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 _______________________________________