Group Fixed Deferred Annuity Election Form for Great-West Life & Annuity Insurance Company

Contract Categories: Business Finance › Subscription Agreements
Summary

This form allows an individual to elect to purchase a Group Deferred Annuity Certificate from Great-West Life & Annuity Insurance Company. The certificate provides a guaranteed lifetime benefit if certain conditions are met, but it does not have cash or surrender value, nor does it pay dividends or death benefits. The owner funds the certificate from an IRA, Roth IRA, or another specified account and must provide personal and contact information. The form must be signed and submitted to the service provider to complete the election.

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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

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