Attached files
Exhibit 4.4
Group Fixed Deferred Annuity Election Form
| [Product Marketing Name] | [Account grouping] | |||||||||||||||||||||
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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: $
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| 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:
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| Signature | Rep Code | Source Code | Lead Source | Date |
GLWB-RBD-ele