocation _____% 10 Year _____ _____% Moderate Allocation
_____% Aggressive Allocation _____ _____% Aggressive Allocation
_____% Small Cap Growth _____ _____% Small Cap Growth
_____% Small Cap Value _____ _____% Small Cap Value
======================= Must total 100% ======================= ======== Must total 100% ========
14C. LIVING BENEFIT - PURCHASE PAYMENT ALLOCATION Check only one if a Living Benefit Option was DCA FIXED PERIOD(S) TRANSFERS**
selected in Section 11. Preservation Plus Program in Section 16 not available. Model Check only one of the six
Allocation selections automatically include Annual Portfolio Rebalancing.
SUBACCOUNTS
SUBACCOUNTS MODEL ALLOCATIONS DCA FIXED PERIODS
[ ] Conservative Allocation
[ ] Conservative Allocation [ ] 7-14 Yrs Conservative [ ] DCA 6 Month* [ ] Moderate Allocation
[ ] Moderate Allocation [ ] 15+ Yrs Conservative [ ] DCA 1 Year* [ ] Diversified Income
[ ] Diversified Income [ ] 7-14 Yrs Moderate
* Complete the DCA Transfers section to MODEL ALLOCATIONS
the right. Any future purchase
payments will be automatically [ ] 7-14 Yrs Conservative
allocated according to the DCA [ ] 15+ Yrs Conservative
Transfer Program selected to the [ ] 7-14 Yrs Moderate
right, unless otherwise specified.
** Monthly transfers will begin 1 month after allocation to the DCA fixed period(s). If the transfer date falls on a weekend
or holiday, the transfer will be made on the following valuation day. Transfers of equal monthly amounts will deplete the DCA
fixed amount(s). The transfers will occur automatically for the duration of the fixed period(s) according to the transfer
selection above.
OPTIONAL - WITH 14B
15. PORTFOLIO REBALANCE PROGRAM Not applicable if purchase payments are allocated to a fixed period.
FREQUENCY VARIABLE ACCOUNT ALLOCATED REBALANCE ALLOCATION
------------------------ -------------------------------------- ---------------------------------------------------------------
Check one: Check one:
[ ] a. Transfer the value in my
[ ] Quarterly subaccounts in proportion to my
purchase payment allocation _____% Mid Cap Value
[ ] Semiannually schedule as indicated in _____% Large Cap Growth _____% High Income
Section 14b. _____% Large Cap Value _____% Global Securities
[ ] Annually _____% Diversified Income _____% Conservative Allocation
[ ] b. Transfer the value in my _____% Bond _____% Moderate Allocation
If the frequency is not subaccounts as indicated to the _____% Money Market _____% Aggressive Allocation
selected, transfers will right. _____% International Stock _____% Small Cap Growth
occur quarterly. ==================> _____% Mid Cap Growth _____% Small Cap Value
If neither is selected, a. will apply. ====== Whole %; must total 100% =========
OPTIONAL - WITH 14B
16. PRESERVATION PLUS PROGRAM Not available if a Model Allocation, Living Benefit, or a Fixed Period investment option is
selected.
I will participate in the Preservation Plus Program. I hereby authorize CUNA Mutual Life Insurance Company to allocate a portion of
the initial purchase payment to the following fixed period: (Check one)
[ ] 1 Year [ ] 3 Year [ ] 5 Year [ ] 7 Year [ ] 10 Year
This portion will be the present value reflecting the guaranteed interest rate as of the contract issue date for the fixed period
indicated. The difference between the initial purchase payment and the portion allocated to the fixed period will be allocated as
indicated in Section 14b.
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Office Use Only: 02
REQUIRED
17. PRIMARY BENEFICIARY Right to change reserved unless otherwise specified. Relationship and address required.
Relationship to
Name _____________________________________________________________________________________ Annuitant _____________________________
First Middle Last
Address ______________________________________________________________ City ____________________ State __________ ZIP ______________
Relationship to
Name _____________________________________________________________________________________ Annuitant _____________________________
First Middle Last
Address ______________________________________________________________ City ____________________ State __________ ZIP ______________
Relationship to
Name _____________________________________________________________________________________ Annuitant _____________________________
First Middle Last
Address ______________________________________________________________ City ____________________ State __________ ZIP ______________
Name of Trust ____________________________________________________________________________ Date of Trust _________________________
Trustee Name(s) ____________________________________________________________________________________________________________________
To list more beneficiaries, use Section 12 or a separate signed and dated paper. DO NOT include fractions or percentages for even
distribution of death proceeds. If no primary beneficiary is listed, the primary beneficiary will be the estate of the annuitant.
The owner has the right to predetermine how the beneficiary will receive the death benefit by completing the Beneficiary Designation
With Restricted Payout Options form. Specific limitations are described in the form.
OPTIONAL
18. CONTINGENT BENEFICIARY Right to change reserved unless otherwise specified. Relationship and address required.
Relationship to
Name _____________________________________________________________________________________ Annuitant _____________________________
First Middle Last
Address ______________________________________________________________ City ____________________ State __________ ZIP ______________
Relationship to
Name _____________________________________________________________________________________ Annuitant _____________________________
First Middle Last
Address ______________________________________________________________ City ____________________ State __________ ZIP ______________
Relationship to
Name _____________________________________________________________________________________ Annuitant _____________________________
First Middle Last
Address ______________________________________________________________ City ____________________ State __________ ZIP ______________
Name of Trust ____________________________________________________________________________ Date of Trust _________________________
Trustee Name(s) ____________________________________________________________________________________________________________________
To list more beneficiaries, use Section 12 or a separate signed and dated paper. DO NOT include fractions or percentages for even
distribution of death proceeds. The owner has the right to predetermine how the beneficiary will receive the death benefit by
completing the Beneficiary Designation With Restricted Payout Options form. Specific limitations are described in the form.
OPTIONAL
19. PROSPECTUS AND ANNUAL REPORTS E-MAIL AUTHORIZATION
[ ] I consent to receiving the prospectus, annual and semiannual reports online. I understand this will be in effect until I revoke
it. I understand I can receive paper copies at any time by calling 0-000-000-0000. I understand I could incur outside costs by
receiving documents online; but I will not be charged by CUNA Mutual Life Insurance Company. My e-mail address is:
Owner's e-mail address: _______________________________________________________________________________________________________
Co-owner's (if any) e-mail address
if different than the owner: __________________________________________________________________________________________________
THESE REPORTS ARE PDF FILES WHICH REQUIRE ADOBE READER.
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REQUIRED
20. AGREEMENT
- I hereby represent that all my statements and answers given on this application are correct and true to the best of my
knowledge and belief and are made as a basis for my application.
- I understand that no agent is authorized to make, modify or discharge any annuity contract provision or waive any of the
Company's rights or requirements.
- If this contract will replace, change or modify an existing policy or contract, I hereby confirm my belief that replacing my
existing contract is suitable, and I have considered product features, fees and charges.
- 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, DEPENDING
ON STATE LAW.
- I UNDERSTAND THAT CONTRACT VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF A VARIABLE ACCOUNT ARE VARIABLE AND NOT
GUARANTEED AS TO A FIXED DOLLAR AMOUNT.
- I UNDERSTAND THAT AMOUNTS WITHDRAWN FROM THE FIXED ACCOUNT OPTION MAY BE ADJUSTED UPWARD OR DOWNWARD BASED ON A MARKET VALUE
FORMULA.
- I ACKNOWLEDGE RECEIPT OF A CURRENT VARIABLE ANNUITY PROSPECTUS.
[ ] I REQUEST A STATEMENT OF ADDITIONAL INFORMATION. Signed at ________________________________ ___________________
City State
------------------------------------- -------------------- ------------------------------------------ -------------------
Signature of Annuitant/Owner Date Signature of Annuitant/Owner's Spouse Date
(Person Named in Section 1) (If Spouse Beneficiary Death Benefit
selected in Section 10)
------------------------------------- -------------------- ------------------------------------------ -------------------
Signature of Co-Annuitant, Co-Owner, Date Signature of Owner Date
or Co-Annuitant & Co-Owner (Person or Trustee(s) named in Section 3a
(Person Named in Section 2) or 3b - Authorized Officer whose title is
in Section 3c)
REQUIRED
21. AGENT SECTION To the best of your knowledge:
1) Does the applicant have any existing life insurance or annuities with our company or any other
company? [ ] Yes [ ] No
2) Will this contract replace, discontinue or change any existing life insurance or annuities? [ ] Yes [ ] No
If yes, I hereby confirm:
(a) That consideration has been given to product features, fees and charges.
(b) That this replacement meets the Company's standards for replacement sales.
(c) All required documents have been completed in compliance with applicable state regulations.
(d) That the following sales material was used: _________________________________________________________________________
_____________________________________________________________________________________________________________________
Compensation Option: [ ] 1 [ ] 2 [ ] 3 [ ] 4 If an Option is not selected, Option 1 will apply.
-------------------------- ------------------------------------------------------------------- ------------------- -----------
Date Signature of Agent/Registered Representative Rep ID CBSI Rep ID
If your Broker/Dealer is CUNA Brokerage Services, Inc., submit Application, VA Checklist, Account Application, check (if any), and
any additional forms to:
CUNA BROKERAGE SERVICES, INC.
0000 XXXXXXXX XXX
XXXXXXX, XX 00000
For other Broker/Dealers, follow their process and use their forms for suitability submission.
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