SecureFoundation Group Fixed Deferred Annuity Certificate Election Form

Contract Categories: Business Finance › Subscription Agreements
Summary

This form allows an individual to elect to purchase a Group Fixed Deferred Annuity Certificate under the SecureFoundation program. The applicant provides personal information and confirms their choice by signing the form. The completed form must be sent to the designated service provider. The agreement becomes effective upon the owner's signature and submission, and is subject to the terms of the annuity program.

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EX-4.3 2 dex43.htm FORM OF ELECTION Form of Election

Exhibit 4.3

 

SecureFoundationSM

  

Group Fixed Deferred Annuity Certificate Election Form

 

 

  [Product Marketing Name]

 

   

 

[Account grouping]  

 

Owner Information

     
                                         

Last Name

      First Name    MI                   Social Security Number                    
 
                           

Address – Number & Street

                   Email Address                        
     
                             

City

    State    Zip Code         

Mo  

    Day      Year        q    Female     q    Male

(         )

         (         )                        

Home Phone

 

        

Work Phone

 

         

    Date of Birth

 

   

Required Signature By signing below, I hereby elect to purchase this Group Fixed Deferred Annuity Certificate.

     
           
            

SecureFoundationSM Owner Signature

       Date   

Owner forward to Service Provider at:

[Service Address]

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

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