[ Great-West Financial - RROC

PO Box 912852

Denver, CO 80291-2852 ]

Overnight Address:

[Wells Fargo Lockbox Svcs 912852

MAC C7301-L25

1740 Broadway St - LL2

Denver, CO 80274 ]

[ Retirement Resource

Operations Center (RROC) ]

[1-877-723-8723 ]

9:00 A.M. to 7:00 P.M. EST.

Annuities are issued by Great-West Life & Annuity Insurance Company

  SECTION 1: OWNERSHIP TYPE AND REGISTRATION (SELECT ONE ONLY)

If you elect an Inherited IRA, please complete an Inherited IRA Form in addition to this Application.

☐ Traditional IRA

☐ Roth IRA

☐ Inherited Traditional IRA     ☐ Inherited Roth IRA

☐ Individual

☐ Joint

☐ Trust             [ ☐ Non-Qualified Inherited IRA     ]

      or

☐ ]

  SECTION 2: OWNERSHIP INFORMATION

A. Primary Owner

☐ Male

Date of Birth (mm/dd/yyyy)

Phone Number

☐ Female

First Name

Middle Name

Last Name

☐  Permanent U.S. resident

Are you a U.S. Citizen?

☐ Yes        ☐ No

    If No, please complete the Foreign Citizen Information:

☐  Non-permanent  U.S. resident

☐  Non-resident of U.S.

Country of Citizenship

Country of Tax Residency (Only applicable to nonresidents of the U.S.

City

State/Province

Country of Birth

Check one and attach a copy of a valid and unexpired Government ID, showing ID number and photo.

Passport Document / Foreign National Identity Document: ☐     DHS Permanent Resident Card: ☐        Employment Authorization: ☐

Non-Natural Owner/Entity Name (if applicable)

Street Address

City                                  State                         Zip Code

Street Address (Line 2)

  SECTION 2: OWNERSHIP INFORMATION (CONTINUED)

[1786 ]

  B. Joint Owner (Spouse Only) Not applicable if this is a Qualified Annuity Contract

☐ Male

SSN/TIN

Date of Birth (mm/dd/yyyy)

Phone Number

☐ Female

First Name

Middle Name

Last Name

☐  Permanent U.S. resident

Are you a U.S. Citizen?

☐ Yes        ☐ No

    If No, please complete the Foreign Citizen Information:

☐  Non-permanent  U.S. resident

☐  Non-resident of U.S.

Country of Citizenship

Country of Tax Residency (Only applicable to nonresidents of the U.S.

City

State/Province

Country of Birth

Check one and attach a copy of a valid and unexpired Government ID, showing ID number and photo.

Passport Document / Foreign National Identity Document: ☐     DHS Permanent Resident Card: ☐        Employment Authorization: ☐

Non-Natural Owner/Entity Name (if applicable)

Street Address

City                                  State                         Zip Code

Street Address (Line 2)

C. Primary Annuitant

☐ Annuitant is the same as Owner

☐ Male

Date of Birth (mm/dd/yyyy)

Phone Number

☐ Female

First Name

Middle Name

Last Name

Street Address

City                                                 State                                             Zip Code

☐  Permanent U.S. resident

Are you a U.S. Citizen?

☐ Yes        ☐ No

    If No, please complete the Foreign Citizen Information:

☐  Non-permanent  U.S. resident

☐  Non-resident of U.S.

Country of Citizenship

Country of Tax Residency (Only applicable to nonresidents of the U.S.

City

State/Province

Country of Birth

Check one and attach a copy of a valid and unexpired Government ID, showing ID number and photo.

Passport Document / Foreign National Identity Document: ☐     DHS Permanent Resident Card: ☐        Employment Authorization: ☐

  SECTION 2: OWNERSHIP INFORMATION (CONTINUED)

[1786 ]

  D. Joint Annuitant

☐ Joint        ☐ Contingent        ☐ Same as Owner        ☐ Same as Joint Owner

☐ Male

Date of Birth (mm/dd/yyyy)

Phone Number

☐ Female

First Name

Middle Name

Last Name

Street Address

City                                                 State                                             Zip Code

☐  Permanent U.S. resident

Are you a U.S. Citizen?

☐ Yes        ☐ No

    If No, please complete the Foreign Citizen Information:

☐  Non-permanent  U.S. resident

☐  Non-resident of U.S.

Country of Citizenship

Country of Tax Residency (Only applicable to nonresidents of the U.S.

City

State/Province

Country of Birth

Check one and attach a copy of a valid and unexpired Government ID, showing ID number and photo.

Passport Document / Foreign National Identity Document: ☐     DHS Permanent Resident Card: ☐        Employment Authorization: ☐

  SECTION 3: BENEFICIARIES

[1786 ]

  If no Beneficiary is named, the Owner’s estate will be deemed to be the Beneficiary. Percentages must equal 100%

☐ Primary        ☐ Contingent

Birth/Trust Date (mm/dd/yyyy)

Relationship

Percentage (no fractionals)

First Name

Middle Name

Last Name

Phone Number

Street Address

City                                                 State                                             Zip Code

☐ Primary        ☐ Contingent

Birth/Trust Date (mm/dd/yyyy)

Relationship

Percentage (no fractionals)

First Name

Middle Name

Last Name

Phone Number

Street Address

City                                                 State                                             Zip Code

  SECTION 3: BENEFICIARIES (CONTINUED)

[1786 ]

  If no Beneficiary is named, the Owner’s estate will be deemed to be the Beneficiary. Percentages must equal 100%

☐ Primary        ☐ Contingent

Birth/Trust Date (mm/dd/yyyy)

Relationship

Percentage (no fractionals)

First Name

Middle Name

Last Name

Phone Number

Street Address

City                                                 State                                             Zip Code

☐ Primary        ☐ Contingent

Birth/Trust Date (mm/dd/yyyy)

Relationship

Percentage (no fractionals)

First Name

Middle Name

Last Name

Phone Number

Street Address

City                                                 State                                             Zip Code

  SECTION 4: SOURCE OF FUNDS

Purchase Payment Amount:  

  A. Qualified

☐ Transfer all or a portion of funds from my existing IRA annuity or other qualified plan. (*Please complete the Acord Form.)

☐ Transfer $ 

from my brokerage account number:

  B. NON-Qualified

☐ Transfer all or a portion of funds from my existing annuity or life insurance policy. (*Please complete Acord form and applicable state replacement forms.)

☐ Transfer $ 

from my brokerage account number:

☐ Check is attached

    Do you consent to Electronic Delivery?.

The [Retirement Resource Operation Center (RROC)] is authorized to act on telephone instructions provided by me. In the absence of this authorization, available telephone instructions will not be allowed.

SECTION 10: PRODUCER INFORMATION *FOR PRODUCER USE ONLY

Does the applicant have existing life insurance policies or annuity contracts?

☐  YES

☐  NO

Do you have reason to believe the annuity applied for will replace any life insurance or annuity with us or with any other company?

☐  YES

☐  NO

If “YES” to replacement, please certify by checking this box that sales material, if any, used in this transaction was company approved and a copy has been left with the applicant

☐  YES

☐  NO

Producer Printed Name

Producer Signature

License Number