Exhibit 4(i)
[[LOGO OF CUNA MUTUAL GROUP] | CUNA MUTUAL GROUP]
MEMBERS LIFE INSURANCE COMPANY
[0000 Xxxxxxxx Xxx, Xxxxxxx, Xxxx 00000]
Telephone: [000.000.0000]
[xxxx://xxx.xxxxxxxxxx.xxx]
SINGLE PREMIUM DEFERRED
MODIFIED GUARANTEED INDEX ANNUITY
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 state law.
INTEREST CREDITED IS BASED ON EXTERNAL INDICES. WHILE CONTRACT VALUES MAY BE
AFFECTED BY AN EXTERNAL INDEX, THIS CONTRACT DOES NOT DIRECTLY PARTICIPATE IN
ANY STOCK OR EQUITY INVESTMENTS.
THIS CONTRACT CONTAINS A MARKET VALUE ADJUSTMENT PROVISION. THE AMOUNT PAYABLE
UPON FULL SURRENDER OR PARTIAL WITHDRAWAL OF THE CONTRACT VALUE MAY BE ADJUSTED
UPWARD OR DOWNWARD BASED ON A MARKET VALUE ADJUSTMENT FORMULA IN ADDITION TO ANY
SCHEDULED SURRENDER CHARGE. THE DEATH BENEFIT IS NOT SUBJECT TO A SURRENDER
CHARGE OR THE MARKET VALUE ADJUSTMENT FORMULA.
WE HOLD RESERVES FOR OUR GUARANTEES UNDER THIS CONTRACT IN A NON-UNITIZED
SEPARATE ACCOUNT ESTABLISHED WITHIN THE GENERAL ACCOUNT. THE ASSETS IN THE
SEPARATE ACCOUNT ARE SUBJECT TO THE LIABILITIES THAT ARISE OUT OF THE 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, [WAVERLY, IOWA], ON THE CONTRACT
ISSUE DATE.
[/s/ Xxxxxx X. Xxxxxx] [/s/ Xxxxxx X. Xxxxxxx]
President Secretary
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RIGHT TO EXAMINE THIS CONTRACT. IF FOR ANY REASON YOU DECIDE NOT TO KEEP THIS
CONTRACT, YOU MAY RETURN IT TO US WITHIN 10 DAYS AFTER YOU RECEIVE IT. IF THIS
CONTRACT IS A REPLACEMENT FOR AN EXISTING CONTRACT, YOU MAY RETURN IT TO US
WITHIN 30 DAYS AFTER YOU RECEIVE IT. YOU MAY RETURN THE CONTRACT TO EITHER OUR
ADMINISTRATIVE OFFICE OR TO THE AGENT WHO SOLD IT TO YOU. RETURN OF THIS
CONTRACT IS EFFECTIVE WHEN POSTMARKED, PROPERLY ADDRESSED AND POSTAGE PAID. WE
WILL CONSIDER THE CONTRACT VOID FROM THE BEGINNING AND WILL REFUND THE PURCHASE
PAYMENT WITHIN 7 DAYS AFTER WE RECEIVE THE RETURNED CONTRACT.
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Income Payments Starting on the Payout Date
Death Benefit Payable at Death of Owner Prior to the Payout Date
Non-Participating
2012-SPDMGIA
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CONTRACT GUIDE AND INDEX
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Data Page....................................................................... Section 1
Definitions..................................................................... Section 2
Parties to the Contract......................................................... Section 3
General Information............................................................. Section 4
Xxxxx, Xxxxxxxxx and Beneficiary................................................ Section 5
Purchase Payment and Risk Control Accounts...................................... Section 6
Automatic Rebalance Program..................................................... Section 7
Credited Index Interest......................................................... Section 8
Contract Value During The Accumulation Period................................... Section 9
Withdrawal Provision............................................................ Section 10
Nursing Home or Hospital/Terminal Illness Withdrawal Privilege.................. Section 11
Death Provisions Prior to the Payout Period..................................... Section 12
Payout Period................................................................... Section 13
Income Payments................................................................. Section 14
Death Provisions During the Payout Period....................................... Section 15
Income Option Rates............................................................. Section 16
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SECTION 1. DATA PAGE CONTRACT NUMBER: [123456789]
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OWNER(S) CONTRACT ISSUE DATE
-------- -------------------
[Xxxx Xxx] [June 1, 2011]
ANNUITANT(S) ANNUITANT(S) ISSUE AGE(S)
------------ -------------------------
[Xxxx Xxx] [35]
PURCHASE PAYMENT: [$5,000]
PAYOUT PERIOD INFORMATION:
ANTICIPATED PAYOUT DATE: [June 1, 2061]
ANTICIPATED INCOME OPTION: [Monthly Life Income - 10 Years]
LIFE INCOME RATES: [Type A]
INITIAL INDEX PERIOD INFORMATION:
INITIAL INDEX PERIOD: [10 Year]
INITIAL INDEX PERIOD EXPIRATION DATE: [June 1, 2022]
MARKET VALUE ADJUSTMENT INDEX 1: [Constant Maturity Treasury]
MARKET VALUE ADJUSTMENT RATE 1 AT ISSUE: [0.00%]
MARKET VALUE ADJUSTMENT INDEX 2: [Bank of America/Xxxxxxx Xxxxx Index for
Corporates]*
MARKET VALUE ADJUSTMENT RATE 2 AT ISSUE: [0.00%]
SURRENDER CHARGE SCHEDULE:
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Contract Year 1 2 3 4 5 6 7 8 9 10 11+
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Surrender Charge % 9% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0%
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RISK CONTROL ACCOUNT INFORMATION EFFECTIVE AS OF: [JUNE 1, 2011]
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Purchase Index Initial Index
Payment Interest Interest Index [Bailout
Allocation Index Rate Floor Rate Cap Value Rate]
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[[Secure Account] [50%] [S&P 500]* [0%] [2%] [1500] [0.1%]
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[Growth Account ]** [50%] [S&P 500]* [-10%] [12%] [1500] [0%]]
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[*The Bank of America/Xxxxxxx Xxxxx Index for Corporates is a trademark of the
Bank of America and has been licensed for use by MEMBERS Life Insurance Company.
This Product is not sponsored, endorsed, sold or promoted by Bank of America,
and Bank of America makes no representation regarding the advisability of
investing in the Product.
*The Standard & Poor's 500 Composite Stock Price Index (S&P500). "Standard &
Poor's(R)", "S&P(R)", "S&P 500(R)", "Standard & Poor's 500(R)" are trademarks of
the XxXxxx-Xxxx Companies, Inc. and have been licensed for use by MEMBERS Life
Insurance Company. This Product is not sponsored, endorsed, sold or promoted by
Standard & Poor's and Standard & Poor's makes no representation regarding the
advisability of investing in the Product. The S&P500 Index does not include
dividends paid by the underlying companies.]
**[Growth Account] is only available before the Initial Index Period Expiration
Date.
ADDITIONAL BENEFITS:
[Change of Annuitant Endorsement]
[Bailout Endorsement
Bailout Rate: See Risk Control Account Information]
[Credit Enhancement Endorsement]
Credit
[Contract Enhancement
Year] Bonus Percentage
1 [0%]
2+ [0%]]
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SECTION 2. DEFINITIONS
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2.1 WHAT ARE THE MOST ACCUMULATION PERIOD - The period of time that: (a) begins on the contract issue date
COMMONLY USED TERMS stated on the Data Page; and (b) continues until the payout date, unless this contract is
AND WHAT DO THEY MEAN? terminated.
ADJUSTED INDEX VALUE - The index value adjusted for the index interest rate cap or index
interest rate floor for the current contract year.
ADMINISTRATIVE OFFICE - MEMBERS Life Insurance Company, [0000 Xxxxxxxx Xxx, Xxxxxxx,
Xxxx 00000].
AUTOMATIC REBALANCE PROGRAM - The program ("rebalancing") to automatically transfer values
between the risk control accounts in order to achieve the balance of contract value equal
to the allocation percentages requested.
AGE - Age as of last birthday.
BUSINESS DAY - Any day both the company and the New York Stock Exchange are open for
business. The company is closed on the following holidays: New Year's Day, Good Friday,
Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day. The company
is closed on the holiday itself if the holiday falls Monday through Friday, the day
immediately preceding the holiday if the holiday falls on a Saturday, and the day
immediately following if the holiday falls on a Sunday.
CONTRACT ANNIVERSARY - The same day and month as the contract issue date for each year the
contract remains in force.
CONTRACT ISSUE DATE - The date from which contract years and contract anniversaries are
determined. The contract issue date is shown on your Data Page. Your contract issue date
is your initial index period start date.
CONTRACT VALUE - The current value of your annuity as provided under this contract during
the accumulation period. On the issue date, contract value is equal to your purchase
payment. On any other day during the accumulation period, contract value is equal to the
risk control accounts.
CONTRACT YEAR - Any twelve-month period beginning on the contract issue date or contract
anniversary and ending one day before the next contract anniversary.
CREDITED INDEX INTEREST - The amount of index interest credited on each contract
anniversary and at time of partial withdrawal, surrender, death and annuitization. Index
interest depends, in part, on an external index.
CREDITED INDEX INTEREST RATE - The rate used to determine the index interest to be applied.
DUE PROOF OF DEATH - 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.
GENERAL ACCOUNT - All of the company's assets other than the assets in segregated asset
accounts which are maintained as "insulated" separate accounts under applicable law.
GOOD ORDER - Receipt in our administrative office of all information we require to process
requests or transactions for your contract.
HOSPITAL - A facility that is licensed and operated as a hospital according to the law of
the jurisdiction in which it is located.
INDEX - The S&P 500 Composite Stock Price or any substituted suitable alternative index.
INDEX INTEREST - Interest we calculate that is based in part on the performance of an
Index.
INDEX INTEREST RATE CAP - The maximum index interest rate that may apply to determine the
index interest. We may change this rate at the beginning of a contract year.
INDEX INTEREST RATE FLOOR - The minimum index interest rate that may apply to determine
the index interest. This rate will not change during the life of your contract.
INITIAL INDEX VALUE - The index value as of the beginning of the current contract year.
INITIAL INDEX PERIOD - The period beginning on the contract issue date and ending on the
initial index period expiration date.
INITIAL INDEX PERIOD EXPIRATION DATE - The last day of the initial index period. Note
this also coincides with the last day that surrender charges and a market value
adjustment apply. The initial index period expiration date is shown on your Data Page.
IRC - The Internal Revenue Code of 1986, as amended.
MARKET VALUE ADJUSTMENT - The amount of adjustment (increased/decreased) that may be
applied to any partial withdrawal or surrender value during the initial index period.
This adjustment will not be applied to the free annual withdrawal amount.
MARKET VALUE ADJUSTMENT INDICES - The indices used to determine the interest rates used
to calculate the market value adjustment. They are shown on the Data Page.
MARKET VALUE ADJUSTMENT INDEX RATE - Rate(s) used to calculate the market value
adjustment.
NURSING HOME - A facility that is licensed and operates as a nursing facility according
to the law of the jurisdiction in which it is located.
PAYOUT DATE - The date we begin making income payments to the payee from the contract.
PAYOUT PERIOD - The phase the contract is in once income payments begin.
PURCHASE PAYMENT - Your contract is issued in return for your purchase payment. Your
purchase payment is shown on the Data Page.
RISK CONTROL ACCOUNT - An investment option that is available to you to allocate your
contract value. Each risk control account has a unique credited index interest rate cap
and index interest rate floor.
SEPARATE ACCOUNT - A non-registered separate account that we established within the
general account and in which we hold reserves for our guarantees under the contract. Our
other general account assets are also available to meet the guarantees under the contract
and our other general obligations. The assets of the separate account are subject to the
liabilities that arise out of the other business that we conduct.
SURRENDER CHARGE - The charge associated with surrendering either some or all of the
contract value before the end of the initial index period.
SURRENDER CHARGE PERIOD - The period of time when a surrender charge and market value
adjustment may be assessed on your contract value if you take a partial withdrawal or
surrender this contract. The surrender charge schedule is shown on your Data Page.
SURRENDER VALUE - The amount you are entitled to receive under this contract in the event
this contract is terminated during the accumulation period. It is equal to your contract
value, less any surrender charges and adjusted for any market value adjustment.
UNADJUSTED INDEX VALUE - The index value as of the date which index interest is
calculated.
WRITTEN REQUEST - A signed and dated written notice in a form satisfactory to us.
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SECTION 3. PARTIES TO THE CONTRACT
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3.1 WHO ARE THE PARTIES TO COMPANY - MEMBERS Life Insurance Company. Also referred to as "we", "our" and "us".
THE CONTRACT?
OWNER - The person(s) (or entities) who own(s) this contract and whose death determines
the death benefit. If there are multiple owners, each owner will be a joint owner of the
contract and all references to owner will mean joint owners. The owner has all rights,
title and interest in this contract during the accumulation period. The owner may
exercise all rights and options stated in this contract, subject to the rights of any
irrevocable beneficiary. The owner is also referred to as "you" or "your".
ANNUITANT (JOINT ANNUITANT) - The natural person(s) whose life (or lives) determines the
income payment amount payable under the contract.
BENEFICIARY - The person(s) (or entities) named on your application (unless later changed
as described in Section 5.3) to receive proceeds payable due to the death of the owner.
Prior to the payout date, if no beneficiary survives the owner, the proceeds will be paid
to the owner's estate.
PAYEE - The person(s) (or entities) who receives income payments during the payout period
while the annuitant is living. The payee is the owner unless otherwise designated. A
minor cannot be named the payee.
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SECTION 4. GENERAL INFORMATION
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4.1 WHAT IS THE ENTIRE This contract form, any attached riders and/or endorsements, and a copy of the attached
CONTRACT? application are the entire contract between you and us. No one except our president or
secretary can change or waive any of our rights or requirements under this contract. Any
change must be in writing.
4.2 WHEN DOES THIS CONTRACT This contract is incontestable from its contract issue date. The statements contained in
BECOME INCONTESTABLE? the application (in the absence of fraud) are considered representations and not
warranties.
4.3 WHAT IF AN ANNUITANT'S If an annuitant's date of birth has been misstated, we will adjust the income payments
DATE OF BIRTH OR GENDER under this contract to be equal to the payout amount the contract value would have
HAS BEEN MISSTATED? purchased based on the annuitant's correct date of birth. If an annuitant's gender has
been misstated, and the Type A life income rates apply (see your Data Page and Section
16), 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.
4.4 WILL ANNUAL REPORTS BE We will send you a report, without charge, at least annually. The report will provide
SENT? information about your contract and will include the contract value prior to the
application of any surrender charge or market value adjustment. It will also specify the
surrender charge and the market value adjustment applicable to determine the surrender
value. The annual report will be mailed to you no later than two months following the
effective date of the information provided.
4.5 DOES THIS CONTRACT The provisions of this contract conform with the minimum requirements of the state of
CONFORM WITH STATE LAW? 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 company will amend this contract to comply with any changes in law governing the
contract or the taxation of benefits under the contract.
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SECTION 5. OWNER, ANNUITANT AND BENEFICIARY
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5.1 WHAT ARE MY RIGHTS AS The owner may exercise all rights and privileges granted by this contract. If there are
AS OWNER OF THIS multiple persons named as owners, each owner will have equal ownership of the contract.
CONTRACT?
5.2 ARE THERE RESTRICTIONS A non-natural person may not jointly own a contract.
ON OWNERSHIP?
5.3 HOW CAN I CHANGE THE You may change the owner or beneficiary of this contract by written request at any time
OWNER OR BENEFICIARY before the payout date. Unless otherwise specified by the owner, the change will take
OF THIS CONTRACT? effect as of the date you signed it. We are not liable for any payment we make or action
we take before receiving any such written request in our administrative office.
If there are multiple owners, the written request for change must be signed by all owners.
A request for change of owner or beneficiary must also be signed by any irrevocable
beneficiary.
5.4 CAN I CHANGE THE You may change the annuitant at any time before the payout date. Written notice of the
ANNUITANT UNDER THIS change of the annuitant must be filed with us and signed by all owners and any irrevocable
CONTRACT? beneficiary. Unless otherwise specified by the owner, such change will take effect on the
date of the written request but will be subject to any payment made or other action taken
by us before the request was filed.
The annuitant may not be changed if the owner is not a natural person.
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SECTION 6. PURCHASE PAYMENT AND RISK CONTROL ACCOUNTS
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6.1 HOW WILL THE PURCHASE The purchase payment will be allocated to the risk control accounts you elected at
PAYMENT BE ALLOCATED contract issue.
TO THE RISK CONTROL
ACCOUNTS?
6.2 CAN I ESTABLISH MORE Each risk control account will have its own index, index interest rate cap and index
THAN ONE RISK CONTROL interest rate floor. The initial index interest rate cap and floor for each risk control
ACCOUNT? accounts are shown on Your Data Page. The provisions below regarding index interest,
contract value, market value adjustment, surrender charges, surrenders and withdrawals
apply to each risk control account.
6.3 CAN MY RISK CONTROL You may change risk control account allocation as of any contract anniversary. Written
ACCOUNT ALLOCATION requests to change risk control accounts or allocation between risk control accounts
PERCENTAGES BE CHANGED? must be received no later than two business days prior to the contract anniversary to take
effect. Requests received within two business days to the current year contract
anniversary will be processed and made effective on the following year contract
anniversary.
If a change is made to the risk control account allocation, we will send confirmation
letters.
After the initial index period and during a continued accumulation period, only risk
control accounts with an index interest rate floor of 0% will be available.
6.4 HOW IS A WITHDRAWAL Withdrawals (including any applicable surrender charge and market value adjustment) will be
ALLOCATED BETWEEN RISK made in the proportion that each risk control account value bears to the contract value at
CONTROL ACCOUNTS? the time of withdrawal.
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SECTION 7. AUTOMATIC REBALANCE PROGRAM
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7.1 WHAT IS THE AUTOMATIC The automatic rebalance program ("rebalancing") transfers values between the risk control
REBALANCE PROGRAM FOR accounts based on the last allocation percentages which you specified. At issue, these
RISK CONTROL ACCOUNTS? percentages are shown on your Data Page. See Section 6.3 for more information regarding
changing allocation percentages among risk control accounts.
Rebalancing is required unless your allocation percentage is 100% to one risk control
account. Rebalancing, if required, will occur automatically on each contract anniversary.
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SECTION 8. CREDITED INDEX INTEREST
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8.1 HOW MUCH INDEX INTEREST For each risk control account, the credited index interest rate will be used to determine
WILL BE CREDITED AND the credited index interest during the accumulation period.
HOW IS IT DETERMINED?
For the purposes of the credited index interest rate calculation:
Adjusted Index Value =
If (Unadjusted Index Value) > (Initial Index Value) x (1 + Index Interest Rate Cap)
Then Adjusted Index Value = (Initial Index Value) x (1 + Index Interest Rate Cap)
If (Unadjusted Index Value) < (Initial Index Value) x (1 + Index Interest Rate Floor)
Then Adjusted Index Value = (Initial Index Value) x (1 + Index Interest Rate Floor)
Otherwise Adjusted Index Value = Unadjusted Index Value
The unadjusted index value for each day is the closing value for the associated index as
of the interest credited date. If the index value is not available on that day, we will
use the next day for which the credited index value is available.
On each day, the credited index interest rate (IIR) for each risk control account is
equal to
(A / B) - 1 where:
A = Adjusted Index Value as of the current date
B = the later of the Adjusted Index Value as of the last withdrawal, or Initial
Index Value
This credited index interest rate (IIR) will be taken times the risk control account
value, as defined in Section 9.1 below, as of the last index interest credited date to
determine the amount of index interest applied.
This process is repeated for each risk control account.
8.2 WHEN WILL INDEX INTEREST Credited index interest will be calculated and applied on each contract anniversary.
BE APPLIED TO THE RISK Credited index interest will also be calculated and applied when a partial withdrawal,
CONTROL ACCOUNTS? surrender, annuitization, or death proceeds are payable.
8.3 WILL THE INDEX INTEREST We may vary the index interest rate cap each contract year based on the contract year
RATE FLOOR AND INDEX and the contract value.
INTEREST RATE CAP CHANGE?
The index interest rate floor associated with each risk control account will not change
during the life of your contract
8.4 CAN AN INDEX BE CHANGED? The same index will be used for each risk control account for the duration of your
contract. However, if the publication of that index is discontinued, or the calculation
of that index is materially changed, we will substitute a suitable index that will be
used for the entire then-current contract year and notify you of the change in advance.
Any change will be approved by the insurance commissioner of the state in which the
contract was issued, if required by state law. Notification will be in your annual report
unless timing of any such change would cause us to send notification prior to your
contract anniversary.
8.5 CAN ADDITIONAL INDICES We may offer additional risk control accounts with additional indices at our discretion.
BE ADDED?
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SECTION 9. CONTRACT VALUE DURING THE ACCUMULATION PERIOD
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9.1 WHAT IS MY CONTRACT VALUE On the contract issue date, the contract value is equal to the purchase payment. The
DURING THE ACCUMULATION contract value on any other given date during the accumulation period is equal to the sum
PERIOD? of the risk control account values. The contract value will be re-calculated at the time
of a partial withdrawal and on each contract anniversary, as well as at the time of
surrender, annuitization and upon death of the owner.
Each risk control account value is calculated using the following formula:
Risk Control Account Value(t)= [Risk Control Account Value effective last contract
anniversary] (t-1) + Index Interest Credited throughout the current contract year
(see Section 8.1) - Gross Withdrawals (defined below)
Where: Risk Control Account Value(t)= risk control account value on the date of
calculation
Risk Control Account Value effective last contract anniversary(t-1) = risk
control account value beginning of the current contract year
Index Interest Credited = the resulting credited index interest amount as
described in Section 8.1
Gross Withdrawals = the sum of all partial withdrawals, taken since the last
contract anniversary, which includes all surrender charges and market
value adjustments, if any.
This process is repeated for each risk control account.
9.2 HOW DOES MY CONTRACT The contract value will be reduced by the sum of all partial withdrawals, including
VALUE CHANGE UPON all surrender charges and market value adjustments, if any.
A PARTIAL WITHDRAWAL?
9.3 WHAT IS THE SURRENDER The surrender value is equal to the contract value as of the date your written request
VALUE? for surrender is received in our administrative office, reduced by any applicable
surrender charge and adjusted (increased/decreased) for any applicable market value
adjustment.
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SECTION 10. WITHDRAWAL PROVISION
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10.1 WHAT ARE THE RULES FOR A After the first contract anniversary and before the payout date, you may make two partial
PARTIAL WITHDRAWAL OF withdrawals per contract year by written request. The written consent of all owners and
THE SURRENDER VALUE? irrevocable beneficiaries must be obtained prior to any partial withdrawal. Partial
withdrawals will be effective as of the date we receive your written request in good
order in our administrative office.
Any applicable surrender charge and market value adjustment will affect the amount
available for a partial withdrawal. If a partial withdrawal would cause the surrender
value to be less than $2,000, we will treat your request as a full surrender.
10.2 WHAT ARE THE RULES FOR A You have the right to surrender this contract during the accumulation period by written
FULL SURRENDER OF THE request. The written consent of all owners and irrevocable beneficiaries must be obtained
CONTRACT? prior to a full surrender. You will be paid the surrender value as of the date we
received your written request in good order in our administrative office.
Upon payment of the surrender value, this contract is terminated, and we have no further
obligation under this contract. We may require that this contract be returned to our
administrative office prior to making payment.
10.3 WHAT AMOUNTS MAY BE The following amounts may be withdrawn without incurring a surrender charge or a market
WITHDRAWN WITHOUT value adjustment:
INCURRING A SURRENDER
CHARGE OR MARKET VALUE a. death benefit proceeds;
ADJUSTMENT? b. nursing home or hospital/terminal illness withdrawals as described in Section 11;
c. your free annual withdrawal amount described below;
d. amounts withdrawn after the initial index period;
e. amounts withdrawn as required minimum distributions under the IRC;
f. income payments during the payout period as described in Section 14.
Your free annual withdrawal amount during the initial index period is a percentage of
your beginning of year contract value. The free annual withdrawal amount is equal to 10%
of the beginning of year contract value, beginning in year 2. There is no free annual
withdrawal amount in contract year 1. If you make a partial withdrawal of less than 10%
of the beginning of year contract value, the remaining free annual withdrawal amount will
be applied to any subsequent partial withdrawal which occurs during the same contract
year. No remaining free annual withdrawal amount will carry over to any subsequent
contract year.
10.4 WHAT IS THE SURRENDER A surrender charge is imposed on amounts withdrawn in excess of the free annual withdrawal
CHARGE? amount described in Section 10.3 above. The surrender charge will reduce the overall
withdrawal amount. The surrender charge schedule is shown on your Data Page and is
expressed as a percentage of your contract value.
The surrender charge amount, if any, is calculated using the following formula:
Surrender Charge Amount = W x SC%
Where:
W = amount of withdrawal (or portion of withdrawal) that is in excess of the
free annual withdrawal amount remaining (if any) for that contract year
SC% = applicable surrender charge percentage based on the contract year of
the withdrawal
10.5 ARE THERE ANY Generally, the amount of any surrender or partial withdrawal will be paid to you within
RESTRICTIONS ON seven days of receipt of your written request in our administrative office in good order.
PAYMENTS FOR SURRENDER
OR PARTIAL WITHDRAWALS? Subject to obtaining prior written approval by the state commissioner if required by
state law, we reserve the right to postpone payment of any surrender or partial
withdrawal for up to six (6) months after we receive your written request. In the event
of postponement, we will pay interest on the proceeds if required by state law. Interest
will be calculated at the effective annual rate and for the time period required under
state law.
10.6 HOW IS THE MARKET VALUE The market value adjustment is not applied to the free annual withdrawal amount, only to
ADJUSTMENT CALCULATED the portion of withdrawals that exceed the free annual withdrawal amount. The market
ON FULL SURRENDER OR value adjustment is only applied during the initial index period and is calculated
PARTIAL WITHDRAWAL DURING separately for each risk control account. The amount of withdrawal applied in the MVA
THE ACCUMULATION PERIOD? formula is proportional to the risk control account value as it bears to the contract
value at the time of withdrawal. On any given date it is calculated using the following
formula:
MVA = (W / (1+IIR*)) x (MVAF - 1)
Where:
W = amount of withdrawal (or portion of withdrawal) that is in excess of the free
annual withdrawal amount remaining (if any) for that contract year
IIR* = the resulting credited index interest rate where (A / B) - 1 where:
A = Adjusted Index Value as of the current date
B = Initial Index Value for current contract year
MVAF = ((1 + I + K)/(1 + J + L))^N
I = The market value adjustment index rate of the Market Value Adjustment Index 1 as
of the contract issue date for a maturity consistent with the initial index period
(shown on your Data Page).
J = The market value adjustment index rate as of the withdrawal date of the Market
Value Adjustment Index 1 for a maturity consistent with the remaining length of the
initial index period.
If there is no corresponding length of the market value adjustment index 1, then the
linear interpolation of the index with maturities closest to N will be used to
determine I and J.
K = The market value adjustment index rate of the Market Value Adjustment Index 2 as
of the contract issue date (shown on your Data Page).
L = The market value adjustment index rate of the Market Value Adjustment Index 2 as
of the withdrawal date.
N = The number of years (whole and partial) from the current date until the end of
the initial index period.
10.7 WHAT HAPPENS IF ANY OF If the publication of any component of the market value adjustment indices is discontinued
THE MARKET VALUE or if the calculation of the market value adjustment indices is changed substantially, we
ADJUSTMENT INDICES ARE may substitute for the discontinued or substantially changed element subject to any
DISCONTINUED? applicable regulatory approval that may be required. Before a substitute index is used, we
shall notify you of the substitution. Any change we make will be on a non-discriminatory
basis.
10.8 HOW WILL THE SURRENDER For each partial withdrawal and upon full surrender of the contract within the initial
CHARGE AND MARKET VALUE index period, the total withdrawal/surrender amount may be reduced by the applicable
ADJUSTMENT AFFECT THE surrender charge and adjusted (increased/decreased) for the market value adjustment as
WITHDRAWAL AMOUNT? stated above.
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SECTION 11. NURSING HOME OR HOSPITAL/TERMINAL ILLNESS WITHDRAWAL PRIVILEGE
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NOTICE: THIS WITHDRAWAL PRIVILEGE IS NOT INTENDED TO PROVIDE LONG-TERM CARE OR NURSING HOME INSURANCE.
11.1 WHAT IS THE NURSING HOME We will waive the surrender charge and/or market value adjustment subject to providing
OR HOSPITAL/TERMINAL proof that one of the following conditions has occurred:
ILLNESS PRIVILEGE?
a.) NURSING HOME OR HOSPITAL. The owner or annuitant has first been admitted to a
licensed nursing home or hospital and has been confined to such nursing home or
hospital for at least 180 consecutive days after the latter of the contract
issue date or the date of change of owner or annuitant. As proof, we may require
verification of confinement in the nursing home or hospital.
The conditions that must be met are that:
o the confinement in a Nursing Home or Hospital is recommended by a Physician
who is duly licensed by the state to treat the injury or sickness causing the
confinement and who is not an employee of the Nursing Home or Hospital where
the annuitant or owner is confined; and
o an additional free annual withdrawal amount request, accompanied by written
proof of confinement and the Physician's recommendation, is received by us no
later than 90 days following the date that the qualifying confinement has
ended.
b.) TERMINAL ILLNESS. The owner or annuitant has been determined to be terminally
ill. Terminally ill means that due to illness or accident, the annuitant's life
expectancy is 12 months or less. As proof, we require determination of the
terminal illness. Such determination must be signed by the physician making the
determination after the latter of the contract issue date or the date of change
of owner or annuitant. The physician may not be a member of your immediate
family.
Proof must be provided at the time of your request for surrender or partial withdrawal.
Before granting the waiver, we may request a second opinion or examination of the owner
or annuitant by one of our examiners. We will bear the cost of such second opinion.
This privilege may be exercised only one time.
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SECTION 12. DEATH PROVISIONS PRIOR TO PAYOUT PERIOD
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Notwithstanding any provision of 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
the IRC.
12.1 WHAT HAPPENS IF AN If you die during the accumulation period, your beneficiary is entitled to a death
OWNER DIES DURING THE benefit. If you have a joint owner, the death benefit will be available when the first
ACCUMULATION PERIOD? joint owner dies.
A beneficiary must make his/her election within sixty (60) days of the date we receive
due proof of death. The following death benefit options are available:
OPTION A: If the sole beneficiary is the surviving spouse of the deceased owner, the
surviving spouse may elect to continue the contract as the new owner.
OPTION B: If the beneficiary is a natural person, payment of the death benefit may be
applied under one of the Income Payout options. Payments under the Income Payout option
must begin within one (1) year of the owner's death and payments may not extend beyond a
period certain equal to the beneficiary's life expectancy.
OPTION C: Lump sum payment of the death benefit.
OPTION D: Payment of the death benefit within five (5) years of the date of the owner's
death.
12.2 WHAT HAPPENS IF THE If the Annuitant dies during the accumulation period, while the owner is living, and no
ANNUITANT DIES DURING joint Annuitant has been named, the owner will become the annuitant, until and unless
THE ACCUMULATION PERIOD? we receive other written notice.
If a joint annuitant has been named, then upon the death of an annuitant, the surviving
joint annuitant will become the annuitant.
If the owner is not a natural person, the annuitant may not be changed and a new
annuitant may not be designated. For purposes of the Death Provisions, the annuitant will
be considered the owner. See Section 12.1.
12.3 WHAT AMOUNT WILL BE The amount that will be paid as death benefit proceeds is equal to the contract value
PAID AS DEATH BENEFIT? adjusted (increased/decreased) for interest credited on the date death proceeds are
payable.
12.4 WHEN ARE DEATH PROCEEDS Death benefit proceeds are payable upon our receipt of due proof of the owner's death.
PAYABLE?
12.5 WILL INTEREST BE PAID We will pay interest on single sum death proceeds, if required by state law. Interest,
ON DEATH PROCEEDS? if any, will be calculated at the rate and for the time period required by state law.
12.6 ARE DEATH BENEFITS SUBJECT So far as permitted by law, the death benefits will not be subject to any claim of
TO CLAIMS OF CREDITORS? the beneficiary's creditors.
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SECTION 13. PAYOUT PERIOD
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13.1 WHAT IS THE PAYOUT PERIOD? The payout period is the period of time that: (a) begins on the 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 will be applied to the income payout
option you selected. If you do not select an income payout option we will make payments
on the following basis, unless otherwise required under the IRC:
a.) Life Income Option with a 10-year guaranteed period certain for contracts with
one (1) annuitant; and
b.) Joint & Survivor Life Income Option with a 10-year guaranteed period certain for
contracts with two (2) annuitants.
If there is only one (1) annuitant on the payout date and you select Option 3 (the Joint
and Survivor Life Income Option described in Section 14.3) or any other available joint
and survivor option, you may name a joint annuitant upon whose life expectancy, in
conjunction with the annuitant's, the income payments will be based.
13.2 CAN THE ANNUITANT OR OWNER You cannot change the annuitant or owner on or after the income payment start
BE CHANGED? date for any reason.
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SECTION 14. INCOME PAYMENTS
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14.1 WHEN WILL INCOME PAYMENTS The first income payment will be paid as of the payout date. The anticipated payout date
BEGIN? is shown on your Data Page. It is equal to the contract anniversary following the
annuitant's 95th birthday.
You may change the payout date to a date other than the anticipated payout date by
written request, provided: (a) the request is made while an owner is alive; (b) the
request is received at our administrative office at least 30 days prior to the
anticipated payout date; and (c) the requested payout date is at least two years after
the contract issue date. Such change is subject to any maximum maturity age restrictions
that may be imposed by law and cannot extend past the latest payout date that is allowed
under this contract.
14.2 TO WHOM ARE INCOME The owner may name the person to receive income payments. If no person is named, payment
PAYMENTS MADE? will be made to the owner.
14.3 WHAT INCOME PAYOUT There are different ways to receive income payments. We call these income payout options.
OPTIONS ARE AVAILABLE? Three income payout options are described below. The payout options described may not be
available in all states at all times. Other income payout options may be available with
our consent.
OPTION 1 - INSTALLMENT OPTION. We will pay monthly income payments for a chosen number
of years, not less than 10, nor more than 30. If the annuitant dies before income
payments have been made for the chosen number of years: (a) income payments will be
continued for the remainder of the period to the payee; or (b) the present value of the
remaining income payments, computed at the interest rate used to create the Option 1
rates, will be paid to the payee or to the owner if there is no surviving payee.
OPTION 2 - LIFE INCOME OPTION - GUARANTEED PERIOD CERTAIN. We will pay monthly income
payments for as long as the annuitant lives. If the annuitant dies before all of the
income payments have been made for the guaranteed period certain: (a) income payments
will be continued during the remainder of the guaranteed period certain to the payee; or
(b) the present value of the remaining income payments, computed at the interest rate
used to create the Option 2 rates, will be paid to the payee or to the owner if there is
no surviving payee.
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. If at
the death of the second surviving annuitant, income payments have been made for less than
10 years: (a) income payments will be continued during the remainder of the guaranteed
period certain to the payee; or (b) the present value of the remaining income payments,
computed at the interest rate used to create the Option 3 rates, will be paid to the
payee or to the owner if there is no surviving payee.
14.4 WHAT ARE THE REQUIREMENTS The minimum amount which can be applied under all payout options is the greater of
FOR CHOOSING AN INCOME $2,500 or the amount required to provide an initial monthly income payment of $20.
PAYOUT OPTION?
We may require due proof of age and gender of any annuitant on whose life an income
payout option is based.
14.5 HOW WILL INCOME PAYMENT The minimum dollar amount of each income payment will be determined by dividing the
VALUES BE DETERMINED? contract value applied by $1,000, and multiplying the result by the applicable option
rate shown in Section 16. The amount of any income payout 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.
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SECTION 15. DEATH PROVISIONS DURING THE PAYOUT PERIOD
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15.1 IS NOTIFICATION OF DEATH We must be notified immediately of the death of an annuitant, owner or payee. Proof of
REQUIRED? death will be required upon the death of an annuitant or owner. We are not responsible
for any misdirected payments that result from failure to notify us of any such death.
15.2 WHAT HAPPENS WHEN THE If an annuitant dies during the payout period, remaining income payouts or death benefits,
ANNUITANT DIES? if any, will be distributed as provided by the income payout option in effect. The income
option payout in effect will determine whether additional income payouts or a death
benefit apply.
15.3 WHAT HAPPENS WHEN THE If an owner dies after on or after the start of income payout, any remaining income payouts
OWNER DIES WHO IS NOT will be distributed at least as rapidly as provided by the income payout option in effect.
THE ANNUITANT?
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SECTION 16. INCOME OPTION RATES
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16.1 WHAT RATES WILL BE USED The rates shown are used to determine the minimum payment values for monthly income
TO DETERMINE PAYMENT payments. We reserve the right on a non-discriminatory basis, to offer higher than
VALUES FOR OPTIONS 1 current income payment levels that may vary based on the contract year in which the
THROUGH 3? payout phase begins.
The amount of each monthly income payment, for purposes of calculating minimum payment
values for Options 2 and 3, are based on each annuitant's gender and his/her adjusted age
for Type A life income rates, and on each annuitant's adjusted age for Type B life income
rates. The life income rates type for this contract is shown on the Data Page.
16.2 HOW IS THE ANNUITANT'S The annuitant's adjusted age is his/her age as of the date of the first payment minus
ADJUSTED AGE FOR 5 years, then subtracted by 2 additional years for each 5 full years elapsed between
OPTIONS 2 AND 1/1/2013 and the Payout Date.
3 DETERMINED?
16.3 WHAT RATES ARE USED TO OPTION 1 - INSTALLMENT OPTION RATES - FIRST PAYMENT DUE AT BEGINNING OF PERIOD.
DETERMINE THE MINIMUM
PAYMENT VALUES FOR NUMBER OF YEARS MONTHLY PAYMENT
OPTION 1? PAYABLE FOR EACH $1,000 APPLIED
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10 8.75
15 5.98
20 4.59
25 3.76
30 3.21
These rates are based on an effective annual rate of 1.00%.
16.4 WHAT RATES ARE USED TO OPTION 2 - LIFE INCOME OPTION RATES - GUARANTEED PERIOD CERTAIN - FIRST PAYMENT DUE AT
DETERMINE THE MINIMUM BEGINNING OF PERIOD. The life income rates type for this contract is shown on the Data
PAYMENT VALUES FOR Page.
OPTION 2?
TYPE A LIFE INCOME RATES - PER $1,000 APPLIED
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Adjusted Age - Male
Years -------------------------------------------------------------------------------
Certain 55 60 65 70 75 80 85 90 95 100
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0 3.22 3.69 4.32 5.19 6.37 8.02 10.34 13.63 18.28 26.51
5 3.22 3.68 4.30 5.13 6.22 7.65 9.45 11.52 13.69 15.74
10 3.20 3.64 4.21 4.92 5.77 6.69 7.55 8.21 8.61 8.74
15 3.16 3.56 4.04 4.57 5.10 5.53 5.81 5.94 5.98 5.98
20 3.09 3.43 3.79 4.12 4.37 4.52 4.58 4.59 4.59 4.59
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Adjusted Age - Female
Years -------------------------------------------------------------------------------
Certain 55 60 65 70 75 80 85 90 95 100
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0 3.01 3.43 3.99 4.77 5.89 7.53 9.98 13.52 18.17 25.44
5 3.01 3.42 3.98 4.73 5.80 7.28 9.24 11.47 13.59 15.55
10 3.00 3.40 3.93 4.62 5.50 6.52 7.49 8.19 8.59 8.73
15 2.98 3.35 3.82 4.38 4.98 5.48 5.80 5.94 5.98 5.98
20 2.94 3.27 3.65 4.03 4.33 4.51 4.58 4.59 4.59 4.59
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TYPE B LIFE INCOME RATES - PER $1,000 APPLIED
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Adjusted Age - Unisex
Years -------------------------------------------------------------------------------
Certain 55 60 65 70 75 80 85 90 95 100
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0 3.05 3.48 4.06 4.85 5.98 7.63 10.05 13.54 18.19 25.65
5 3.05 3.47 4.04 4.81 5.88 7.35 9.28 11.48 13.61 15.59
10 3.04 3.45 3.98 4.68 5.55 6.55 7.50 8.20 8.59 8.74
15 3.01 3.40 3.87 4.42 5.00 5.49 5.80 5.94 5.98 5.98
20 2.97 3.30 3.68 4.05 4.34 4.51 4.58 4.59 4.59 4.59
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These rates are based on the Annuity 2000 Tables with compound interest at an effective
annual rate of 1.00%. Rates for years payable and guaranteed periods certain are not
shown. If allowed by us, they will be calculated on an actuarially equivalent basis and
will be available upon request.
16.5 WHAT RATES ARE USED TO OPTION 3 - LIFE INCOME OPTION RATES - JOINT AND SURVIVOR - 10 YEAR GUARANTEED PERIOD
DETERMINE THE MINIMUM CERTAIN - FIRST PAYMENT DUE AT BEGINNING OF PERIOD. The life income rates type for
PAYMENT VALUES FOR this contract is shown on the Data Page.
OPTION 2?
TYPE A LIFE INCOME RATES - PER $1,000 APPLIED
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Adjusted Age - Female
Adjusted ------------------------------------------------------------------------------
Age - Male 55 60 65 70 75 80 85 90 95 100
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55 2.66 2.81 2.94 3.04 3.11 3.15 3.18 3.19 3.19 3.20
60 2.77 2.98 3.18 3.35 3.47 3.56 3.60 3.63 3.64 3.64
65 2.86 3.13 3.40 3.66 3.88 4.04 4.13 4.18 4.20 4.21
70 2.92 3.24 3.59 3.97 4.31 4.59 4.77 4.87 4.91 4.92
75 2.95 3.31 3.74 4.22 4.72 5.16 5.48 5.66 5.74 5.77
80 2.98 3.36 3.83 4.40 5.05 5.68 6.18 6.49 6.63 6.68
85 2.99 3.38 3.88 4.52 5.28 6.09 6.78 7.23 7.46 7.54
90 2.99 3.39 3.91 4.58 5.42 6.35 7.20 7.78 8.09 8.20
95 3.00 3.40 3.92 4.61 5.48 6.48 7.42 8.08 8.46 8.59
100 3.00 3.40 3.93 4.61 5.50 6.52 7.49 8.18 8.58 8.72
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TYPE B LIFE INCOME RATES - PER $1,000 APPLIED
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Adjusted Age - Unisex
Adjusted ------------------------------------------------------------------------------
Age - Male 55 60 65 70 75 80 85 90 95 100
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55 2.63 2.76 2.86 2.93 2.98 3.01 3.03 3.03 3.04 3.04
60 2.76 2.95 3.11 3.24 3.34 3.39 3.43 3.44 3.45 3.45
65 2.86 3.11 3.36 3.58 3.75 3.87 3.93 3.96 3.98 3.98
70 2.93 3.24 3.58 3.91 4.21 4.43 4.57 4.64 4.67 4.68
75 2.98 3.34 3.75 4.21 4.66 5.05 5.31 5.46 5.53 5.55
80 3.01 3.39 3.87 4.43 5.05 5.64 6.10 6.37 6.51 6.55
85 3.03 3.43 3.93 4.57 5.31 6.10 6.76 7.19 7.42 7.50
90 3.03 3.44 3.96 4.64 5.46 6.37 7.19 7.77 8.08 8.18
95 3.04 3.45 3.98 4.67 5.53 6.51 7.42 8.08 8.44 8.58
100 3.04 3.45 3.98 4.68 5.55 6.55 7.50 8.18 8.58 8.72
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These rates are based on the Annuity 2000 Tables with compound interest at an effective
annual rate of 1.00%. Rates for years payable and guaranteed periods certain are not
shown. If allowed by us, they will be calculated on an actuarially equivalent basis and
will be available upon request.
SINGLE PREMIUM DEFERRED
MODIFIED GUARANTEED INDEX ANNUITY
Income Payments Starting on the Payout Date
Death Benefit Payable at Death of Owner Prior to the Payout Date
Non-Participating
MEMBERS LIFE INSURANCE COMPANY
[0000 XXXXXXXX XXX, XXXXXXX, XXXX 00000]
[TELEPHONE: 000.000.0000]
