Owner’s Signature  Date Signed 

DFS-H1-1980 Rule 69B-162.011, F.A.C.Effective 10/21/2014 

2000 Heritage Way Waverly, IA 50677 

ANNUITY SUITABILITY QUESTIONNAIRE 

Owner: Last First Middle

Date of Birth    / / Age Sex

Entity:

Tax Status  Relationship to Annuitant(s):  

Form of Ownership: 

Supporting documents (list): 

Annual Income:

Source of Income: 

Annual Household Income: 

Existing Assets 

Existing Liquid Net Worth: 

Do you currently own any annuities?  Please list: 

 Yes  No 

Do you currently own life insurance?  Please list: 

 Yes  No 

Does your income cover all your living expenses including medical?  Yes  No 

Do you expect changes to your living expenses?   Yes  No 

Do you anticipate changes in your out-of-pocket medical expenses?   Yes  No 

Is your income sufficient to cover future changes in your living and/or out-of-pocket medical expenses during the surrender charge period?   Yes  No 

Do you have an emergency fund for unexpected expenses?   Yes  No 

Why are you purchasing this annuity?

What are your financial objectives for this purchase? (Check all that apply)

 Income   Growth (long term)   Safety of Principal and Income 

 Safety of Principal and Growth   Pass assets to a beneficiary or beneficiaries at death 

Other:

Office Use OnlyDoc Code:  92 

Owner’s Signature  Date Signed 

DFS-H1-1980 Page 2 of 4  Rule 69B-162.011, F.A.C. Effective 10/21/2014 

Describe your risk tolerance: (Check all that apply)

 Conservative  Moderately conservative   Moderate   Moderately aggressive 

 Aggressive   Other: 

Comments:

Describe your investment experience by type and length of time:

What is the source of the funds for the purchase of the proposed annuity? 

How many years from today will you need access to your funds without a penalty?

Will the proposed annuity replace any product?   Yes  No 

If yes, will you pay a penalty or other charge to obtain these funds?   Yes  No 

If yes, the amount of the charge or penalty  $

Additional Information:

Owner’s Signature  Date Signed 

DFS-H1-1980 Page 3 of 4  Rule 69B-162.011, F.A.C. Effective 10/21/2014 

Note: The following three sections to be completed by the agent, insurer, or Managing General Agent proposing purchase; each section requires a response; no section may be left blank or contain a response consisting of “None” or “N/A”. 

Advantages of purchasing the proposed annuity: 

Disadvantages of purchasing the proposed annuity: 

The basis for my recommendation to purchase the proposed annuity or to replace or exchange your existing annuity(ies): 

Agent’s Signature  Date Signed 

Note: No questions or response areas are to be left blank when offered to the Owner for signature. If any information requested is unavailable, not applicable or unknown, the insurance agent or insurer must indicate that. 

ACKNOWLEDGEMENTS AND SIGNATURES 

I understand that should I decline to provide the requested information or should I provide inaccurate information, I am limiting the protection afforded me by the Florida Statutes regarding the suitability of this purchase. 

 I REFUSE to provide this information at this time. 

 I have chosen to provide LIMITED information at this time. 

 My annuity purchase IS NOT BASED on the recommendation of this agent or the insurer. 

 My annuity purchase IS BASED on the recommendation of this agent or the insurer. 

APPLICANT:DO NOT SIGN THIS FORM IF ANY ITEM HAS BEEN LEFT BLANK, BEFORE CAREFULLY REVIEWING THE INFORMATION RECORDED, OR IF ANY OF THE INFORMATIONRECORDED IS NOT TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE.

THE OWNER MAY SUBSTITUTE THEIR INITIALS FOR SIGNATURES ON ALL FORM PAGES WITH THE EXCEPTION OF THE SIGNATURES BELOW, WHICH ARE REQUIRED. 

Owner’s Signature  Date Signed 

DFS-H1-1980 Page 4 of 4  Rule 69B-162.011, F.A.C. Effective 10/21/2014 

EXPLANATION OF TERMS

“Age” is the natural person’s attained age on the day the form is completed.

“Tax Status” is the owner’s Federal Income Tax filing status such as “single” or “married filing jointly”; if “Exempt”, so state. 

“Form of Ownership” is the type of entity, other than a natural person, including a corporation, trust, partnership, limited liability company, or other business or not-for-profit entity. 

“Supporting documents” are the documents that provide a basis for the relationship between the Proposed Annuitant, and the Owner as it may exist. 

“Annual income” is income received during a calendar year, whether earned or unearned. 

“Source of annual income” is the income-generating source, such as pension income, dividends, or earned income etc. 

“Annual household income” is the combined annual income received by all household members each calendar year. 

“Existing Assets” are financial assets including life insurance and annuities. 

“Existing Liquid Net Worth” is applicable to those net assets that can readily be converted into their cash equivalent, without loss of principal after all surrender charges or other deductions have been taken. 

“Financial Objectives” are the owner’s stated goals as described to the insurance agent or insurer, if no insurance agent is involved. These may include but are not limited to the following: (1) Income, (2) Growth (long term capital appreciation), (3) Safety of Principal and Income, (4) Safety of Principal and Growth, (5) To pass the investment to a beneficiary or beneficiaries at death. 

“Risk Tolerance” means the degree of uncertainty that an investor can reasonably tolerate with regard to a negative change in his or her investments. Examples of risk tolerance levels may include the following: (1) Conservative (prefer little or no risk), (2) Moderately conservative (some risk, reduced safety of principal), (3) Moderate (average risk with potential losses and potentially higher returns), (4) Moderately aggressive (above average risk with potential losses, risk of principal and potentially higher returns), (5) Aggressive (willing to sustain losses or loss of principal in pursuit of higher returns). 

“Source of the funds” to be used to purchase the proposed annuity means from where the funds will come to purchase the annuity, and may include but are not limited to; (1) An existing annuity or life insurance contract, (2) Liquid Assets, including but not limited to, cash in banks, maturing certificates of deposit, and money market accounts, (3) Personal Loans, (4) Equity Loans, (5) Mortgages, Reverse Mortgages, (6) Death Benefit Proceeds, (7) Funds received upon retirement from employment, including but not limited to, 401(k) accounts, pensions, and other tax-sheltered funds, (8) Equities, mutual funds, or bonds, (9) Proceeds from real estate transactions. 

All parties must be age 90 or younger on contract issue date. Any owner named below must be atleast age 18 (age 19 in Alabama).

Check only one guarantee rate period for the plan option you select.1. PLAN OPTION

The annuitant is the owner unless a different owner is named in section 2b. If annuitant is under age 18 (age 19 in Alabama), adifferent owner must be named in section 2b.

For non-qualified only. For a trust owner, include a copy of the pages of the trust document which indicate trustname, trust date, trustee name(s), investment authority and signature(s), or complete form 1919(CML), Trustee Certification of Insurance/AnnuityPowers.

REQUIRED.

a. Annuitant (Owner)

Gender Male FemaleSSN Date of Birth

Daytime PhoneMailing Address

State ZipCity

Page 1SPDAAPP-2009

Individual Deferred FixedAnnuity Application

4-year 5-year 6-year

Yes NoU.S. Citizen

Person Authorized to Receive Correspondence

b. Owner (if other than Annuitant)

SSN/TIN/EIN

Date of Trust

Daytime PhoneMailing Address

State ZipCityYes NoU.S. Citizen

Gender Male Female

MEMBERS Focus Fixed Annuity

Trustee/Authorized Officer Name(s)

®

Date of Birth

Name First

NameIndividual/Trust/Credit Union

RelationshipTo Annuitant

2. PARTIES TO THE CONTRACT

MI Last

If Trust or Credit Union

If Trust or Credit Union

5-year 7-year 10-yearMEMBERS Select Fixed Annuity II® Single Premium Deferred Annuity with Guarantee Rate Periods:

The following ID verification information is required per the USA Patriot Act.Driver's License Passport Green Card Other Photo ID (list type):

Card No. Expiration Date Country/State of Issue

The following ID verification information is required per the USA Patriot Act.Driver's License Passport Green Card Other Photo ID (list type):

Card No. Expiration Date Country/State of Issue

For non-qualified only. Only a co-owner who is the spouse of the annuitant, as defined under federal tax law, will qualify for certain taxbenefits available to spouses under federal tax law.

c. Co-owner

Gender Male FemaleSSN Date of BirthYes NoU.S. CitizenMailing Address

State ZipCity Daytime Phone

RelationshipTo Annuitant

NameFirst MI Last

The following ID verification information is required per the USA Patriot Act.Driver's License Passport Green Card Other Photo ID (list type):

Card No. Expiration Date Country/State of Issue

Date FormedIf Trust or Credit Union: Country/State Where Formed

Modified Single Premium Deferred Annuity with Guarantee Rate Periods:

Arizona:

Individual/Trust/Credit Union

REQUIRED.

Upon written request, we will provide the owner within a reasonable time reasonable factual information regarding the benefits andprovisions of the contract. If for any reason you decide not to keep your contract, return it to us within 30 days after you receive it for a refund of theamount paid. You may return it to CMFG Life Insurance Company, 2000 Heritage Way, Waverly, Iowa 50677, or to the agent who sold it to you.

Doc Code 020915

2000 Heritage WayWaverly, IA 50677

MEMBERS Select Fixed Annuity II is a Modified Single Premium Deferred Annuity.Florida:MEMBERS Select Fixed Annuity II is a Modified Guaranteed Annuity.Illinois:

Montana: MEMBERS Select Fixed Annuity II is a Modified Single Premium Deferred Annuity.

Rollover

Rollover Transfer

REQUIRED. Complete sections 3a, 3b and 3c. Complete section 3d if there are multiple sources ofpayments.

Select only one plan type and complete the row for that type. For SEP IRA, complete form 5305-SEP.Beneficiary IRA is not available if Select II is selected in section 1. For Beneficiary IRA, complete forms CLS-520, CLS-521 and CLS-381. Onlycredit union-owned 457 plans are allowed. For IRAs, current and prior year contributions will be determined based on signed date of application.

Make checks payable to CMFG Life Insurance Company.

For each payment, list the source/company name from which funds are expected, estimated amount and plan type ofexisting contract.

If you selected the Focus in section 1, the minimum is $25,000 and the maximum cannot exceed $1,000,000 without priorCompany approval. If you selected the Select II in section 1, the minimum is $10,000 and the maximum is $999,999.

Oregon: SEP IRA is not available.

Submitted with Application $ Estimated Total Amount $

$Non-qualifiedPAYMENT CLASSIFICATION

$

$$$$$

c. Source of Payments

PLAN TYPE

Non-1035Exchange

1035 Exchange

SOURCE/COMPANY NAME ESTIMATED AMOUNT EXISTING PLAN TYPE

3. PLAN TYPE AND PURCHASE PAYMENT

Traditional IRA $ $ $Current YrContribution

$Prior YrContribution

Roth IRA $Rollover

$Transfer

$ $ $Roth Conversion

SEP IRA $ $Transfer

$ $

Beneficiary IRA $Rollover

$Transfer

457(b) $New Money

$Transfer

457(f) $New Money

$Transfer

By Check or Draft From All Sources

Focus: Select II:All sources of payments listed in section 3cAt least $25,000, but less than $100,000At least $100,000, but less than $500,000At least $500,000, but less than $1,000,000$1,000,000 or more

All sources of payments listed in section 3cAt least $10,000, but less than $100,000At least $100,000, but less than $250,000At least $250,000, but less than $1,000,000

Page 2

For Focus FixedAnnuity only.

SPDAAPP-2009

Prior YrContribution

Prior YrContribution

Current YrContribution

Current YrContribution

Once issued, any additional funds (of up to two times initial purchase payment) that are received at the Company's administrative office within 120days following the issue date, may be applied as window purchase payments. However, if you selected the Focus in section 1, total purchasepayments cannot exceed $1,000,000. Note: If you check a box that is less than one-third of the estimated total amount, you may exceedyour window payment limit, and the excess funds cannot be applied to this contract.

Doc Code 020915

Purchase Paymenta.

b. Plan Type and Payment Classification

Required if there are multiple sources listed in section 3c. Check only one box for the plan option selected in section 1.The box that is checked will establish the interest rate band and the maximum total window amount allowed. If no box is checked, the annuitywill be issued when all sources of payments have been received.

d. Multiple Sources

Issue my annuity when the following has been received at the Company's administrative office:

Do you have any existing life insurance policies or annuity contracts with our Company or any other company?Yes No

Will this contract replace, discontinue or change any existing life insurance policies or annuity contracts with our Company or any othercompany?

Yes No

COMPANY NAME OF POLICY/CONTRACT BEING REPLACED POLICY/CONTRACT NUMBER

If yes, a completed Important Notice: Replacement of Life Insurance or Annuities must accompany this application if required by theowner's state of residence.

If yes, a completed Replacement Form must accompany this application if required by the owner's state of residence.

Answer both questions and complete as appropriate. See the Instruction Sheet provided with this application todetermine if replacement forms are required in owner's state of residence for any "yes" responses below.4. REPLACEMENT REQUIRED.

To list more beneficiaries, use section 6 or a separate signed and dated paper. If no primary beneficiary is named, the primary will be the estate ofthe annuitant. If the type of beneficiary is not checked, we will assume the type is primary. The owner has the right to predetermine how thebeneficiary will receive the death benefit by completing form 40RESTRICT, Beneficiary Designation with Restricted Payout Options. Do not includefractions or percents for even distribution of proceeds.

PrimaryContingent

SSN Date of Birth

Name Address

Relationship

List each beneficiary for your contract and check whether they are primary or contingent.5. BENEFICIARY REQUIRED.

FOR INDIVIDUAL BENEFICIARIES:

Trustee Name(s)

Name of Trust Address

Date of Trust

FOR TRUST BENEFICIARIES:

PrimaryContingent

PrimaryContingent

PrimaryContingent

PrimaryContingent

PrimaryContingent

Page 3

PrimaryContingent

SPDAAPP-2009

Name

Relationship

Address

SSN Date of Birth

Name

Relationship

Address

SSN Date of Birth

Name

Relationship

Address

SSN Date of Birth

Name

Relationship

Address

SSN Date of Birth

Name

Relationship

Address

SSN Date of Birth

Doc Code 020915

Refer to the warning for the owner's state of residence shown below.7. FRAUD WARNING REQUIRED.

Page 4

Please print clearly.6. SPECIAL INSTRUCTIONS OPTIONAL.

SPDAAPP-2009Doc Code 02

0915

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfullypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

See section 9. The Florida Office of Insurance Regulation requires the fraud warning that applies to you to appear directly above yoursignature.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents falseinformation in an application for insurance, may be guilty of a crime and may be subject to fines and confinement in prison, depending on statelaw.

All other states:

Refer to the notice for the owner's state of residence shown below based on the plan option selected in section 1.8. STATE NOTICE REQUIRED.

Focus:All states: There is no market value adjustment for partial withdrawals and full surrenders at any time; however a surrender charge may applyduring the first 6 contract years.

Select II:

All other states: I UNDERSTAND THAT PARTIAL WITHDRAWALS AND FULL SURRENDERS MAY BE ADJUSTED UPWARD ORDOWNWARD DURING THE FIRST 10 CONTRACT YEARS BASED ON A MARKET VALUE ADJUSTMENT, IN ADDITION TO ANYSURRENDER CHARGE.

•

•

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer orany other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materiallyrelated to a claim was provided by the applicant.

District of Columbia:

Florida:

There is no market value adjustment for partial withdrawals and full surrenders at any time; however a surrender charge may applyduring the first 10 contract years.Missouri:•

Alabama:

During the first 10 contract years, I can withdraw 10% of my contract value without incurring a surrender charge (or market valueadjustment, if applicable, as shown in section 8) as my annual free withdrawal amount. If I withdraw an amount that exceeds my annual freewithdrawal amount or surrender my contract during the first 10 contract years, a surrender charge will be imposed (and a market value adjustmentmay apply, if applicable, as shown in section 8). The surrender charge schedule for contract years 1 through 10 is as follows: 8%, 7%, 7%, 7%,6%, 5%, 4%, 3%, 2%, 1%.

For administrative purposes only. Not to be used for any change that requires the owner's agreement in writing.10. HOME OFFICE ONLY

Page 5

Read and have all parties to the contract named in section 2 sign below.9. AGREEMENT REQUIRED.

Focus: During the first 6 contract years, I can withdraw 10% of my contract value without incurring a surrender charge as my annual freewithdrawal amount. If I withdraw an amount that exceeds my annual free withdrawal amount or surrender my contract during the first 6 contractyears, a surrender charge will be imposed. The surrender charge schedule for contract years 1 through 6 is as follows: 8%, 7%, 7%, 6%, 5%, 4%.

Select II:

State

Signature of Annuitant/Owner (Named in Section 2a)

Signature of Owner/Trustee/Authorized Officer (Named inSection 2b)

Date

Date

Signed atCity

Title of Authorized Officer

Signature of Co-owner (Named in Section 2c )

Date(If Credit Union is Named in Section 2b)

• I have read the application and represent that all statements and answers, as they pertain to me, are true and complete to the best of myknowledge and belief and are the basis for any contract issued by the Company; and I understand that no information will be considered to havebeen given to the Company unless it is stated in this application.

• I understand that no agent is authorized to make, void, waive or change any conditions or provisions of the application or contract.

• I understand that the Company will have no liability until a contract is issued, delivered and accepted by me while the annuitant is living, and nointerest will be credited to any funds received by the Company prior to the interest start date.

• In order to receive the current interest rate in effect on the date this application is received by the Company (rate lock start date), I understand thatif funds are coming from another financial institution, or an existing CMFG Life Insurance Company contract, then all paperwork required to requestfunds must be submitted along with this application and the funds must be received within 60 days of the rate lock start date. Otherwise, mycontract will be issued at the then-current interest rate, which may be different than the rate in effect on the rate lock start date.

• I understand the following applies based on the plan option I selected in section 1.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containingany false, incomplete, or misleading information is guilty of a felony of the third degree.

SPDAAPP-2009

Date

Doc Code 020915

To be completed by agent.11. AGENT SECTION REQUIRED.

See the Instruction Sheet provided with this application to determine if replacement forms are required in the owner's state of residence for any "yes"responses below.

Does the applicant have any existing life insurance policies or annuity contracts with our Company or any other company?To the best of my knowledge:

Yes No

If yes, I confirm:a. This replacement meets the standards for replacement sales identified in CMFG Life Insurance Company's Statement

Regarding the Acceptability of Life and Annuity Replacement Sales.b. The following sales materials were used:

Yes NoIf yes, a completed Important Notice: Replacement of Life Insurance or Annuities must accompany this application ifrequired by the owner's state of residence.

•

If yes, a completed Replacement Form must accompany this application if required by the owner's state of residence.

If no sales materials were used, state "None."

In accordance with the USA Patriot Act:•

Have you reviewed the owner's identity documents and recorded all necessary information?Yes NoI select the following compensation option:If no option is selected, then option 1 will apply.

•

Focus Select II1 (T000)2 (T025)

1 (T000)

If the applicant is an active duty member of the United States Armed Forces (including active duty military reserve personnel), I certify thatthis application was not solicited and/or signed on a military base or installation.

•

If sales materials were used, I certify that I have used only CMFG Life Insurance Company’s approved sales materials in connection withthis sale and that copies of all sales materials used were left with the applicant.

•

I have explained to the owner(s) how the annuity will meet their current financial needs and objectives.•

I certify that I have reviewed this application and have determined that its proposed purchase is suitable as required under law, based in parton information provided by the owner(s), as applicable, including age, income, net worth, tax status and any existing investments andinsurance program.

•

I certify that I have truly and accurately recorded the information provided by the applicant.•

Signature of Agent

Agent ID5-Digit Rep Number

Credit Union ID8-Digit CU Number (If Applicable)

Broker/Dealer IDB/D Number Assigned by CMFGLife (If B/D Other Than CBSI)

General Agent IDGA Number (If Applicable)

I UNDERSTAND THAT WHEN I SIGN THIS APPLICATION, I AM AGREEING TO ALL THE TERMS AND CONDITIONS APPLICABLE TO MEAS AN AGENT.

Signature

Agent Name

Credit Union Name

Print Full Name

Print Name of Credit Union (If Applicable)

Broker/Dealer NamePrint Name of Broker/Dealer (If Applicable)

General Agent NamePrint Name of General Agent (If Applicable)

Date

Page 6

-----------

Agent License ID Agent PhoneBest Number to CallFlorida Only

Agent E-mailPrint E-Mail Address

SPDAAPP-2009

Will this contract replace, discontinue or change any existing life insurance policies or annuity contracts with our Company orany other company?

Doc Code 020915

APPLICATION HELP SHEET FORMEMBERS FOCUS FIXED ANNUITYÒ

Submit the application, disclosure signature page, annuity suitability profile, any other forms as required andcheck to:

CMFG Life Insurance Company (CMFG Life)2000 Heritage WayWaverly, IA 50677

Sales over $1 MillionSales over $1,000,000 require Company approval. Contact the MEMBERS Product Sales Desk at 877.345.GROW(4769), option 1, option 1, prior to submitting the application.

Serial AnnuitiesIf the member has a CMFG Life nonqualified deferred annuity which was issued in the current calendar year and thisapplication will be nonqualified, the client will then have a "series" of deferred annuity contracts. If a distribution is madefrom any one of the deferred annuities in the "series", the taxable amount of that distribution will be determined using thecontract values of all contracts in the series. Because distributions from a deferred annuity contract are generally taxed onan "income-first basis", this could result in a larger amount of the distribution being taxable than if the contract was notpart of a "series".

Contact us with questions - For assistance at any time during the application process, please contact us at the followingnumbers:

For case consultation and questions on product features, illustrations and state availability:MEMBERS Product Sales Desk877.345.GROW (4769), option 1, option 1

MEMBERS Annuity New Business877.345.GROW (4769), option 2, option 1

For application and paperwork questions:

To verify your appointment status:MEMBERS Licensing877.345.GROW (4769), option 5, then ext. 3283

Provide the required disclosure to the applicant and submit the disclosure signature page with the application.

Product Disclosure Requirements

If a state requires a form(s) to be completed and submitted with the application it is provided in this applicationpackage, with one exception. In states which have not adopted the NAIC Model Replacement regulation, usethe Life Portraits category of "Replacement" to obtain the replacement form(s) when this annuity is replacing anexisting annuity. In states which have adopted the NAIC Model Replacement regulation, form number REPL isprovided. Complete and submit it with the application when the applicant has existing insurance.

State-specific Form Requirements

Buyer's Guide RequirementsThe National Association of Insurance Commissioners requires that the Buyer's Guide found in this applicationpackage be given to the applicant when selling a fixed annuity.

Application Submission Requirements

This application package contains the MEMBERS Focus Fixed Annuity Disclosure required in the state you selected.

UND-186-3 0212

2000 Heritage WayWaverly, IA 50677

MEMBERS Focus Fixed Annuity Disclosure

Office Use Only:  92

(Required with Application)

2009-SPDA-Disclosure Signature 0110

Owner(s) Statement of Understanding & Acknowledgement

I understand and acknowledge the following:

Buyer’s Guide to Fixed Deferred Annuities.

Date

Insurance Producer/Agent/Broker Certification

I certify that:

I have given and explained the to the Owner(s).MEMBERS Focus Fixed Annuity Disclosure

I have given a copy of the Buyer’s Guide to Fixed Deferred Annuities to the Owner(s).

I have made no promises or guarantees about expected future values of any non-guaranteed values.

I have made no statements that are inconsistent with any material given to the Owner(s) related to the

Signature of Insurance Producer/Agent/Broker Date

MEMBERS Focus Fixed Annuity Disclosure Signature Page®

MEMBERS Focus Fixed Annuity.

Signature of Owner (and Co-Owner, if applicable)

My annuity contract is a long-term investment. There may be surrender charges if during the 6-year surrendercharge period I surrender the contract or withdraw more than 10% of the annuity's value in a contract year.

The guarantee rate period is the length of time the interest rate is guaranteed and may be a different length than thesurrender charge period.

Any projected values, other than the guaranteed values, are not guarantees, promises, or warranties.

If funds are withdrawn prior to age 59 ½, the taxable amount may be subject to an Internal Revenue Servicepremature distribution penalty of 10%.

If this is a tax-qualified plan, I will receive no additional tax advantage from this annuity.

I have received and read the and I understand it.

I have received the

0212

2000 Heritage WayWaverly, IA 50677

Owner’s Signature  Date Signed 

DFS-H1-1980 Rule 69B-162.011, F.A.C.Effective 10/21/2014 

2000 Heritage Way Waverly, IA 50677 

ANNUITY SUITABILITY QUESTIONNAIRE 

Owner: Last First Middle

Date of Birth    / / Age Sex

Entity:

Tax Status  Relationship to Annuitant(s):  

Form of Ownership: 

Supporting documents (list): 

Annual Income:

Source of Income: 

Annual Household Income: 

Existing Assets 

Existing Liquid Net Worth: 

Do you currently own any annuities?  Please list: 

 Yes  No 

Do you currently own life insurance?  Please list: 

 Yes  No 

Does your income cover all your living expenses including medical?  Yes  No 

Do you expect changes to your living expenses?   Yes  No 

Do you anticipate changes in your out-of-pocket medical expenses?   Yes  No 

Is your income sufficient to cover future changes in your living and/or out-of-pocket medical expenses during the surrender charge period?   Yes  No 

Do you have an emergency fund for unexpected expenses?   Yes  No 

Why are you purchasing this annuity?

What are your financial objectives for this purchase? (Check all that apply)

 Income   Growth (long term)   Safety of Principal and Income 

 Safety of Principal and Growth   Pass assets to a beneficiary or beneficiaries at death 

Other:

Office Use OnlyDoc Code:  92 

Owner’s Signature  Date Signed 

DFS-H1-1980 Page 2 of 4  Rule 69B-162.011, F.A.C. Effective 10/21/2014 

Describe your risk tolerance: (Check all that apply)

 Conservative  Moderately conservative   Moderate   Moderately aggressive 

 Aggressive   Other: 

Comments:

Describe your investment experience by type and length of time:

What is the source of the funds for the purchase of the proposed annuity? 

How many years from today will you need access to your funds without a penalty?

Will the proposed annuity replace any product?   Yes  No 

If yes, will you pay a penalty or other charge to obtain these funds?   Yes  No 

If yes, the amount of the charge or penalty  $

Additional Information:

Owner’s Signature  Date Signed 

DFS-H1-1980 Page 3 of 4  Rule 69B-162.011, F.A.C. Effective 10/21/2014 

Note: The following three sections to be completed by the agent, insurer, or Managing General Agent proposing purchase; each section requires a response; no section may be left blank or contain a response consisting of “None” or “N/A”. 

Advantages of purchasing the proposed annuity: 

Disadvantages of purchasing the proposed annuity: 

The basis for my recommendation to purchase the proposed annuity or to replace or exchange your existing annuity(ies): 

Agent’s Signature  Date Signed 

Note: No questions or response areas are to be left blank when offered to the Owner for signature. If any information requested is unavailable, not applicable or unknown, the insurance agent or insurer must indicate that. 

ACKNOWLEDGEMENTS AND SIGNATURES 

I understand that should I decline to provide the requested information or should I provide inaccurate information, I am limiting the protection afforded me by the Florida Statutes regarding the suitability of this purchase. 

 I REFUSE to provide this information at this time. 

 I have chosen to provide LIMITED information at this time. 

 My annuity purchase IS NOT BASED on the recommendation of this agent or the insurer. 

 My annuity purchase IS BASED on the recommendation of this agent or the insurer. 

APPLICANT:DO NOT SIGN THIS FORM IF ANY ITEM HAS BEEN LEFT BLANK, BEFORE CAREFULLY REVIEWING THE INFORMATION RECORDED, OR IF ANY OF THE INFORMATIONRECORDED IS NOT TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE.

THE OWNER MAY SUBSTITUTE THEIR INITIALS FOR SIGNATURES ON ALL FORM PAGES WITH THE EXCEPTION OF THE SIGNATURES BELOW, WHICH ARE REQUIRED. 

Owner’s Signature  Date Signed 

DFS-H1-1980 Page 4 of 4  Rule 69B-162.011, F.A.C. Effective 10/21/2014 

EXPLANATION OF TERMS

“Age” is the natural person’s attained age on the day the form is completed.

“Tax Status” is the owner’s Federal Income Tax filing status such as “single” or “married filing jointly”; if “Exempt”, so state. 

“Form of Ownership” is the type of entity, other than a natural person, including a corporation, trust, partnership, limited liability company, or other business or not-for-profit entity. 

“Supporting documents” are the documents that provide a basis for the relationship between the Proposed Annuitant, and the Owner as it may exist. 

“Annual income” is income received during a calendar year, whether earned or unearned. 

“Source of annual income” is the income-generating source, such as pension income, dividends, or earned income etc. 

“Annual household income” is the combined annual income received by all household members each calendar year. 

“Existing Assets” are financial assets including life insurance and annuities. 

“Existing Liquid Net Worth” is applicable to those net assets that can readily be converted into their cash equivalent, without loss of principal after all surrender charges or other deductions have been taken. 

“Financial Objectives” are the owner’s stated goals as described to the insurance agent or insurer, if no insurance agent is involved. These may include but are not limited to the following: (1) Income, (2) Growth (long term capital appreciation), (3) Safety of Principal and Income, (4) Safety of Principal and Growth, (5) To pass the investment to a beneficiary or beneficiaries at death. 

“Risk Tolerance” means the degree of uncertainty that an investor can reasonably tolerate with regard to a negative change in his or her investments. Examples of risk tolerance levels may include the following: (1) Conservative (prefer little or no risk), (2) Moderately conservative (some risk, reduced safety of principal), (3) Moderate (average risk with potential losses and potentially higher returns), (4) Moderately aggressive (above average risk with potential losses, risk of principal and potentially higher returns), (5) Aggressive (willing to sustain losses or loss of principal in pursuit of higher returns). 

“Source of the funds” to be used to purchase the proposed annuity means from where the funds will come to purchase the annuity, and may include but are not limited to; (1) An existing annuity or life insurance contract, (2) Liquid Assets, including but not limited to, cash in banks, maturing certificates of deposit, and money market accounts, (3) Personal Loans, (4) Equity Loans, (5) Mortgages, Reverse Mortgages, (6) Death Benefit Proceeds, (7) Funds received upon retirement from employment, including but not limited to, 401(k) accounts, pensions, and other tax-sheltered funds, (8) Equities, mutual funds, or bonds, (9) Proceeds from real estate transactions. 

Pays income to youfor the number of years selected (no less than 10 or more than 30) or toyour successor payee if you die during that period.

Designated period of time (Installment income):

Pays income equal to the interest earned on the valueapplied to this option. Income continues for as long as you live. Thevalue applied to this option is paid to your successor payee when youdie. (This option is not available until the 7th contract year for annuitycontracts issued in Florida, New York and Oregon.)

One payout.

Interest income:

Lump sum:

What happens after I die?

Your annuity earns interest at a for a(guarantee rate period). When you buy your annuity,

you choose a guarantee rate period of 4, 5, or 6 years. The guaranteedrate depends on the current rate we've declared for the guarantee rateperiod you choose. Interest compounds daily at an effective annual interestrate. The 6-year guarantee rate period includes a 1% interest rate bonusduring the first contract year. As a result, the interest rate for the remainderof the guarantee rate period is decreased by 1%. The guaranteed rates forthe duration of the guarantee rate period are shown on the Data Page ofyour annuity contract.

Page 1

This document reviews important points to think about before you buy this CMFG Life Insurance Company annuity. It is a modified single premium deferredannuity which means you buy it with one premium payment. You are allowed to make additional "window" payments (limited to the maximum amount shown onyour annuity contract Data Page) during the first 120 days of your annuity contract. This is a fixed annuity which means it earns a specified interest rate duringthe guarantee rate period. This annuity is which means you don't pay taxes on the interest it earns until the money is paid to you.

You can use an annuity to save money for retirement and to receive retirement income for life. It is

If you have questions about this annuity, please ask your insurance producer/agent/broker or contact a company representative at 800.798.6600.

THE ANNUITY CONTRACTHow will the value of my annuity grow?

(Base Forms ICC09-SPDA and 2009-SPDA)

tax-deferred guaranteed rateguaranteed period

At the end of the guarantee rate period, interest will be declared andguaranteed for one-year periods. You are guaranteed to receive no lessthan the minimum guaranteed interest rate required by state law, which canrange from 1% to 3% and is shown on your Data Page.The value of your annuity cannot go down unless you take moneyout.

BENEFITSHow do I get income (payouts) from my annuity?

Life income: Guarantees income for as long as you live. Paymentsstop when you die.

Life income with period certain:you live. If you die within the "period certain" (usually 10 or 20 years),the remaining payments for the rest of the period are paid to yourbeneficiary (successor payee).

Guarantees income for as long as

Joint and survivor life income: Guarantees income for as long asyou or another individual you name (usually a spouse) live. If a"period certain" is selected and both die within this period, theremaining payments for the rest of the period are paid to thesuccessor payee.

This is an "annuitant-driven" contract, which means that death benefitproceeds are payable when the annuitant dies (last surviving annuitant ifthere are co-annuitants).

If you are the sole owner and annuitant and you die before we start to payyou income from your annuity, we pay the value of your annuity (the deathbenefit proceeds) to your beneficiary. If you die after the payout starts,depending on the type of payout you chose, we pay the remaining incomepayments or benefit amount, if any, to the successor payee. If there is nosuccessor payee, payment will be made to your estate.

If you are not the sole owner and annuitant, what happens when you diedepends on whether or not there is a surviving annuitant and/or survivingowner as well as the relationship between you and the surviving parties tothe contract. For example, if a non-annuitant owner dies and the new (orsurviving) owner is the deceased person's spouse, the contract may becontinued. But if the new (or surviving) owner is someone other than thedeceased person's spouse, the surrender value (the value of your annuity,reduced by any applicable surrender charge) must be distributed to the newowner. See Section 12 of your contract for further details in the event youare not the sole owner and annuitant (Section 11 for contracts issued inOregon).

MEMBERS Focus Fixed Annuity Disclosure

tax-deferred,

not meant to be used to meet short-term financial goals.

®

Once payouts begin, you can't:

Surrender or withdraw any moneyChange the payout optionChange the payout start date

OPTIONAL BENEFIT RIDERS AND THEIR FEESWhat other benefits can I choose?

There are no optional benefit riders available.

2009-SPDA-Disclosure 1010

The Anticipated Payout Date will be shown on the Data Page in yourannuity contract. You may request to change your payout date to anotherdate that is at least 2 years after issue (one year after issue for annuitycontracts issued in Florida and thirteen months after issue for annuitycontracts issued in New York.) Prior to the payout date, a reminder of youroptions (including the option to extend the payout date to the RequiredPayout Date shown on the Data Page) will be sent to you. If you don'tchoose an option prior to the payout date, the payment option explained inSection 15 of your annuity contract (Section 14 for contracts issued inOregon) will begin on the payout date. The options include:

2000 Heritage WayWaverly, IA 50677

0212

CMFG Life Insurance Company offers a wide variety of retirement andfinancial security products, including life insurance, annuities and long-termcare insurance.  We have been providing for the financial well-being of policyowners for over 70 years.

CMFG Life Insurance Company2000 Heritage WayWaverly, IA  50677Telephone:  800.798.6600http://www.cunamutual.com

What else do I need to know?

Page 2

OTHER INFORMATION

What should I know about the insurance company?

FEES, EXPENSES & OTHER CHARGESWhat happens if I take out some or all of the money from my annuity?

Before a payout begins, you can take out all of your annuity's valueor part of it You can take a partial

withdrawal as long as the withdrawal amount is at least $100 and theamount left in your annuity is at least $5,000. Non-scheduled withdrawalsare limited to two per contract year.

(full surrender) (partial withdrawal).

of the sixth contract year. We allow a withdrawal of up to 10% of the valuewithout charge each contract year. Here is how the charge is calculated:

We take a surrender charge from amounts you withdraw before the end

Your annuity is tax-deferred, which means you don't pay taxes on theinterest it earns until money is paid to you. When you take payouts or makewithdrawals, you pay ordinary income taxes on the earned interest. Youmay also pay a 10% federal income tax penalty on earnings you withdrawbefore age 59 ½. If your annuity is part of a tax-deferred retirement plan,any amount withdrawn may be subject to taxation and the federal income taxpenalty. You may wish to talk to your tax advisor.

You can exchange one tax-deferred annuity for another without paying taxeson the earnings when you make the exchange. Before you do, compare thebenefits, features, and costs of the 2 annuities. You may pay a surrendercharge if you make an exchange during the first 6 years you own thisannuity. Also, you may pay a surrender charge if you make withdrawalsfrom the new annuity during the first years you own it.

How will payouts and withdrawals from my annuity be taxed?TAXES

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

If your value is $25,000 and you withdraw $10,000 during thethird contract year, your surrender charge is $525. ($25,000 x 10% =$2,500 free of charge, $10,000-$2,500 = $7,500 x .07 = $525). If you takeout any amount during the seventh contract year or later, there's no charge.

Death benefit proceeds paid due to the annuitant's death arenot subject to a surrender charge. And, if certain hardships have occurred,the surrender charge is waived as explained in Section 11 of your annuitycontract. (The waiver due to certain hardships is not available for annuitycontracts issued in Oregon.)

Do I pay any other fees or charges?

No. There aren't any other fees or charges on this annuity.

Example:

Exceptions:

Does buying an annuity in a retirement plan provide extra tax benefits?

Buying an annuity within an IRA, 401(k), or other tax-deferred retirementplan doesn't give you any extra tax benefits. Choose your annuity based onits other features and benefits as well as its risks and costs, not its taxbenefits.

Changes to your contract

We may change your annuity contract from time to time to follow federal orstate laws and regulations. If we do, we'll tell you about the changes inwriting.

Compensation

We pay the insurance producer/agent/broker for selling the annuity to you.Compensation for selling this annuity contract may differ and could be higherthan the compensation they would have received for selling another annuitycontract.

Free Look

Many states have laws that give you a set number of days to look at anannuity after you buy it. If you decide during that time that you don't want it,you can return the annuity and get all your money back. Your(Right to Examine) period is 30 days, or the number of days required bystate law if more than 30. Read your contract cover page to learn about yourRight to Examine period.

free look

This is a summary document and not part of your contractwith CMFG Life Insurance Company.

2009-SPDA-Disclosure 1010 0212

ANNBG 2013 

Buyer’s Guide for Deferred Annuities 

Prepared by the  NAIC

National Association of Insurance Commissioners 

This guide does not endorse any company or policy 

Reprinted by 

CMFG Life Insurance Company MEMBERS Life Insurance Company 

It’s important that you understand how annuities can be different from each other so you can choose the type 

of annuity that’s best for you.  The purpose of this Buyer’s Guide is to help you do that.  This Buyer’s  

Guide isn’t meant to offer legal, financial, or tax advice.  You may want to consult independent advisors  

that specialize in these areas. 

This Buyer’s Guide is about deferred annuities in general and some of their most common features.  It's not about any particular annuity product. The annuity you select may have unique features this Guide 

doesn’t describe.  It’s important for you to carefully read the material you’re given or ask your annuity 

salesperson, especially if you’re interest in a particular annuity or specific annuity features. 

This Buyer’s Guide includes questions you should ask the insurance company or the annuity salesperson (the 

agent, producer, broker, or advisor). Be sure you’re satisfied with the answers before you buy an annuity. 

ANNBG 2013

Table of Contents

What Is an Annuity? ...................................................................................................................... 1 

When Annuities Start to Make Income Payments ...................................................................................... 1

How Deferred Annuities Are Alike ............................................................................................................ 1 

How Deferred Annuities Are Different ....................................................................................................... 2 

How Does the Value of a Deferred Annuity Change? ............................................................. 3

Fixed Annuities ............................................................................................................................................ 3 

Fixed Indexed Annuities .............................................................................................................................. 3 

Variable Annuities ....................................................................................................................................... 4 

What Other Information Should You Consider? .................................................................. 4 

Fees, Charges, and Adjustments ................................................................................................................. 4 

How Annuities Make Payments .................................................................................................................. 5 

How Annuities Are Taxed ........................................................................................................................... 6 

Finding an Annuity That's Right for You ................................................................................................... 6 

Questions You Should Ask ......................................................................................................................... 7 

When You Receive Your Annuity Contract ............................................................................................... 7 

ANNBG 2013  1

What Is an Annuity? 

An annuity is a contract with an insurance company. All annuities have one feature in common, and it makes annuities different from other financial products. With an annuity, the insurance company promises to pay you income on a regular basis for a period of time you choose—including the rest of your life. 

When Annuities Start to Make Income Payments 

Some annuities begin paying income to you soon after you buy it (an immediate annuity). Others begin at some later date you choose (a deferred annuity). 

How Deferred Annuities Are Alike 

There are ways that most deferred annuities are alike. 

They have an accumulation period and a payout period. During the accumulation period, the value of your annuity changes based on the type of annuity. During the payout period, the annuity makes income payments to you. 

They offer a basic death benefit. If you die during the accumulation period, a deferred annuity with a basic death benefit pays some or all of the annuity’s value to your survivors (called beneficiaries) either in one payment or multiple payments over time. The amount is usually the greater of the annuity account value or the minimum guaranteed surrender value. If you die after you begin to receive income payments (annuitize), your chosen survivors may not receive  

anything  unless: 1) your annuity guarantees to payout at least as much as you paid into the annuity, or 2) you chose a payout option that continues to make payments after your death. For an extra cost, you may be able to choose enhanced death benefits that increase the value of the basic death benefit. 

You usually have to pay a charge (called a surrenderor withdrawal charge) if you take some or all of your money out too early (usually before a settime period ends). Some annuities may not charge if you withdraw small amounts (for example, 10% or less of the account value) each year. 

Any money your annuity earns is tax deferred. That  means you won’t pay income tax on earnings until you take them out of the annuity. 

You can add features (called riders) to manyannuities, usually at an extra cost. 

An annuity salesperson must be licensed by your state insurance department. A person selling avariable annuity also must be registered withFINRA1 as a representative of a broker/dealerthat’s a FINRA member. In some states, the state securities department also must license a personselling a variable annuity. 

1 FINRA (Financial Industry Regulatory Authority) regulates the companies and salespeople who sell variable annuities. 

Sources of Information 

Contract: The legal documentbetween you and the insurancecompany that binds both of you tothe terms of the agreement.

Disclosure: A document thatdescribes the key features of yourannuity, including what is guaranteedand what isn’t, and your annuity’sfees and charges. If you buy avariable annuity, you’ll receive aprospectus that includes detailedinformation about investmentobjectives, risks, charges, andexpenses.

Illustration: A personalizeddocument that shows how yourannuity features might work. Askwhat is guaranteed and what isn’tand what assumptions were madeto create the illustration.

•

•

•

•

•

•

ANNBG 2013  2

Insurance companies sell annuities. You want to buy from an insurance company that’s financially sound. There are various ways you can research an insurance company’s financial strength. You  can visit the insurance company’s website or ask your annuity salesperson for more information.  You also can review an insurance company’s rating from an independent rating agency. Four main firms currently rate insurance companies. They are A.M. Best Company, Standard and Poor’s Corporation, Moody’s Investors Service, and Fitch Ratings. Your insurance department may have  more information about insurance companies. An easy way to find contact information for your insurance department is to visit www.naic.org and click on “States and Jurisdictions Map.”

Insurance companies usually pay the annuity salesperson after the sale, but the payment doesn’t reduce the amount you pay into the annuity. You can ask your salesperson how they earn money  from the sale. 

How Deferred Annuities Are Different 

There are differences among deferred annuities. Some of the differences are: 

Whether you pay for the annuity with one or more than one payment (called a premium).

The types and amounts of the fees, charges, and adjustments. While almost all annuities have some fees and charges that could reduce your account value, the types and amounts can be different among annuities. Read the Fees, Charges, and Adjustments section in this Buyer’s Guide for more information. 

Whether the annuity is a fixed annuity or a variable annuity. How the value of an annuity changes  is different depending on whether the annuity is fixed or variable. 

Fixed annuities guarantee your money will earn at least a minimum interest rate. Fixed annuities may earn interest at a rate higher than the minimum but only the minimum rate is guaranteed. The insurance company sets the rates. 

Fixed indexed annuities are a type of fixed annuity that earns interest based on changes in  a market index, which measures how the market or part of the market performs. The interest rate is guaranteed to never be less than zero, even if the market goes down. 

Variable annuities earn investment returns based on the performance of the investment portfolios, known as “subaccounts,” where you choose to put your money. The return earned in a variable annuity isn’t guaranteed. The value of the subaccounts you choose could go up or down. If they go up, you could make money. But, if the value of these subaccounts goes down, you could lose money. Also, income payments to you could be less than you expected. 

Some annuities offer a premium bonus, which usually is a lump sum amount the insurance company adds to your annuity when you buy it or when you add money. It’s usually a set percentage of the amount you put into the annuity. Other annuities offer an interest bonus, which is an amount the insurance company adds to your annuity when you earn interest. It’s usually a set percentage of the interest earned. You may not be able to withdraw some or all of your premium bonus for a set period  of time. Also, you could lose the bonus if you take some or all of the money out of your annuity within a set period of time. 

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How Does the Value of a Deferred Annuity Change? 

Fixed Annuities 

Money in a fixed deferred annuity earns interest at a rate the insurer sets. The rate is fixed (won’t change) for some period, usually a year. After that rate period ends, the insurance company will set another fixed interest rate for the next rate period. That rate could be higher or lower than the earlier rate.

Fixed deferred annuities do have a guaranteed minimum interest rate—the lowest rate the annuity can earn.  It’s stated in your contract and disclosure and can’t change as long as you own the annuity. Ask about: 

The initial interest rate – What is the rate? How long until it will change? The renewal interest rate – When will it be announced? How will the insurance  company tell you what the new rate will be? 

Fixed Indexed Annuities 

Money in a fixed indexed annuity earns interest based on changes in an index. Some indexes are measures of how the overall financial markets perform (such as the S&P 500 Index or Dow Jones Industrial Average) duringa set period of time (called the index term). Othersmeasure how a specific financial market performs(such as the Nasdaq) during the term. The insurancecompany uses a formula to determine how a change in the index affects the amount of interest to add to your annuity at the end of each index term. Once interest is added to your annuity for an index term, those earnings usually are locked in and changes in the index in the next index term don’t affect them. If you take money from an indexed annuity before an index term ends, the annuity may not add all of the index-linked interest for that term to your account. 

Insurance companies use different formulas to calculate the interest to add to your annuity. They look at changes in the index over a period of time. See the box “Fixed Deferred Indexed Formulas” that describes how changes in an index are used to calculate interest. 

The formulas insurance companies use often meanthat interest added to your annuity is based on onlypart of a change in an index over a set period oftime.  Participation rates, cap rates, and spread rates(sometimes called margin or asset fees) all are termsthat describe ways the amount of interest added to your annuity may not reflect the full change in the index.But  if the index goes down over that period, zero interest is added to your annuity. Then your annuity value won’t go down as long as you don’t withdraw the money. 

When you buy an indexed annuity, you aren’t investing directly in the market or the index. Some indexed annuities offer you more than one index choice. Many indexed annuities also offer the choice to put part of your money in a fixed interest rate account, with a rate  that won’t change for a set period. 

Fixed Deferred Indexed Formulas

Annual Point-to-Point – Change inindex calculated using two dates oneyear apart.

Multi-Year Point-to-Point – Changein index calculated using two datesmore than one year apart.

Monthly or Daily Averaging – Change in index calculated usingmultiple dates (one day of everymonth for monthly averaging, everyday the market is open for dailyaveraging). The average of thesevalues is compared with the indexvalue at the start of the index term.

Monthly Point-to-Point – Change inindex calculated for each monthduring the index term. Each monthlychange is limited to the “cap rate”for positive changes, but not when thechange is negative. At the end of theindex term, all monthly changes(positive and negative) are added. Ifthe result is positive, interest is addedto the annuity. If the result is negativeor zero, no interest (0%) is added.

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Variable Annuities 

Money in a variable annuity earns a return based on the performance of the investment portfolios, known as  “subaccounts,”  where you choose to put your money. Your investment choices likely will include subaccounts with different types and levels of risk. Your choices will affect the return you earn on your annuity. Subaccounts usually have no guaranteed return, but you may have a choice to put some money in a  fixed interest rate account, with a rate that won’t change for a set period. 

The value of your annuity can change every day as the subaccounts’ values change. If the subaccounts’ values increase, your annuity earns money. But there’s no guarantee that the values of the subaccounts will increase. If the subaccounts’ values go down, you may end up with less money in your annuity than you paid into it. 

An insurer may offer several versions of a variable deferred annuity product. The different versions usually  are identified as share classes. The key differences between the versions are the fees you’ll pay every year you  own the annuity. The rules that apply if you take money out of the annuity also may be different. Read the prospectus carefully. Ask the annuity salesperson to explain the differences among the versions. 

What Other InformationShould You Consider? 

Fees, Charges, and Adjustments 

Fees and charges reduce the value of your annuity. They help cover the insurer’s costs to sell and manage the annuity and pay benefits. The insurer may subtract these costs directly from your annuity’s value. Most annuities have fees and charges but they can be different fordifferent annuities. Read the contract and disclosure or prospectus carefully and ask the annuity salesperson to describe these costs. 

A surrender or withdrawal charge is a charge if you take part or all of the money out of your annuity during a set period of time. The charge is a percentage of the amount you take out of the annuity. The percentageusually goes down each year until the surrender charge period ends. Look at the contract and the disclosure or prospectus for details about the charge. Also look for any waivers for events (such as a death) or the right to take out a small amount (usually up to 10%) each year without paying the charge. If you take all of your money out of an annuity, you’ve surrendered it and no longer have any right to future income payments. 

Some annuities have a Market Value Adjustment(MVA). An MVA could increase or decrease yourannuity’s account value, cash surrender value, and/ordeath benefit value if you withdraw money from your account. In general, if interest rates are lower when you 

How Insurers Determine Indexed Interest 

Participation Rate – Determineshow much of the increase in the indexis used to calculate index linkedinterest. A participation rate usuallyis for a set period. The period can befrom one year to the entire term.Some companies guarantee the ratecan never be lower (higher) than aset minimum (maximum).Participation rates are often less than100%, particularly when there’s nocap rate.

Cap Rate – Typically, the maximumrate of interest the annuity will earnduring the index term. Some annuitiesguarantee that the cap rate will neverbe lower (higher) than a set minimum(maximum). Companies often use acap rate, especially if theparticipation rate is 100%.

Spread Rate – A set percentage theinsurer subtracts from any change inthe index. Also called a “margin orasset fee.” Companies may use thisinstead of or in addition to aparticipation or cap rate.

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withdraw money than they were when you bought the annuity, the MVA could increase the amount you could take from your annuity. If interest rates are higher than when you bought the annuity, the MVA could  reduce the amount you could take from your annuity. Every MVA calculation is different. Check your contract and disclosure or prospectus for details. 

How Annuities Make Payments 

Annuitize 

At some future time, you can choose to annuitize your annuity and start to receive guaranteed fixed incomepayments for life or a period of time you choose. After payments begin, you can’t take any other money out of the annuity. You also usually can’t change the amount of your payments. For more information, see “Payout Options” in this Buyer’s Guide. If you die before the payment period ends, your survivors may not receive any payments, depending on the payout option youchoose.

Full Withdrawal 

You can withdraw the cash surrender value of theannuity in a lump sum payment and end your annuity. You’ll likely pay a charge to do this if it’s during the surrender charge period. If you withdraw your annuity’s cash surrender value, your annuity is cancelled. Once that happens, you can’t start or continue to receiveregular income payments from the annuity. 

Partial Withdrawal 

You may be able to withdraw some of the money from the annuity’s cash surrender value without ending the annuity. Most annuities with surrender charges let you take out a certain amount (usually up to 10%) each year without paying surrender charges on that amount. Check your contract and disclosure or prospectus. Ask your annuity salesperson about other ways you can take money from the annuity without paying charges. 

Living Benefits for Fixed Annuities 

Some fixed annuities, especially fixed indexed annuities, offer a guaranteed living benefits rider, usually at an extra cost. A common type is called a guaranteed lifetime  withdrawal benefit that guarantees to make income payments you can’t outlive. While you get payments, the money still in your annuity continues to earn interest. You can choose to stop and restart the payments or you might be able to take extra money from your annuity. Even if the payments reduce the annuity’s value to zero  at some point, you’ll continue to get payments for the rest of your life. If you die while receiving payments,  your survivors may get some or all of the money left in your annuity. 

Annuity Fees  and Charges 

Contract fee – A flat dollar amount orpercentage charged once or annually.

Percentage of purchase payment –Afront-end sales load or other chargededucted from each premium paid.The percentage may vary over time.

Premium tax – A tax some statescharge on annuities. The insurer maysubtract the amount of the tax whenyou pay your premium, when youwithdraw your contract value, whenyou start to receive income payments,or when it pays a death benefit to yourbeneficiary.

Transaction fee – A charge forcertain transactions, such as transfersor withdrawals.

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Mortality and expense (M&E) risk charge – A fee charged on variableannuities. It’s a percentage of theaccount value invested in subaccounts.

Underlying fund charges –  Fees andcharges on a variable annuity’ssubaccounts; may include aninvestment management fee,distribution and service (12b-1) fees,and other fees.

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Living Benefits for Variable Annuities 

Variable annuities may offer a benefit at an extra cost that guarantees you a minimum account value, aminimum lifetime income, or minimum withdrawalamounts regardless of how your subaccounts perform. See “Variable Annuity Living Benefit Options” at right. Check your contract and disclosure or prospectus or ask your annuity salesperson about these options. 

How Annuities Are Taxed 

Ask a tax professional about your individual situation. The information below is general and should not be considered tax advice. 

Current federal law gives annuities special taxtreatment. Income tax on annuities is deferred. Thatmeans you aren’t taxed on any interest or investment returns while your money is in the annuity. This isn’t the same as tax-free. You’ll pay ordinary income tax when you take a withdrawal, receive an income stream, or receive each annuity payment. When you die, your survivors will typically owe income taxes on any death benefit they receive from an annuity. 

There are other ways to save that offer tax advantages, including Individual Retirement Accounts (IRAs). Youcan buy an annuity to fund an IRA, but you also can fund your IRA other ways and get the same tax advantages.When you take a withdrawal or receive payments, you’ll  pay ordinary income tax on all of the money you receive  (not just the interest or the investment return). Youalso may have to pay a 10% tax penalty if you withdraw money before you’re age 59½. 

Finding an Annuity That’sRight for You 

An annuity salesperson who suggests an annuity must choose one that they think is right for you, based on information from you. They need complete information about your life and financial situation to make asuitable recommendation. Expect a salesperson to askabout your age; your financial situation (assets, debts, income, tax status, how you plan to pay for the annuity); your tolerance for risk; your financial objectives andexperience; your family circumstances; and how youplan to use the annuity. If you aren’t comfortable with the annuity, ask your annuity salesperson to explainwhy they recommended it. Don’t buy an annuity you don’t understand or that doesn’t seem right for you. 

Variable Annuity Living  Benefit Options 

Guaranteed Minimum Accumulation Benefit (GMAB) – Guarantees your account value willequal some percentage (typically100%) of premiums less withdrawals,at a set future date (for example, atmaturity). If your annuity is worthless than the guaranteed amount atthat date, your insurance companywill add the difference.

Guaranteed Minimum Income Benefit (GMIB) – Guarantees aminimum lifetime income. You usuallymust choose this benefit when youbuy the annuity and must annuitizeto use the benefit. There may bea waiting period before you canannuitize using this benefit.

Guaranteed Lifetime Withdrawal Benefit (GLWB) – Guarantees youcan make withdrawals for the restof your life, up to a set maximumpercentage each year.

Payout Options 

You’ll have a choice about how toreceive income payments. Thesechoices usually include:

For your lifetimeFor the longer of yourlifetime or your spouse’slifetimeFor a set time periodFor the longer of yourlifetime or a set timeperiod

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Within each annuity, the insurer may guarantee some values but not others. Some guarantees may be only for a year or less while others could be longer. Ask about risks and decide if you can accept them. For  example, it’s possible you won’t get all of your money back or the return on your annuity may be lower than  you expected. It’s also possible you won’t be able to withdraw money you need from your annuity without  paying fees or the annuity payments may not be as much as you need to reach your goals.  These risks vary  with the type of annuity you buy. All product guarantees depend on the insurance company’s financial strength and claims- paying ability. 

Questions You Should Ask 

Do I understand the risks of an annuity? Am I comfortable with them? 

How will this annuity help me meet my overall financial objectives and time horizon? 

Will I use the annuity for a long-term goal such as retirement? If so, how could I  achieve that goal if the income from the annuity isn’t as much as I expected it to be? 

What features and benefits in the annuity, other than tax deferral, make it  appropriate for me? 

Does my annuity offer a guaranteed minimum interest rate? If so, what is it? 

If the annuity includes riders, do I understand how they work? 

Am I taking full advantage of all of my other tax-deferred opportunities,  such as 40l(k)s, 403(b)s, and IRAs? 

Do I understand all of the annuity’s fees, charges, and adjustments? 

Is there a limit on how much I can take out of my annuity each year without  paying a surrender charge? Is there a limit on the total amount I can withdraw  during the surrender charge period? 

Do I intend to keep my money in the annuity long enough to avoid paying  any surrender charges? 

Have I consulted a tax advisor and/or considered how buying an annuity  will affect my tax liability? 

How do I make sure my chosen survivors (beneficiaries) will receive any  payment from my annuity if I die? 

If you don’t know the answers or have other questions, ask your annuity salesperson for help. 

When You Receive Your Annuity Contract 

When you receive your annuity contract, carefully review it. Be sure it matches your understanding. Also, read the disclosure or prospectus and other materials from the insurance company. Ask your annuity salesperson to explain anything you don’t understand. In many states, a law gives you a set number of days  (usually 10 to 30 days) to change your mind about buying an annuity after you receive it. This often is called  a free look or right to return period. Your contract and disclosure or prospectus should prominently state  your free look period. If you decide during that time that you don’t want the annuity, you can contact the insurance company and return the contract. Depending on the state, you’ll either get back all of your money  or your current account value. 

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A decision to buy a new policy and discontinue or change an existing policy may be a wise choice or amistake.

Get all the facts. Make sure you fully understand both the proposed policy and your existing policy or policies.New policies may contain clauses which limit or exclude coverage of certain events in the initial period of thecontract, such as the suicide and incontestable clauses, which may have already been satisfied in yourexisting policy or policies.

Your best source for facts on the proposed policy is the proposed company and its agent. The best sourceon your existing policy is the existing company and its agent.

Hear from both before you make your decision. This way you can be sure your decision is in your bestinterest.

If you indicate that you intend to replace or change an existing policy, Florida regulations require notificationof the company that issued the policy.

Florida regulations give you the right to receive a written Comparative Information Form which summarizesyour policy values. Indicate whether or not you wish a Comparative Information Form from the proposedcompany and your existing insurer or insurers by placing your initials in the appropriate box below.

Yes NoDo not take action to terminate your existing policy until your new policy has been issued and youhave examined it and found it acceptable.

I have read this notice and received a copy of it.

Applicant’s Signature Date

Agent’s Signature Date

Agent’s Name (Printed or Typed)

Agent’s Address (Printed or Typed) Agent’s Company (Printed or Typed)

Information on Policies which may be replaced:

Company Name Policy Number Name of Insured

Send original to the Home Office.Give one copy to the applicant and put one copy in applicant’s file.

1202 0718

NOTICE TO APPLICANTREGARDING REPLACEMENT

OF LIFE INSURANCE2000 Heritage WayWaverly, IA 50677Phone: 800.798.6600

Office Use Only:Doc code: 54WQ:Policy/Order #:

PLEASE READ CAREFULLY. This information has been prepared for you so that youmay make an informed decision on the use of any of your policy values to fund the purchase of a new policy. Please see the second page of this form for explanatory notesand instructions as to how this form has been completed.

PART A – CURRENT POLICY INFORMATION LIFE ANNUITY

Policyowner’s Name  Policy Number

Current Death Benefit $ Current Premium Amount $ Mode of Payment

Cash Surrender Value $ Paid-up Addition Value $ Dividend Value $(The BENEFIT and VALUES stated above will be reduced as funds are used to purchase the policy proposed in Part B, below.)

PART B – PROPOSED POLICY INFORMATION LIFE ANNUITY

Initial Death Benefit $ Proposed Premium Amount $ Mode of Payment

Proposed Effective Date     Premium Payable to Age   or for   Years

NOTE: If you are replacing your current policy, or using 25% or more of your policy values, you may request a WRITTENcomparison between your current policy and the proposed policy. The comparison is to illustrate the policy values for bothpolicies.

PART C – SOURCE OF FUNDING FOR THE PROPOSED POLICY

A loan in the amount of $ will be taken from the value of your CURRENT POLICY each

(mode), bearing a current loan interest rate of  %.

A partial surrender in the amount of $ will be taken from the value of your CURRENT

POLICY each  (mode).

A dividend withdrawal in the amount of $ will be taken from the value of your CURRENT

POLICY each  (mode).

PART D – YOUR CURRENT POLICY COULD TERMINATE

If the policy values of your CURRENT POLICY are used as a source of funding for the purchase of an additional policy, it

is estimated that your CURRENT POLICY will terminate on  (date).

It is estimated that you will begin making premium payments for the PROPOSED POLICY from your own funds on

(date) in the amount of $ to be paid each  (mode).

NOTE:  Since the values and premiums stated on this form may change over time, the estimated date upon which you willneed to begin making premium payments from your own funds for the PROPOSED POLICY may also change. Estimatesas to dates when policies will terminate or payments must begin assume the continuation of current (or guaranteed) factors,and such calculations are based upon the assumption that any premiums or interest due on loans are paid when due.

Policyowner Signature Date

Agent or Company Officer Signature Date ____________________

Florida Licensed Agent ID No. or Corporate Title

Send original to the Home Office.Give one copy to the applicant and put one copy in applicant’s file.

1749FL 0718

Office Use Only:  542000 Heritage WayWaverly, IA 50677Phone: 800.798.6600

1749FL 0718

Office Use Only:  54 

POLICY DISCLOSURE FORM AND INSTRUCTIONS COMPLETE ONE FORM FOR EACH PREVIOUSLY ISSUED POLICY. 

ANY REQUIRED REPLACEMENT AND SALES FORMS MUST ALSO BE COMPLETED. ONE COPY IS DELIVERED TO THE POLICYOWNER AND ONE COPY MAINTAINED BY THE INSURER 

Any and all information applicable to the transaction shall be fully and completely disclosed on Form 1749FL. If the information requested does not apply to the transaction, the words "not applicable" or "N/A" shall be entered. 

PART A 

The information to be disclosed in Part A of Form 1749FL shall apply to the current, in-force policy for which policy values are being utilized as a source of funding for the purchase of additional insurance contract(s). For purposes of this for, "current death benefit" is defined as the sum of the death benefit payable under the base policy, all life insurance riders covering the principal insured (other than special contingency death riders), paid-up additional insurance and dividends, minus outstanding indebtedness. The term "cash surrender value" is defined as the cash value of the policy or contract net of any outstanding indebtedness and surrender charges, and less any dividend value. The term "paid-up addition value" is defined as the cash value of additional insurance purchased with policy dividends. The term "dividend value" is defined as the total cash value of all policy dividend left on deposit with the company to accumulate at interest. 

PART B 

The information to be disclosed in Part B of Form 1749FL shall apply to the proposed additional insurance contract(s) being funded by policy values in a current, in-force policy. For purposes of this form, "proposed premium amount" is defined as any recurring payment which is planned to be paid or which is required to be paid under the proposed policy. 

PART C 

The information to be disclosed in Part C of Form 1749FL shall apply to the current, in-force policy, and shall indicate the manner in which the policy values are being used to fund the purchase of the proposed policy. Part C is not to be completed if the current policy is totally surrendered. However, in the event of a total surrender of the current policy, Parts A, B, D, and the signature block of this form must be completed. 

When completing Part C of this form, each and every source of funding for the proposed policy must be identified, i.e., whether a policy loan, partial surrender, or dividend withdrawal or any combination thereof is being utilized. If more than one source of funding will be utilized to fund the initial and/or future premiums for the proposed policy, all applicable sections of Part C shall be completed. 

For purposes of this form, a "partial surrender" is defined as any amount taken from the value of the current policy which is less than the total cash value available under such policy. The term "mode" is defined as the frequency upon which a policy loan, partial surrender or dividend withdrawal will be taken from the value of the current policy. In the event of a single loan, surrender or withdrawal, the words "one time only" shall be entered in the space provided. The term "loan interest rate" is defined as the rate of interest in effect on the date that this form is completed, as specified in the current policy contract. 

PART D 

The information to be disclosed in Part D of Form 1749FL shall apply to the current, in-force policy and the proposed additional policy, respectively. 

SIGNATURES 

In order to evidence that the required disclosure has been made, Form 1749FL shall be signed and dated by the soliciting agent or by a Corporate Officer, as well as by the policyowner. For identification purposes, the agent, or Corporate Officer shall enter his or her Florida License Number or Corporate title, respectively, in the space provided. 

APPLICANT INFORMATION  POLICY INFORMATIONName    Policy Generic Name 

Address    Policy Number 

  Date of Issue     Issue Age 

Telephone   Contestible Period Expires  

Date of Birth    Age    Suicide Period Expires Policy Loan Rate  

POLICY/RIDER DESCRIPTION    INITIAL/ INITIAL/  POLICY/  CONTINUING  (Age) BENEFIT  RENEWAL ANNUAL  (Age) PAYABLE  RIDER NAME  BENEFIT  FROM  TO  PREMIUM  FROM  TO         

Total Initial Annual Premium    Mode of Payment   Amount 

Total Renewal Annual Premium      Amount 

COMPOSITE DISCLOSURE OF PROPOSED INSURANCE FOR PRIMARY INSUREDGUARANTEES PROJECTIONS*

ANNUAL CUMLTV CASH DEATH YR/AGE PREMIUM PREMIUM VALUE

  1  2  3  4  5  6  7  8  91011121314151617181920

55606570758595

* Projections include dividends and current interest rates which are not guaranteed.

IMPORTANT NOTICE: The income tax treatment of the benefits illustrated above may significantly affect their magnitude. Competenttax advice should be secured to clarify income tax implications.

REMARKS:**

** This space may be used for information regarding newly developed or unusual type products or other comments an agent might want to convey to his prospect.

Send original to the Home Office. Give one copy to the applicant and put one copy in applicant’s file.Form 1167FL 0114

COMPARATIVE INFORMATIONFor Proposed/Existing Insurance

Replacing Agent’s Name

Office Use Only:  54

$

$

$

$

BENEFITCASH DEATHVALUE BENEFIT

ANNUALPREMIUM

CUMLTVPREMIUM

2000 Heritage WayWaverly, IA 50677

Signature Guarantee Information

A signature guarantee may be required by an external company in order to exchange, liquidate, or transfer funds. When this is thecase, please obtain the appropriate signature guarantee from yourbroker/dealer, a credit union, bank or other financial institution.

Sig Guar Instr 0615

ANNBG 2013

Buyer’s Guide for Deferred Annuities

Prepared by the

NAIC National Association of Insurance Commissioners

This guide does not endorse any company or policy

Reprinted by

CMFG Life Insurance Company MEMBERS Life Insurance Company

It’s important that you understand how annuities can be different from each other so you can choose the type

of annuity that’s best for you. The purpose of this Buyer’s Guide is to help you do that. This Buyer’s

Guide isn’t meant to offer legal, financial, or tax advice. You may want to consult independent advisors

that specialize in these areas.

This Buyer’s Guide is about deferred annuities in general and some of their most common features.

It's not about any particular annuity product. The annuity you select may have unique features this Guide

doesn’t describe. It’s important for you to carefully read the material you’re given or ask your annuity

salesperson, especially if you’re interest in a particular annuity or specific annuity features.

This Buyer’s Guide includes questions you should ask the insurance company or the annuity salesperson (the

agent, producer, broker, or advisor). Be sure you’re satisfied with the answers before you buy an annuity.

ANNBG 2013 

Table of Contents

What Is an Annuity? ...................................................................................................................... 1

When Annuities Start to Make Income Payments ...................................................................................... 1

How Deferred Annuities Are Alike ............................................................................................................ 1

How Deferred Annuities Are Different ....................................................................................................... 2

How Does the Value of a Deferred Annuity Change? ............................................................. 3

Fixed Annuities ............................................................................................................................................ 3

Fixed Indexed Annuities .............................................................................................................................. 3

Variable Annuities ....................................................................................................................................... 4

What Other Information Should You Consider? .................................................................. 4

Fees, Charges, and Adjustments ................................................................................................................. 4

How Annuities Make Payments .................................................................................................................. 5

How Annuities Are Taxed ........................................................................................................................... 6

Finding an Annuity That's Right for You ................................................................................................... 6

Questions You Should Ask ......................................................................................................................... 7

When You Receive Your Annuity Contract ............................................................................................... 7

ANNBG 2013 1

What Is an Annuity?

An annuity is a contract with an insurance company. All annuities have one feature in common, and it makes annuities different from other financial products. With an annuity, the insurance company promises to pay you income on a regular basis for a period of time you choose—including the rest of your life.

When Annuities Start to Make Income Payments

Some annuities begin paying income to you soon after you buy it (an immediate annuity). Others begin at some later date you choose (a deferred annuity).

How Deferred Annuities Are Alike

There are ways that most deferred annuities are alike.

• They have an accumulation period and a payout period. During the accumulation period, the value of your annuity changes based on the type of annuity. During the payout period, the annuity makes income payments to you.

• They offer a basic death benefit. If you die during the accumulation period, a deferred annuity with a basic death benefit pays some or all of the annuity’s value to your survivors (called beneficiaries) either in one payment or multiple payments over time. The amount is usually the greater of the annuity account value or the minimum guaranteed surrender value. If you die after you begin to receive income payments (annuitize), your chosen survivors may not receive

anything unless: 1) your annuity guarantees to pay out at least as much as you paid into the annuity, or 2) you chose a payout option that continues to make payments after your death. For an extra cost, you may be able to choose enhanced death benefits that increase the value of the basic death benefit.

• You usually have to pay a charge (called a surrender or withdrawal charge) if you take some or all of your money out too early (usually before a set time period ends). Some annuities may not charge if you withdraw small amounts (for example, 10% or less of the account value) each year.

• Any money your annuity earns is tax deferred. That means you won’t pay income tax on earnings until you take them out of the annuity.

• You can add features (called riders) to many annuities, usually at an extra cost.

• An annuity salesperson must be licensed by your state insurance department. A person selling a variable annuity also must be registered with FINRA1 as a representative of a broker/dealer that’s a FINRA member. In some states, the state securities department also must license a person selling a variable annuity.

                                                            1 FINRA (Financial Industry Regulatory Authority) regulates the companies and salespeople who sell variable annuities.

Sources of Information

Contract: The legal document between you and the insurance company that binds both of you to the terms of the agreement.

Disclosure: A document that describes the key features of your annuity, including what is guaranteed and what isn’t, and your annuity’s fees and charges. If you buy a variable annuity, you’ll receive a prospectus that includes detailed information about investment objectives, risks, charges, and expenses.

Illustration: A personalized document that shows how your annuity features might work. Ask what is guaranteed and what isn’t and what assumptions were made to create the illustration. 

ANNBG 2013 2

• Insurance companies sell annuities. You want to buy from an insurance company that’s financially sound. There are various ways you can research an insurance company’s financial strength. You can visit the insurance company’s website or ask your annuity salesperson for more information. You also can review an insurance company’s rating from an independent rating agency. Four main firms currently rate insurance companies. They are A.M. Best Company, Standard and Poor’s Corporation, Moody’s Investors Service, and Fitch Ratings. Your insurance department may have more information about insurance companies. An easy way to find contact information for your insurance department is to visit www.naic.org and click on “States and Jurisdictions Map.”

• Insurance companies usually pay the annuity salesperson after the sale, but the payment doesn’t reduce the amount you pay into the annuity. You can ask your salesperson how they earn money from the sale.

How Deferred Annuities Are Different

There are differences among deferred annuities. Some of the differences are:

• Whether you pay for the annuity with one or more than one payment (called a premium).

• The types and amounts of the fees, charges, and adjustments. While almost all annuities have some fees and charges that could reduce your account value, the types and amounts can be different among annuities. Read the Fees, Charges, and Adjustments section in this Buyer’s Guide for more information.

• Whether the annuity is a fixed annuity or a variable annuity. How the value of an annuity changes is different depending on whether the annuity is fixed or variable.

Fixed annuities guarantee your money will earn at least a minimum interest rate. Fixed annuities may earn interest at a rate higher than the minimum but only the minimum rate is guaranteed. The insurance company sets the rates.

Fixed indexed annuities are a type of fixed annuity that earns interest based on changes in a market index, which measures how the market or part of the market performs. The interest rate is guaranteed to never be less than zero, even if the market goes down.

Variable annuities earn investment returns based on the performance of the investment portfolios, known as “subaccounts,” where you choose to put your money. The return earned in a variable annuity isn’t guaranteed. The value of the subaccounts you choose could go up or down. If they go up, you could make money. But, if the value of these subaccounts goes down, you could lose money. Also, income payments to you could be less than you expected.

• Some annuities offer a premium bonus, which usually is a lump sum amount the insurance company adds to your annuity when you buy it or when you add money. It’s usually a set percentage of the amount you put into the annuity. Other annuities offer an interest bonus, which is an amount the insurance company adds to your annuity when you earn interest. It’s usually a set percentage of the interest earned. You may not be able to withdraw some or all of your premium bonus for a set period of time. Also, you could lose the bonus if you take some or all of the money out of your annuity within a set period of time.

ANNBG 2013 3

How Does the Value of a Deferred Annuity Change?

Fixed Annuities

Money in a fixed deferred annuity earns interest at a rate the insurer sets. The rate is fixed (won’t change) for some period, usually a year. After that rate period ends, the insurance company will set another fixed interest rate for the next rate period. That rate could be higher or lower than the earlier rate.

Fixed deferred annuities do have a guaranteed minimum interest rate—the lowest rate the annuity can earn. It’s stated in your contract and disclosure and can’t change as long as you own the annuity. Ask about:

• The initial interest rate – What is the rate? How long until it will change? • The renewal interest rate – When will it be announced? How will the insurance

company tell you what the new rate will be?

Fixed Indexed Annuities

Money in a fixed indexed annuity earns interest based on changes in an index. Some indexes are measures of how the overall financial markets perform (such as the S&P 500 Index or Dow Jones Industrial Average) during a set period of time (called the index term). Others measure how a specific financial market performs (such as the Nasdaq) during the term. The insurance company uses a formula to determine how a change in the index affects the amount of interest to add to your annuity at the end of each index term. Once interest is added to your annuity for an index term, those earnings usually are locked in and changes in the index in the next index term don’t affect them. If you take money from an indexed annuity before an index term ends, the annuity may not add all of the index-linked interest for that term to your account.

Insurance companies use different formulas to calculate the interest to add to your annuity. They look at changes in the index over a period of time. See the box “Fixed Deferred Indexed Formulas” that describes how changes in an index are used to calculate interest.

The formulas insurance companies use often mean that interest added to your annuity is based on only part of a change in an index over a set period of time. Participation rates, cap rates, and spread rates (sometimes called margin or asset fees) all are terms that describe ways the amount of interest added to your annuity may not reflect the full change in the index. But if the index goes down over that period, zero interest is added to your annuity. Then your annuity value won’t go down as long as you don’t withdraw the money.

When you buy an indexed annuity, you aren’t investing directly in the market or the index. Some indexed annuities offer you more than one index choice. Many indexed annuities also offer the choice to put part of your money in a fixed interest rate account, with a rate that won’t change for a set period.

Fixed Deferred Indexed Formulas

Annual Point-to-Point – Change in index calculated using two dates one year apart.

Multi-Year Point-to-Point – Change in index calculated using two dates more than one year apart.

Monthly or Daily Averaging – Change in index calculated using multiple dates (one day of every month for monthly averaging, every day the market is open for daily averaging). The average of these values is compared with the index value at the start of the index term.

Monthly Point-to-Point – Change in index calculated for each month during the index term. Each monthly change is limited to the “cap rate” for positive changes, but not when the change is negative. At the end of the index term, all monthly changes (positive and negative) are added. If the result is positive, interest is added to the annuity. If the result is negative or zero, no interest (0%) is added. 

ANNBG 2013 4

Variable Annuities

Money in a variable annuity earns a return based on the performance of the investment portfolios, known as “subaccounts,” where you choose to put your money. Your investment choices likely will include subaccounts with different types and levels of risk. Your choices will affect the return you earn on your annuity. Subaccounts usually have no guaranteed return, but you may have a choice to put some money in a fixed interest rate account, with a rate that won’t change for a set period.

The value of your annuity can change every day as the subaccounts’ values change. If the subaccounts’ values increase, your annuity earns money. But there’s no guarantee that the values of the subaccounts will increase. If the subaccounts’ values go down, you may end up with less money in your annuity than you paid into it.

An insurer may offer several versions of a variable deferred annuity product. The different versions usually are identified as share classes. The key differences between the versions are the fees you’ll pay every year you own the annuity. The rules that apply if you take money out of the annuity also may be different. Read the prospectus carefully. Ask the annuity salesperson to explain the differences among the versions.

What Other Information Should You Consider?

Fees, Charges, and Adjustments

Fees and charges reduce the value of your annuity. They help cover the insurer’s costs to sell and manage the annuity and pay benefits. The insurer may subtract these costs directly from your annuity’s value. Most annuities have fees and charges but they can be different for different annuities. Read the contract and disclosure or prospectus carefully and ask the annuity salesperson to describe these costs.

A surrender or withdrawal charge is a charge if you take part or all of the money out of your annuity during a set period of time. The charge is a percentage of the amount you take out of the annuity. The percentage usually goes down each year until the surrender charge period ends. Look at the contract and the disclosure or prospectus for details about the charge. Also look for any waivers for events (such as a death) or the right to take out a small amount (usually up to 10%) each year without paying the charge. If you take all of your money out of an annuity, you’ve surrendered it and no longer have any right to future income payments.

Some annuities have a Market Value Adjustment (MVA). An MVA could increase or decrease your annuity’s account value, cash surrender value, and/or death benefit value if you withdraw money from your account. In general, if interest rates are lower when you

How Insurers Determine Indexed Interest

Participation Rate – Determines how much of the increase in the index is used to calculate index linked interest. A participation rate usually is for a set period. The period can be from one year to the entire term. Some companies guarantee the rate can never be lower (higher) than a set minimum (maximum). Participation rates are often less than 100%, particularly when there’s no cap rate.

Cap Rate – Typically, the maximum rate of interest the annuity will earn during the index term. Some annuities guarantee that the cap rate will never be lower (higher) than a set minimum (maximum). Companies often use a cap rate, especially if the participation rate is 100%.

Spread Rate – A set percentage the insurer subtracts from any change in the index. Also called a “margin or asset fee.” Companies may use this instead of or in addition to a participation or cap rate. 

ANNBG 2013 5

withdraw money than they were when you bought the annuity, the MVA could increase the amount you could take from your annuity. If interest rates are higher than when you bought the annuity, the MVA could reduce the amount you could take from your annuity. Every MVA calculation is different. Check your contract and disclosure or prospectus for details.

How Annuities Make Payments

Annuitize

At some future time, you can choose to annuitize your annuity and start to receive guaranteed fixed income payments for life or a period of time you choose. After payments begin, you can’t take any other money out of the annuity. You also usually can’t change the amount of your payments. For more information, see “Payout Options” in this Buyer’s Guide. If you die before the payment period ends, your survivors may not receive any payments, depending on the payout option you choose.

Full Withdrawal

You can withdraw the cash surrender value of the annuity in a lump sum payment and end your annuity. You’ll likely pay a charge to do this if it’s during the surrender charge period. If you withdraw your annuity’s cash surrender value, your annuity is cancelled. Once that happens, you can’t start or continue to receive regular income payments from the annuity.

Partial Withdrawal

You may be able to withdraw some of the money from the annuity’s cash surrender value without ending the annuity. Most annuities with surrender charges let you take out a certain amount (usually up to 10%) each year without paying surrender charges on that amount. Check your contract and disclosure or prospectus. Ask your annuity salesperson about other ways you can take money from the annuity without paying charges.

Living Benefits for Fixed Annuities

Some fixed annuities, especially fixed indexed annuities, offer a guaranteed living benefits rider, usually at an extra cost. A common type is called a guaranteed lifetime withdrawal benefit that guarantees to make income payments you can’t outlive. While you get payments, the money still in your annuity continues to earn interest. You can choose to stop and restart the payments or you might be able to take extra money from your annuity. Even if the payments reduce the annuity’s value to zero at some point, you’ll continue to get payments for the rest of your life. If you die while receiving payments, your survivors may get some or all of the money left in your annuity.

Annuity Fees and Charges

Contract fee – A flat dollar amount or percentage charged once or annually.

Percentage of purchase payment – A front-end sales load or other charge deducted from each premium paid. The percentage may vary over time.

Premium tax – A tax some states charge on annuities. The insurer may subtract the amount of the tax when you pay your premium, when you withdraw your contract value, when you start to receive income payments, or when it pays a death benefit to your beneficiary.

Transaction fee – A charge for certain transactions, such as transfers or withdrawals.

* * *

Mortality and expense (M&E) risk charge – A fee charged on variable annuities. It’s a percentage of the account value invested in subaccounts.

Underlying fund charges – Fees and charges on a variable annuity’s subaccounts; may include an investment management fee, distribution and service (12b-1) fees, and other fees. 

ANNBG 2013 6

Living Benefits for Variable Annuities

Variable annuities may offer a benefit at an extra cost that guarantees you a minimum account value, a minimum lifetime income, or minimum withdrawal amounts regardless of how your subaccounts perform. See “Variable Annuity Living Benefit Options” at right. Check your contract and disclosure or prospectus or ask your annuity salesperson about these options.

How Annuities Are Taxed

Ask a tax professional about your individual situation. The information below is general and should not be considered tax advice.

Current federal law gives annuities special tax treatment. Income tax on annuities is deferred. That means you aren’t taxed on any interest or investment returns while your money is in the annuity. This isn’t the same as tax-free. You’ll pay ordinary income tax when you take a withdrawal, receive an income stream, or receive each annuity payment. When you die, your survivors will typically owe income taxes on any death benefit they receive from an annuity.

There are other ways to save that offer tax advantages, including Individual Retirement Accounts (IRAs). You can buy an annuity to fund an IRA, but you also can fund your IRA other ways and get the same tax advantages. When you take a withdrawal or receive payments, you’ll pay ordinary income tax on all of the money you receive (not just the interest or the investment return). You also may have to pay a 10% tax penalty if you withdraw money before you’re age 59½.

Finding an Annuity That’s Right for You

An annuity salesperson who suggests an annuity must choose one that they think is right for you, based on information from you. They need complete information about your life and financial situation to make a suitable recommendation. Expect a salesperson to ask about your age; your financial situation (assets, debts, income, tax status, how you plan to pay for the annuity); your tolerance for risk; your financial objectives and experience; your family circumstances; and how you plan to use the annuity. If you aren’t comfortable with the annuity, ask your annuity salesperson to explain why they recommended it. Don’t buy an annuity you don’t understand or that doesn’t seem right for you.

Payout Options

You’ll have a choice about how to receive income payments. These choices usually include:

• For your lifetime • For the longer of your

lifetime or your spouse’s lifetime

• For a set time period • For the longer of your

lifetime or a set time period

Variable Annuity Living Benefit Options

Guaranteed Minimum Accumulation Benefit (GMAB) – Guarantees your account value will equal some percentage (typically 100%) of premiums less withdrawals, at a set future date (for example, at maturity). If your annuity is worth less than the guaranteed amount at that date, your insurance company will add the difference.

Guaranteed Minimum Income Benefit (GMIB) – Guarantees a minimum lifetime income. You usually must choose this benefit when you buy the annuity and must annuitize to use the benefit. There may be a waiting period before you can annuitize using this benefit.

Guaranteed Lifetime Withdrawal Benefit (GLWB) – Guarantees you can make withdrawals for the rest of your life, up to a set maximum percentage each year. 

ANNBG 2013 7

Within each annuity, the insurer may guarantee some values but not others. Some guarantees may be only for a year or less while others could be longer. Ask about risks and decide if you can accept them. For example, it’s possible you won’t get all of your money back or the return on your annuity may be lower than you expected. It’s also possible you won’t be able to withdraw money you need from your annuity without paying fees or the annuity payments may not be as much as you need to reach your goals. These risks vary with the type of annuity you buy. All product guarantees depend on the insurance company’s financial strength and claims- paying ability.

Questions You Should Ask

• Do I understand the risks of an annuity? Am I comfortable with them?

• How will this annuity help me meet my overall financial objectives and time horizon?

• Will I use the annuity for a long-term goal such as retirement? If so, how could I achieve that goal if the income from the annuity isn’t as much as I expected it to be?

• What features and benefits in the annuity, other than tax deferral, make it appropriate for me?

• Does my annuity offer a guaranteed minimum interest rate? If so, what is it?

• If the annuity includes riders, do I understand how they work?

• Am I taking full advantage of all of my other tax-deferred opportunities, such as 40l(k)s, 403(b)s, and IRAs?

• Do I understand all of the annuity’s fees, charges, and adjustments?

• Is there a limit on how much I can take out of my annuity each year without paying a surrender charge? Is there a limit on the total amount I can withdraw during the surrender charge period?

• Do I intend to keep my money in the annuity long enough to avoid paying any surrender charges?

• Have I consulted a tax advisor and/or considered how buying an annuity will affect my tax liability?

• How do I make sure my chosen survivors (beneficiaries) will receive any payment from my annuity if I die?

If you don’t know the answers or have other questions, ask your annuity salesperson for help.

When You Receive Your Annuity Contract

When you receive your annuity contract, carefully review it. Be sure it matches your understanding. Also, read the disclosure or prospectus and other materials from the insurance company. Ask your annuity salesperson to explain anything you don’t understand. In many states, a law gives you a set number of days (usually 10 to 30 days) to change your mind about buying an annuity after you receive it. This often is called a free look or right to return period. Your contract and disclosure or prospectus should prominently state your free look period. If you decide during that time that you don’t want the annuity, you can contact the insurance company and return the contract. Depending on the state, you’ll either get back all of your money or your current account value.

2000 Heritage Way Waverly, IA 50677 Phone: 800.798.6600

DISCLOSURE AND COMPARISON OF ANNUITY CONTRACTS

Office Use Only Doc Code: 54

DFS-H1-1981 Page 1 of 5 Rule 69B-162.011, F.A.C. Effective 07/01/2018

EXISTING ANNUITY CONTRACT PROPOSED ANNUITY CONTRACT

Annuitant(s) Annuitant(s):

Insurer Insurer:

Contract # Application #:

EXISTING ANNUITY CONTRACT

REPLACEMENT ANNUITY

Contract Issue Date Mo Day Yr Mo Day Yr (Est)

Generic Contract Type

Marketing Name

Initial Premium Source of Initial Premium N/A

Qualified Contract? Yes No Yes No

Annuity Maturity Date

Death Benefit Amount

Change of Annuitant Upon Death Available?

Yes No Yes No

Surrender Charge Period in Years First Year Surrender Charge Percentage Rate

% %

Surrender Charge Schedule for Remaining Years

Free Withdrawals Available? Yes No Yes No Annual Free Withdrawal Percentage Rate % % Potential tax penalty for surrender/sale/ exchange/annuitization (Describe)

Investment/Insurance components (Describe)

Waiver of Surrender Charge Benefit or Similar Benefit?

Yes No Yes No

Riders, Features/Cost (Describe)

Loss of Benefits or Enhancements if existing contract exchanged? (Describe)

DFS-H1-1981 Page 2 of 5 Adopted in Rule 69B-162.011, F.A.C. Effective 07/01/2018

EXISTING ANNUITY CONTRACT

REPLACEMENT ANNUITY

Living Benefits (Describe)

Minimum Guaranteed Interest Rate % % Limitations on interest returns (Describe)

Interest Rate Cap / Term / /

Participation Rate / Term / /

Indexing Method / Term / /

Other Fees (Describe)

Initial Bonus Percentage or Amount

Potential Loss of Bonus if Exchanged?

Yes No Yes No

Limits and Exclusions for Bonuses that may be payable (Describe)

Comments and continuation from above:

Owner’s Signature Date Signed

DFS-H1-1981 Page 3 of 5 Adopted in Rule 69B-162.011, F.A.C. Effective 07/01/2018

DISCLOSURE OF SURRENDER CHARGES IF EXISTING ANNUITY IS REPLACED OR EXCHANGED

EXISTING ANNUITY CONTRACT NO.

Annuity Total Value $ Annuity Surrender Value $

Surrender Charges Applicable at exchange $ ~ this is the estimated amount that will be deducted from the existing annuity’s total value if surrendered, replaced, or exchanged, with an anticipated surrender date of / / .

Have you surrendered or exchanged an annuity contract in the last 36 months? If yes, provide details: Yes No

ACKNOWLEDGEMENTS AND SIGNATURES

I acknowledge that I have provided the Applicant with a completed and signed copy of this form.

Agent’s Name (please print) Florida License No.

Agent’s Signature Date Signed

NOTE: NO QUESTIONS OR RESPONSE AREAS ARE TO BE LEFT BLANK WHEN OFFERED TO THE ANNUITANT AND/OR APPLICANT FOR SIGNATURE. IF ANY INFORMATION REQUESTED IS UNAVAILABLE, NOT APPLICABLE OR UNKNOWN, THE INSURANCE AGENT OR INSURER MUST INDICATE THAT.

THE OWNER MAY SUBSTITUTE THEIR INITIALS FOR SIGNATURES ON ALL FORM PAGES WITH THE EXCEPTION OF THE SIGNATURES BELOW, WHICH ARE REQUIRED.

APPLICANT: DO NOT SIGN THIS FORM IF:

1. ANY ITEM HAS BEEN LEFT BLANK;

2. WITHOUT CAREFULLY REVIEWING THE INFORMATION RECORDED; OR

3. IF ANY OF THE INFORMATION RECORDED IS NOT TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE.

Owner’s Name (please print)

Owner’s Signature Date Signed

DFS-H1-1981 Page 4 of 5 Adopted in Rule 69B-162.011, F.A.C. Effective 07/01/2018

EXPLANATION OF TERMS

“Generic Contract Type” is the generic name of the annuity contract form as approved by the Florida Office of Insurance Regulation. Examples of generic annuity contract names are Flexible Premium Equity Indexed Annuity (FPEIDA), Single Premium Immediate Annuity (SPIA), Flexible Premium Variable Deferred Annuity (FPVDA), and Single Premium Deferred Annuity (SPDA).

“Marketing Name” is the name adopted by the insurer to identify the contract form.

“Qualified Contract” means a product used to fund any type of pension plan approved by the Internal Revenue Service.

“Annuity Maturity Date” is the final date of termination of the contract at which time the proceeds of the contract must be paid out.

“Surrender Charge” is the amount deducted from annuity contract values upon surrender of an annuity, or for withdrawals exceeding any free withdrawal provision of the contract, regardless how this charge is titled in the policy, e.g., deferred sales charge.

“Surrender Charge Period” is the number of annuity contract years a surrender charge may be applicable.

“Initial Surrender Charge Percentage Rate” is the original percentage rate that is deducted from annuity values at the inception of the existing annuity contract, or that will be deducted from the recommended replacement contract at its inception if purchased.

“Surrender Charge Percentage Schedule for Remaining Years” the percentage rate that would be deducted from the existing annuity contract if surrendered, or for any withdrawals exceeding the “free withdrawal” limit.

“Minimum Guaranteed Interest Rate” is the minimum interest rate payable under the annuity contract as guaranteed by the insurer in the annuity contract.

“Initial Bonus Percentage or Amount” is a bonus paid by the insurer, generally, at inception of the annuity contract, and may be expressed as a percentage of the initial premium or other amount, or a dollar amount, and must be stated in the annuity contract.

“Potential Loss of Bonus if Exchanged” refers to whether any bonus would be lost if the annuity contract was exchanged or terminated for any reason.

“Interest Rate Cap” this is the maximum rate of interest the annuity will earn.

Owner’s Signature Date Signed

DFS-H1-1981 Page 5 of 5 Adopted in Rule 69B-162.011, F.A.C. Effective 07/01/2018

EXPLANATION OF TERMS (Continued)

“Participation Rate” the participation rate decides how much of the increase in the index will be used to calculate index –linked interest.

“Indexing Method” means the approach used to measure the amount of change, if any, in the index and includes annual reset (ratcheting), high-water mark and point-to-point. The index term is the period over which index-linked interest is calculated. “Market Value Adjustment” is the increase or decrease in the surrender value of the contract that is adjusted to reflect market fluctuations.

“Administrative Fees or Margins” are charges that amount to the difference between the percentage gain in the index and the actual amount credited to the annuity contract.

“Asset Fees” are the fees the insurer charges that are a percentage of the value of the annuity contract.

“Death Benefit Amount” is the net amount that would be paid to the annuitant’s designated beneficiary or beneficiaries of an existing annuity, or the death benefit that the proposed replacement policy would pay as of the contract issue date.

“Free Withdrawals” are the withdrawals that may be taken from an annuity’s values that are not subject to surrender or other charges and are a provision of the annuity contract.

“Annual Free Withdrawal Percentage Rate” is the percentage of available funds that may be withdrawn from an annuity contract, generally on an annual basis and is stated in the annuity contract.

“Change of Annuitant upon Death” is a provision that allows another person to become the annuitant upon the death of the original annuitant allowing the contract to remain in force.

“Waiver of Surrender Charge Benefit or Similar Benefit or Provision” is a benefit that is built into individual annuity contracts or added by rider, endorsement or amendment. The benefits are triggered by a qualifying event associated with either the annuitant or owner, as specified in the contract.

Owner’s Signature Date Signed

CLS-413 1 of 4 1119

2000 Heritage Way Waverly, IA 50677 Phone: 800.798.6600

Fixed Annuity Suitability Profile

Office Use Only:

Doc Code 154

CMFG Life Insurance Company requires that your licensed agent determine whether the purchase of an annuity is consistent with your financial needs and objectives. CMFG Life relies on the information presented on this form to validate whether the annuity purchase is suitable for you.

Fixed Deferred Annuity Single Premium Immediate Annuity (SPIA) Deferred Income Annuity (DIA)

Instructions: Complete this form using the contract owner’s information. This form must be completed in its entirety, signed, and dated in order to consider your application.

Incomplete forms may affect our ability to determine the suitability of the purchase and will delay processing. Do not leave any questions blank. All responses must be legible.

Section I– Client Profile Information 1a. Owner Name

1b. Owner Age          

1c. What is your employment status? Employed Retired Unemployed

Other:

2a. Joint Owner Name

2b. Joint Owner Age          

2c. What is your employment status? Employed Retired Unemployed

Other:

3. What is your experience level with financial, insurance, or investment products?

None Limited Moderate Extensive

4. Which financial products do you own or have you previously owned? (check all that apply)

Checking/Savings Money Market, CDs Stocks Bonds

Mutual Funds Life Insurance Variable Annuity Fixed Annuity

Other:

5. What is your risk tolerance with respect to the purchase of this annuity? (check one)

Conservative I prefer little to no market risk.

Moderate I am willing to accept some market risk for potential higher returns.

Aggressive I am willing to accept a higher degree of market risk for potential greater returns.

6. What are your financial goals for purchasing this annuity? (check all that apply)

Immediate Income Safety of Principal

Future Income Pass to Beneficiary(ies)

Tax Deferred Growth Estate Planning

Growth Potential Other:

7. When do you anticipate taking your first distribution from this annuity? (check one)

Less than 1 year Between 1 and 5 years 6 and 9 years Ten or more years None anticipated

8. How do you anticipate taking distributions from this annuity? (check all that apply)

Free/Partial Withdrawals Immediate Income Lump Sum Surrender Annuitize

Systematic Withdrawals Required Minimum Distribution Do Not Anticipate Distributions N/A (SPIA/DIA only)

Other:         

9. Does a reverse mortgage exist or are there plans to apply for one? Yes No

If yes, are the financial resources used to fund this annuity from a reverse mortgage? Yes No

If yes, explain:  

10. For Massachusetts applicants - Please list all existing policies or contracts previously sold by the same producer to the same consumer:

CLS-413 2 of 4 1119

Section II– Purchase Payment Information

11. Purchase Payment: $         

12. Source of Funds:

Annuity Life Insurance Reverse Mortgage Home Equity Employer Retirement Plan

Savings/Checking/Money Market Certificate of Deposit (CD) Stocks/Bonds/Mutual Funds Inheritance Other          

Section III– Financial Information 13. What is your federal income tax bracket?

Less than or equal to 15% 15.1–32% Greater than 32%

14. What is your gross annual income?

0-$24,999 $25,000-$49,999 $50,000-$99,999 $100,000-$199,999 $200,000-$299,999 $300,000-$399,999 $400,000-$499,999 $500,000+

15. Identify the source(s) of your income. (check all that apply)

Employment/Self Employment Social Security Pension/Retirement Benefits Reverse Mortgage Investments Unemployment Benefits Other         

16. What is your estimated net worth? (Total assets – total debits = net worth. Exclude primary residence, furnishings and automobiles).

0-$24,999 $150,000-$199,999 Over $1,000,000 $25,000-$49,999 $200,000-$249,999 $50,000-$99,999 $250,000-$499,999 $100,000-$149,999 $500,000-$999,999

17. What is your liquid net worth after the annuity purchase? (Liquid net worth is the amount that can be easily converted into cash without incurring any kind of penalty or surrender charge).

0-$24,999 $150,000-$199,999 Over $1,000,000 $25,000-$49,999 $200,000-$249,999 $50,000-$99,999 $250,000-$499,999 $100,000-$149,999 $500,000-$999,999

18. After the purchase of this annuity, will you have sufficient available cash or other sources of income to cover current expenses, debts and other obligations?

Yes No

(If no, explain)

19. Do you have sufficient available cash or other sources of income for emergencies or unexpected expenses?

Yes No

(If no, explain)

20. Do you anticipate any significant changes in your financial situation or needs, income, expenses, existing assets, liquidity needs, liquid net worth or tax status?

Yes No

(If yes, explain)          

21. Are you purchasing this annuity to become eligible for any needs-based governmental benefit program, such as Medicaid or a veteran’s benefit (exclude Social Security and Medicare)?

Yes No

(If yes, explain)          

         

Note: CMFG Life Annuity products are not designed with the intent of satisfying the requirements of ‘spend down’ strategies typically associated with qualifying for needs-based governmental benefit programs, such as Medicaid or veteran’s benefits.

22. Do you currently reside in or plan to enter into a nursing home or assisted living facility?

Yes No

(If yes, explain)

CLS-413 3 of 4 1119

Section IV– Replacement Information 23. Will the purchase of this annuity result in a replacement of an existing annuity contract or life insurance policy?

Yes No (If no, skip questions 24-26)

24. Excluding this replacement, have you had any other annuity exchange or replacement within the past 60 months?

Yes No

COMPLETE TABLE BELOW IF THIS IS A REPLACEMENT OF EXISTING LIFE INSURANCE OR ANNUITY

Complete this section in its entirety. If requested information is unknown, contact your existing company. If information is not applicable, fill in “N/A”.

If replacing more than one policy/contract, completely fill in the information for each replacement. If replacing more than two contracts, complete additional charts, and the owner(s) and agent(s) should sign and date the additional paperwork.

Existing Annuity Contract Information Existing Contract #1 Existing Contract #2

Company Name    

Type of Policy/Contract (Life Insurance, Fixed, Index or Variable Annuity)    

Contract Issue Date    

Current Contract Value $          $         

Death Benefit Value $          $         

Actual or Estimated Amount Being Transferred to CMFG Life $          $         

Surrender Charge or Penalty Assessed on Amount Being Transferred $          $         

Market Value Adjustment (MVA)? Yes No Yes No

Estimated MVA amount that will apply (if none, list $0). Indicate if the MVA amount will be added (+) to or subtracted (-) from the amount being transferred as listed above.

$          $         

Optional Living Benefit Yes No Yes No

Guaranteed Minimum Interest Rate (provide only for fixed deferred annuity replacement or fixed account)

          %           %

Annual Administrative/Expense fees $          $         

Same selling agent on existing contract and new contract? Yes No Yes No

25. Provide a summary explaining why the annuity contract being replaced is no longer meeting your financial objectives and how the replacing annuity contract will meet your current needs and financial objectives.

         

26. For SPIA or DIA Only: Will the income annuity being purchased provide a higher income stream than available under the terms of your existing annuity contract that is being replaced?

Yes No

(If no, explain)          

         

CLS-413 4 of 4 1119

Section V– Owner Acknowledgements and Signatures

OWNER: By signing this form, I (and Joint Owner, if any) acknowledge each of the following:

To the best of my knowledge and belief, the information I provided to my agent and shown above is true and complete and was obtained prior to my purchase of the annuity. I understand that my failure to provide true and complete information may affect the ability of my agent and CMFG Life to determine the suitability of the annuity product being applied for and may limit the protection provided by regulations regarding suitability of the annuity being purchased.

I have been informed of the various features and potential consequences of the annuity being purchased, including favorable and unfavorable.

I understand that the purchase or exchange of an annuity may have tax consequences and that I should contact my tax advisor for information regarding how this transaction may impact my specific tax situation.

For Fixed Deferred Only: I understand that if I withdraw funds in excess of the free withdrawal amount that I may be subject to a surrender charge and penalty.

For SPIA or DIA Only: I understand that I am permanently converting my premium into an income stream.

For New Jersey residents Only: The sale and suitability of annuities is regulated by the Department of Banking and Insurance. You may obtain assistance from the Department by contacting 609-292-7272 or 1-800-446-7467, or by visiting the Department website at www.njdobi.org.

Owner’s Signature Date

Joint Owner’s Signature Date

Section VI– Agent Acknowledgements and Signatures

AGENT:

By signing this form, I acknowledge the following:

To the best of my knowledge and belief, the information on this Annuity Suitability Profile is true and complete and was obtained prior to the purchase of the annuity. Based on information provided by the customer(s) and my review of such information, I have recommended this annuity as suitable for the financial needs and objectives of the customer(s).

My recommendation reflects the care, skill, prudence, and diligence that a prudent person acting in a like capacity and familiar with such matters would use under the circumstances then prevailing.

In my opinion, (a) the transaction is suitable for the client, based on the client’s suitability information provided to me; (b) the customer would benefit from certain features of the contract being applied for; and (c) the client has the financial ability to meet the financial commitments under the contract.

I have reasonably informed the customer about the applicable features and potential consequences of the proposed transaction, including favorable and unfavorable, and I have disclosed to the customer in a reasonable summary format, all relevant suitability considerations and product information that provide the basis for my recommendation.

I have disclosed to the customer the manner in which I would be compensated for the proposed transaction and for servicing of the contract.

I only considered the customer’s interests when making the recommendation to purchase this annuity and I have adequate knowledge to make the recommendation.

The recommendation was not influenced by any compensation or incentives that I or anyone affiliated with me would receive.

I did not use the title or designation of “financial planner”, “financial advisor,” or any similar title without being appropriately licensed or certified to provide securities or other non-insurance financial services.

Agent’s Name (Print) Agent Number

Agent’s Signature Date

Broker/Dealer, Firm or Affiliation