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Exhibit 5(a)(v)
Office Use Only: 02
(CUNA MUTUAL LIFE INSURANCE COMPANY (R) LOGO)
A Mutual Insurance Copany
0000 Xxxxxxxx Xxx - Xxxxxxx, xxxx 00000
FLEXIBLE PREMIUM DEFERRED
VARIABLE ANNUITY APPLICATION
________________________ _____________________________________________
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
U.S. Citizen: [ ] Yes [ ] No
Name _____________________________________________________
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 issue date
and for b. & c. must be at least age 18 (19 in NE & Relationship to
AL, 21 in MS). Annuitant ___________________________
[ ] A. CO-ANNUITANT Must be spouse of annuitant.
[ ] B. CO-OWNER
[ ] C. CO-ANNUITANT & CO-OWNER Must be spouse of Gender: [ ] Male [ ] Female
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. Must be at least age 18 (19 in NE &
AL, 21 in MS) and no older than age 85 on the Relationship to
contract issue date. Annuitant ___________________________
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 ____________________________________________ SSN __ __ __-__ __-__ __ __ __
or
ATTN _____________________________________________________ EIN __ __-__ __ __ __ __ __ __
Address __________________________________________________
Date of Trust __ __ __ __ __ __ __ __
Month Day Year
City ________________________ State ______ ZIP ___________
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? _______________________________________________________
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Office Use Only: 02
REQUIRED
5. PLAN TYPE/TAX QUALIFICATION STATUS Check only one plan type.
[ ] Nonqualified $___________ Is this a 1035 Exchange? [ ] Yes [ ] No
(Min. Total
First Year: $5,000)
ROLLOVER TRANSFER CURRENT YR PRIOR YR
AMOUNT AMOUNT CONTRIBUTION CONTRIBUTION CONVERSION AMOUNT
------------ -------- ------------ ------------ -----------------------
[ ] Traditional IRA AMOUNT FROM TRADITIONAL
[ ] Xxxx XXX YEAR _______ YEAR _______ IRA TO XXXX XXX
[ ] SEP IRA $___________ $_______ $___________ $___________ $_____________
(Min. Total First Year: $2,000)
CONTRIBUTION TRANSFER
AMOUNT AMOUNT
------------ --------
TOTAL INITIAL PURCHASE PAYMENT
[ ] 403(b)(TSA) $___________ $_______ $____________
(Min. Total First Year: $2,000) Total of dollar amounts in Section 5.
CONTRIBUTION TRANSFER THE INITIAL PURCHASE PAYMENT APPLIED WILL BE EQUAL TO
Credit Unions only: AMOUNT AMOUNT THE ACTUAL AMOUNT RECEIVED
------------ -------- BY CUNA MUTUAL LIFE INSURANCE COMPANY.
[ ] 457(b)
[ ] 457(f) $___________ $_______ MAKE CHECK PAYABLE TO CUNA MUTUAL LIFE INSURANCE
(Min. Total First Year: $2,000) 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) - [ ] Monthly [ ] Quarterly [ ] Semiannually [ ] Annually
Complete Section 7.
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
Page 2
Optional
9. SPOUSAL CONTINUATION Available at no additional charge.
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:
[ ] Spouse Beneficiary Death Benefit Spouse Date of Birth _____ ___ ____ [ ] Male [ ] Female
Month Day Year
Available only if:
a. The annuitant/owner and their spouse beneficiary are both age 75 or less on the contract issue date;
b. There is a sole annuitant/owner (no one is named in Sections 2 and 3);
c. 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)
d. The Earnings Enhanced Death Benefit is not applied for; and
e. The annuitant/owner's spouse signs in Section 20.
Optional
11. OPTIONAL LIVING BENEFIT Available at an additional charge - see prospectus. Not available on a 403(b) (TSA)
Plan Type in Section 5. 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 Section 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
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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 (Whole %; minimum 1% per subaccount)
fixed period) 6 Month 1 Year
______% Mid Cap Value ______ ______% Mid Cap Value
______% Large Cap Growth ______% DCA 6 Month* ______ ______% Large Cap Growth
______% Large Cap Value ______% DCA 1 Year* ______ ______% Large Cap Value
______% Balanced * COMPLETE THE DCA FIXED PERIOD TRANSFERS ______ ______% Balanced
______% Bond SECTION TO THE RIGHT. IF NOT COMPLETED, ______ ______% Bond
______% Money Market TRANSFERS WILL BE AUTOMATICALLY ______ ______% Money Market
______% International Stock DISTRIBUTED TO THE MONEY MARKET ______ ______% International Stock
______% Mid Cap Growth SUBACCOUNT. ______ ______% Mid Cap Growth
______% High Income ______% 1 Year ______ ______% High Income
______% Global Securites ______% 3 year ______ ______% Global Securites
______% Conservative Allocation ______% 5 Year ______ ______% Conservative Allocation
______% Moderate Allocation ______% 7 Year ______ ______% Moderate Allocation
______% Aggressive Allocation ______% 10 Year ______ ______% Aggressive Allocation
======================= Must total 100% ======================= ======== Must total 100% ========
** 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 SUBACCOUNTS SELECTED ABOVE: The minimum monthly
amount will be transfered. To transfer a larger amount complete the Dollar Cost Averaging form - CLS-217.
Additional transfers are allowed by request.
14C. LIVING BENEFIT - PURCHASE PAYMENT ALLOCATION Check only one if a Living Benefit Option was selected in
Section 11.
Preservation Plus Program in Section 16 not available.
SUBACCOUNTS MODEL ALLOCATIONS
[ ] Conservative Allocation [ ] 7 - 14 Years Conservative Model ) Model Allocation selections
[ ] Moderate Allocation [ ] 15+ Years Conservative Model ) automatically include Annual
[ ] Balanced [ ] 7 - 14 Years Moderate Model ) Portfolio Rebalancing.
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: _____% Mid Cap Value _____% Mid Cap Growth
[ ] Quarterly [ ] a. Transfer the value _____% Large Cap Growth _____% High Income
[ ] Semiannually in my subaccounts in _____% Large Cap Value _____% Global Securites
[ ] Annually proportion to my _____% Balanced _____% Conservative Allocation
purchase payment _____% Bond _____% Moderate Allocation
If the frequency is not allocation schedule _____% Money Market _____% Aggressive Allocation
selected, transfers as indicated in _____% International Stock
will occur quarterly. Section 14b.
======= Whole %; must total 100% =======
[ ] b. Transfer the value
in my subaccounts as
indicated to the
right.
===============>
If neither is selected, a.
will apply.
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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REQUIRED
17. PRIMARY BENEFICIARY Right to change reserved unless otherwise specified. Relationship and address required.
Relationship
Name ________________________________________________________________________ to Annuitant ______________________
First Middle Last
Address ______________________________________ City _____________________ State ________________ ZIP ________
Relationship
Name ________________________________________________________________________ to Annuitant ______________________
First Middle Last
Address ______________________________________ City _____________________ State ________________ ZIP ________
Relationship
Name ________________________________________________________________________ to 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
Name ________________________________________________________________________ to Annuitant ______________________
First Middle Last
Address ______________________________________ City _____________________ State ________________ ZIP ________
Relationship
Name ________________________________________________________________________ to Annuitant ______________________
First Middle Last
Address ______________________________________ City _____________________ State ________________ ZIP ________
Relationship
Name ________________________________________________________________________ to 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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Office Use Only: 02
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, or Date Signature of Owner Date
Co-Annuitant & Co-Owner (Person or Trustee(s) named in Section 3a or 3b -
(Person Named in Section 2) 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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