Market Value Adjusted Annuity Application between Applicant and GE Life and Annuity Assurance Company

Summary

This application is for individuals or trusts seeking to purchase a Market Value Adjusted Annuity from GE Life and Annuity Assurance Company. The applicant provides personal and financial information, selects the type of annuity and funding source, and designates beneficiaries. The agreement outlines the right to examine and return the contract within a specified period, and includes fraud warnings as required by various states. The application is a preliminary step and does not itself guarantee issuance of an annuity contract.

EX-4.C 5 dex4c.txt APPLICATION Exhibit 4(c) Market Value Adjusted Annuity Application - ----------------------------------------- GE Life and Annuity Assurance Company Plan Information Product Name:_____________________________________________________________________________________________ Total Cash For 1035 Exchange(s) or Transfer(s) Submitted With Application: $ |__|__|,|__|__|__|,|__|__|__|.|__|__| and/or estimated premium $|__|__|,|__|__|__|,|__|__|__| to be transferred Complete Section Qualified or Non-Qualified [_] Non-Qualified Qualified Initial Interest Term - ------------- --------- (Check all that apply) [_] Traditional IRA or [_] ROTH IRA [_] 1 Year [_] 6 Years [_] Initial purchase Custodial IRA Yes [_] No [_] [_] 2 Years [_] 7 Years [_] 1035 Exchange(s) [_] TSA 403(b) or [_] SEP [_] 3 Years [_] 8 Years [_] Other |__|__|__|__|__|__|__|__|__|__| [_] 4 Years [_] 9 Years Check all that apply [_] 5 Years [_] 10 Years [_] Transfer [_] Rollover [_] Direct Rollover [_] New contribution for tax year |__|__|__|__| Owner (Name or name of trust and trustee) (Last, First, M.) Gender |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| M [_] F [_] Date of birth or trust date (mm-dd-yyyy) Social Security no. or Tax ID Telephone no. |__|__| -- |__|__| -- |__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__|__| Address |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__| |__|__| |__|__|__|__|__|__| Joint Owner (Optional): Name (Last, First, M.) [_] spouse [_] Non-Spouse Gender |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__|__|__|__|__|__|__|__| M [_] F [_] Date of birth (mm-dd-yyyy) Social Security no. or Tax ID Telephone no. |__|__| -- |__|__| -- |__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__| Address |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__| |__|__| |__|__|__|__|__|__| Annuitant (if other than Owner) (Last, First, M.) Gender |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__|__|__|__|__|__|__| [_] M [_] F Date of birth (mm-dd-yyyy) Social Security no. or Tax ID Telephone no. |__|__| -- |__|__| -- |__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__|__| Address |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__| |__|__| |__|__|__|__|__|__| Joint Annuitant: Name (Last, First, M.): Only use for Non-Qualified Funds [_] Spouse [_] Non-Spouse Gender |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__|__|__|__|__|__|__|__| M [_] F [_] Date of birth (mm-dd-yyyy) Social Security no. or Tax ID Telephone no. |__|__| -- |__|__| -- |__|__|__|__| |__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__|__| Address |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||__|__|__|__| |__|__| |__|__|__|__|__|__| ==================================================================================================================================== Regular Mail For Inquiries and/or Questions Overnight Delivery - ------------ ------------------------------ ------------------ GE Life and Annuity Assurance Company Internet: www.gefinancialservice.com GE Life and Annuity Assurance Company Attn: Annuity New Business Toll free: (800) 352-9910 Attn: Annuity New Business P.O. Box 85093 6610 W. Broad Street Richmond, VA ###-###-#### Richmond, VA 23230

Page 1 of 3 Market Value Adjusted Annuity Application - ----------------------------------------- GE Life and Annuity Assurance Company Beneficiary (Name or name of trust and trustee) (Last, First, M.) % of Shares [_] Primary |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__| % [_] Contingent Relationship Date of birth or Trust date (mm-dd-yyyy) Social Security no. or Tax ID Gender |__|__|__|__|__|__|__|__|__|__|__| |__|__| -- |__|__| -- |__|__|__|__|__| |__|__|__|__|__|__|__|__|__|__| M [_] F [_] Address Telephone no. |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__| |__|__|__|__|__| Beneficiary: Name (Last, First, M.) % of shares [_] Primary |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__| % [_] Contingent Relationship Date of birth or Trust date (mm-dd-yyyy) Social Security no. or Tax ID Gender |__|__|__|__|__|__|__|__|__|__|__| |__|__| -- |__|__| -- |__|__|__|__|__| |__|__|__|__|__|__|__|__|__|__| M [_] F [_] Address Telephone no. |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__| |__|__|__|__|__| Beneficiary: Name (Last, First, M.) % of shares [_] Primary |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__| % [_] Contingent Relationship Date of birth or Trust date (mm-dd-yyyy) Social Security no. or Tax ID Gender |__|__|__|__|__|__|__|__|__|__|__| |__|__| -- |__|__| -- |__|__|__|__|__| |__|__|__|__|__|__|__|__|__|__| M [_] F [_] Address Telephone no. |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__| -- |__|__|__| -- |__|__|__|__| City State Zip code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__| |__|__|__|__|__|

Fraud and Disclosure Statements ARIZONA RESIDENTS, PLEASE NOTE: RIGHT TO EXAMINE On written request, GE Life and Annuity Assurance Company (GE Life & Annuity) will provide to the Contract Owner within a reasonable time, reasonable factual information regarding the benefits and provisions of this Contract. If for any reason the Contract Owner is not satisfied, the Contract may be returned to the Company or producer within 20 days after delivery, and the Contract Value will be returned. ARKANSAS, COLORADO, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW MEXICO, OHIO, OKLAHOMA, PENNSYLVANIA AND TENNESSEE RESIDENTS, PLEASE NOTE: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Colorado, any insurance company, or agent of an insurance company, who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding, or attempting to defraud, the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FLORIDA RESIDENTS: Any person who knowingly, and with intent to injure, defraud, aor deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Owner Signature(s) NOTE: REPLACEMENT QUESTION MUST BE ANSWERED The undersigned hereby apply to GE Life & Annuity for an Annuity Contract in accordance with the information contained in this application. The undersigned understand that upon acceptance of this application by GE Life & Annuity, they will be bound by the provisions and entitled to the benefits of the Annuity. Each spouse Joint Owner appoints the other to exercise annuity rights. Non-Spouse Ownership: Tax laws require that all proceeds be distributed to Non-Spouse Beneficiary(ies) at the death of the Owner or Joint Owner, whichever occurs first. The undersigned represent that all statements set forth in this application are full, complete, and true as written and correctly recorded, to the best of their knowledge. Will the proposed annuity replace any existing annuity or insurance contract? [_] Yes [_] No Have your received a current prospectus to the applied for policy? [_] Yes [_]No DO YOU UNDERSTAND THAT THE BENEFITS AND VALUES UNDER THIS CONTRACT MAY BE ADJUSTED UPWARD OR DOWNWARD BY THE APPLICATION OF A MARKET VALUE ADJUSTMENT FORMULA, AND THAT ANY DEATH BENEFIT MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT? [_] Yes [_] No ================================================================================================================================ Owner (sign as Fiduciary if Owner is a Trust*) Joint Owner (if applicable) Date of signature (mm-dd-yyyy) _________________________________________________ ___________________________________ |__|__| -- |__|__| -- |__|__|__|__| Annuitant (required if other than Owner) Joint Annuitant (if applicable) Date of signature (mm-dd-yyyy) _________________________________________________ ___________________________________ |__|__| -- |__|__| -- |__|__|__|__| State application signed in State contract will be delivered |__|__| |__|__| *If Trustee, Attorney in Fact, Guardian, or other Fiduciary, you must sign in your official capacity (i.e., John Doe, Trustee).
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Market Value Adjusted Annuity Application - ----------------------------------------- GE Life and Annuity Assurance Company Agent(s) or Broker(s) Information and Signature(s) Do you have reason to believe that the proposed annuity will replace any existing annuity or insurance contract? [_] Yes [_] No If yes, submit completed replacement form, where required. By signing, you certify that you have witnessed the above signature(s) and that all information contained in this application is true to the best of your knowledge and belief. ==================================================================================================================================== Primary Agent/Broker Signature Print name (Last, First, M.) ___________________________________________________________ |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Date of signature (mm-dd-yyyy) Signed in following state Telephone No. |__|__| - |__||__| - |__|__|__|__| |__|__| |__|__||__| - |__||__||__| - |__|__|__|__| Social Security No. (Florida License No.) Agent/Broker No. Commission Split |__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__|__|__|__| |__|__|__|% Broker/Dealer Name/Branch # Client Account No. |__|__|__|__|__|_|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__|__|_|__|__|__|__|__|__| ==================================================================================================================================== Additional Agent/Broker Signature Print name (Last, First, M.) ___________________________________________________________ |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Date of signature (mm-dd-yyyy) Signed in following state Telephone No. |__|- |__|__|- |__|__|__|__| |__|__| |__|__|__| - |__|__|__| - |__|__|__|__| Social Security No. (Florida License No.) Agent/Broker No. Commission Split |__|__|__|__|__||__|__|__|__|__|__|__|__| |__|__|__|__|__|__|__| |__|__|__|% Broker/Dealer Name/Branch # Client Account No. |__|__|__|__|__|__|__||__|__|__|__|__|__|__||__|__|__|__|__|__|__||__|__| |__|__|__|__|__|__|__|__|__|__| ====================================================================================================================================
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