Exhibit
4.2


 


GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY


(“Great-West”)


A Stock Company


 


	
  [8515 East
  Orchard Road

  	
  Greenwood Village, CO  80111]

  



 


For service, call  [1-800-537-2033
(extension 73343)]


 


APPLICATION
FOR GROUP ANNUITY CONTRACT


 


	
  SECTION
  A. PLAN SPONSOR

  	
   

  
	
   

  	
   

  
	
  NAME
  OF PLAN SPONSOR

  	
  FEDERAL
  TAX ID #

  
	
   

  	
   

  
	
  ADDRESS

  	
  SITUS

  
	
   

  	
   

  
	
  STREET

  	
  CITY

  	
  STATE

  	
  ZIP
  CODE

  	
   

  
	
  TELEPHONE #

  	
  FAX
  #

  	
  TYPE
  OF ENTITY:

  
	
   

  	
  [o  Church] [o Public
  School]

  
	
   

  	
  [o  Government]
   [o 501(c)(3) ]   [o  S Corp]

  
	
   

  	
  [o  Corporation]  [o Partnership]  [o  LLC]

  
	
   

  	
  [o  Sole Proprietorship]
  [o  Other
                  ]

  
	
   

  	
   

  
	
  FULL LEGAL NAME OF PLAN

  	
   

  
	
   

  	
   

  
	
  SECTION B. CONTRACTHOLDER

  	
   

  
	
   

  	
   

  
	
  NAME
  OF CONTRACHOLDER, IF DIFFERENT THAN THE PLAN SPONSOR

  	
  [FEDERAL TAX
  ID #, if applicable

  
	
   

  	
   

  
	
  ADDRESS

  	
  SITUS,
  if applicable

  
	
   

  	
   

  
	
  STREET

  	
  CITY

  	
  STATE

  	
  ZIP
  CODE

  	
   

  
	
  TELEPHONE #

  	
  FAX
  #]

  	
  TYPE
  OF ENTITY:

  
	
   

  	
  [o  Bank]                   [o  Trust Company]

  
	
   

  	
  [o  Individual(s)]       [o  Other
                  ]

  
	
   

  	
   

  
	
  SECTION C. PLAN INFORMATION

  	
   

  
	
   

  	
   

  
	
  [o  401(a) Plan]      [o ERISA]      [o Non-ERISA]

  	
  [o  457(b) Governmental Plan]

  
	
  [o  401(k) Plan]      [o ERISA]      [o Non-ERISA]

  	
  [o 
                                          ]  

  
	
  [o  403(b) Plan]      [o ERISA]      [o Non-ERISA]

  	
   

  
	
   

  	
   

  
	
  SECTION D.  COVERED FUND

  	
   

  
	
   

  	
   

  
	
  [o  Maxim SecureFoundationSM Balanced Portfolio]

  	
   

  
	
  [o  Maxim SecureFoundationSM Lifetime Portfolios]

  	
   

  
	
  [o 
                                                              ]

  	
   

  
						



 


SECTION E. AGREEMENT AND SIGNATURES


 


AGREEMENT:


 


By
signing this Application, Plan Sponsor and Contractholder, if different than
Plan Sponsor, understand, accept, and otherwise agree to the provisions of the
attached Group Annuity Contract, certify and otherwise represent that the
information contained on this application is true and correct to the best of
their knowledge, and agree to notify Great-West of any changes to the
information provided above.  Please refer
to page 2 of this Application for applicable fraud warnings.


 


	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Signature of Plan Sponsor

  	
  Date

  	
   

  	
   Signature
  of Contractholder

  	
  Date

  
	
   

  	
   

  	
   if
  different than Plan Sponsor

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Title

  	
   

  	
   Title

  



 


1

















 


FRAUD NOTICE


 


NOTICE:  Any person who knowingly
presents a false or fraudulent claim for payment of a loss or benefit, or
knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to fines, confinement in prison, and
denial of insurance benefits, depending upon state law.


 


STATE
INSURANCE FRAUD WARNINGS


 


	
  Notice to AR, KY, LA, NM, OH and PA residents only:  Any person
  who, knowingly and with intent to injure, defraud or deceive any insurance
  company or other person, files an application for insurance or statement of
  claim containing any materially false information or conceals for the purpose
  of misleading, information concerning any fact material thereto commits a
  fraudulent insurance act, which is a crime and may subject such person to
  criminal and civil penalties, fines, imprisonment, or a denial of insurance
  benefits.

   

  Notice to CO residents only:  FRAUD WARNING:  It is unlawful to knowingly
  provide false, incomplete, or misleading facts or information to an insurance
  company for the purpose of defrauding or attempting to defraud the company.
  Penalties may include imprisonment, fines, denial of insurance and civil
  damages. Any insurance company or agent of an insurance company who knowingly
  provides false, incomplete, or misleading facts or information to a
  policyholder or claimant for the purpose of defrauding or attempting to
  defraud the policyholder or claimant with regard to a settlement or award
  payable from insurance proceeds shall be reported to the Colorado division of
  insurance within the department of regulatory agencies

   

  	
  Notice to
  DC residents only:  WARNING: it is a crime
  to provide false or misleading information to an insurer for the purpose of
  defrauding the insurer or any other person. Penalties include imprisonment
  and/or fines.  In addition, an insurer
  may deny insurance benefits if false information materially related to a claim
  was provided by the applicant.

   

  Notice to
  MD residents only:  WARNING: 
  Any person who knowingly and willfully presents a
  false or fraudulent claim for payment of a loss or benefit or who knowingly
  and willfully presents false information in an application for insurance is
  guilty of a crime and may be subject to fines and confinement in prison.

   

  Notice to
  ME, TN, VA and WA residents only:  It is a crime to
  knowingly provide false, incomplete or misleading information to an insurance
  company for the purpose of defrauding the company.  Penalties include imprisonment, fines and
  denial of insurance benefits.

   

  Notice to
  NJ residents only: Any person who includes any false or
  misleading information on an application for an insurance policy is subject
  to criminal and civil penalties.

   

  Notice to OK residents only: WARNING: Any person who knowingly,
  and with intent to injure, defraud or deceive any insurer, makes any claim
  for the proceeds of an insurance policy containing any false, incomplete or
  misleading information is guilty of a felony.

  



 


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