Group Fixed Deferred Annuity Election Form

EX-4.4 4 d257332dex44.htm FORM OF ELECTION FORM Form of Election Form

Exhibit 4.4

Group Fixed Deferred Annuity Election Form

 

 

[Product Marketing Name]   [Account grouping]

 

Certificate Owner Information

     
                     
Last Name   First Name   MI           Social Security Number
 
             
Address – Number & Street           Email Address
     
                                 
City   State   Zip Code                
                  Mo     Day     Year     ¨    Female    ¨     Male
(        )     (        )                      
Home Phone     Work Phone           Date of Birth  

 

Required Signature By signing below, I hereby elect to purchase this Group Deferred Annuity Certificate (“Certificate”). In doing so, I understand the following:

 

  •  

The Certificate provides for a Guaranteed Lifetime Benefit, but only if certain specified conditions are satisfied;

 

  •  

The Certificate has no cash value or surrender value;

 

  •  

The Certificate does not pay dividends or death benefits;

 

  •  

The Certificate Owner owns the Covered Fund; and

 

  •  

The Accounts and the investments of the Covered Fund are not assets of Great-West Life & Annuity Insurance Company

Source of Funds:

It is my intent to fund this Certificate with: (select only one):

¨ Funds from my Individual Retirement Account (“IRA”)

¨ Funds from the Roth IRA

¨ Funds from other Account:                                                                                  

             (please specify)

Initial Contribution: $            

 

 

     

 

   
Certificate Owner Signature      Date   

Owner forward to Service Provider at:

[Service Address]

[Phone#: 1-NNN-NNN-NNNN]

[Fax#: 1-NNN-NNN-NNNN]

For Agent Use Only:

 

 

     

 

     

 

     

 

     

 

Signature      Rep Code      Source Code      Lead Source      Date

GLWB-RBD-ele