SecureFoundationSM GROUP [FIXED] DEFERRED ANNUITY CERTIFICATE
EX-4.3 7 electionform43.htm ELECTION FORM electionform43.htm
SecureFoundationSM
GROUP [FIXED] DEFERRED ANNUITY CERTIFICATE
Election Form
OWNER INFORMATION
Last Name | First Name and MI |
Street Address | City, State, Zip |
Home Phone | Gender |
Date of Birth | Social Security Number |
| By signing below, I acknowledge that I have received a copy of the prospectus for the Group [Fixed] Deferred Annuity Certificate and elect to purchase this Certificate. |
DATE________________________SIGNATURE OF ELECTOR _______________________________________