Document:

Form of Certificate

 Exhibit 4.1 

 

	
	Great-West Life & Annuity Insurance Company
	A Stock Company
	 [8515 East Orchard Road             Greenwood Village, CO
80111]
  

  

	
	Group Fixed Deferred Annuity Certificate (the “Certificate”)

 PLEASE READ THE CERTIFICATE CAREFULLY. 
 Great-West Life & Annuity Insurance Company (“Great-West”) has issued the Certificate in connection with your Investment Portfolio. Great-West agrees, subject to the terms and
conditions of the Certificate, to provide benefits set forth in the Certificate while the Certificate is in force. The Certificate Owner owns the Investment Portfolio. 
 The Certificate is issued to the Certificate Owner(s) shown on the Certificate Data Page. It takes effect on the Effective Date shown on the Certificate Data Page. 

The Certificate has no cash value or surrender value. 
 The Certificate does not pay dividends or death benefits. 

Non-Participating. 
 Non-Assignable. 
 Signed for Great-West Life & Annuity Insurance
Company on the issuance of the Certificate. 
  

									
		 	 /s/ Richard Schultz
	 		 	 /s/ Mitchell T.G. Graye
	  	
		 	[Richard Schultz,]	 		 	[Mitchell T.G. Graye,]	  	
		 	[Secretary]	 		 	[President and Chief Executive Officer]	  	

 CERTIFICATE DATA 

 

	 Certificate Election Date: 
	[January 1, 2011] 

	 Certificate Owner: 
	[John B. Doe] 

  

	 Group Contractholder: 
	[Orchard Trust Company f/b/o customers of Financial Services Providers] 

  

	 Financial Services Provider: 
	[PNC Bank] 

  

	 Initial Benefit Base: 
	[Covered Fund Value on Certificate Election Date] 

	 Maximum Benefit Base: 
	[$5,000,000] 

	 Ratchet Date: 
	[Certificate Anniversary Date] 

	 Interest Rate Reset Date: 
	[Anniversary of Initial Installment Date] 

 Guaranteed Withdrawal
Percentage: 

											
	 Age at First
 Withdrawal                %
	 	 	  	 	  	 	 	 	 	 
	(Single Covered Person)*	  	Minimum GAW%	  	Maximum GAW%	 	 	 	 
						
	[59.5-64]	 	10YR x [.70]	  	3.0%	  	5.6%	 		 	
	[65-69]	 	10YR	  	4.0%	  	8.0%	 		 	
	[70-74	 	10 YR x [1.10]	  	4.5%	  	8.3%	 		 	
	[75+]	 	10 YR x [1.20]	  	5.0%	  	8.5%	 		 	

 * If there are Joint Covered Persons, age at first withdrawal is based on age of younger Covered Person and the
Guaranteed Withdrawal Percentage is multiplied by [.90%] 
 Annual Charges: 

 

			
	 Certificate Current Guarantee Benefit Fee:
	  	[1.0%] of Benefit Base
	 Certificate Minimum Guarantee Benefit Fee:
	  	.70% of Benefit Base
	 Certificate Maximum Guarantee Benefit Fee:
	  	1.5% of Benefit Base

  
 1 

 TABLE OF CONTENTS 

 

							
	 Section 1
	  	DEFINITIONS	  	 	3	  
			
	 Section 2
	  	OWNERSHIP PROVISIONS	  	 	5	  
			
	 Section 3
	  	GLWB ELECTION	  	 	6	  
			
	 Section 4
	  	THE ACCUMULATION PHASE AND THE CALCULATION OF THE BENEFIT BASE	  	 	6	  
			
	 Section 5
	  	WITHDRAWAL PHASE	  	 	8	  
			
	 Section 6
	  	SETTLEMENT PHASE	  	 	12	  
			
	 Section 7
	  	BENEFIT BASE CAP	  	 	13	  
			
	 Section 8
	  	GUARANTEE BENEFIT FEE	  	 	13	  
			
	 Section 9
	  	FEES ASSOCIATED WITH INVESTMENT PORTFOLIO	  	 	13	  
			
	 Section 10
	  	GROUP CONTRACT TERMINATION	  	 	13	  
			
	 Section 11
	  	CERTIFICATE TERMINATION	  	 	14	  
			
	 Section 12
	  	GENERAL PROVISIONS	  	 	14	  
			
	 Section 13
	  	ANNUITY PAYMENT OPTIONS	  	 	16	  
			
	 Section 14
	  	MISSTATEMENT OF AGE OR DEATH	  	 	16	  

  
 2 

 SECTION 1: DEFINITIONS 

 
  

10 Year Treasury Yield (10YR) – The U.S. Treasury 10-Year Yield as of the end of the last Business Day of the previous week as reported
by the United States Department of Treasury. 
 Account – A separate record maintained by Great-West in the name of each Certificate
Owner which reflects his or her interest in both Covered Fund(s) and other investment options in the Investment Portfolio. 
 Accumulation
Phase – The period of time between the Certificate Election Date and the Initial Installment Date. 
 Administrative Offices
– [8515 East Orchard Road, Greenwood Village, CO 80111.] 
 Age Adjustment– For a single Covered Person, a factor based on the
age of the Covered Person(s) on the Initial Installment Date that is multiplied by the 10 Year Treasury Yield to determine the GAW%. For a joint Covered Person, a factor based on the age of the younger Covered Person on the Initial Installment Date
that is multiplied by the 10YR and an additional adjustment shown in Section 5.01. 
 Annuitant – The person upon whose life
the payment of an annuity is based. 
 Annuity Commencement Date – The date that annuity payments begin to an Annuitant. 

Applicable Tax – The amount of tax, if any, charged by a state or other governmental authority. 

Beneficiary – A person or entity named by the Certificate Owner or the terms of the Investment Portfolio to receive all or a portion of the
Investment Portfolio at his or her death. 
 Benefit Base – The amount that is multiplied by the Guaranteed Annual Withdrawal
Percentage to calculate the Guaranteed Annual Withdrawal. The Benefit Base increases dollar-for-dollar upon any Certificate Contribution and is reduced proportionately for an Excess Withdrawal. The Benefit Base can also increase with positive
Covered Fund performance on the Ratchet Date and may also be adjusted on the Ratchet Date pursuant to the terms of Section 5.05. Each Covered Fund will have its own Benefit Base. A Covered Fund cannot be transferred to another Covered Fund
except as otherwise provided in Section 4.02. 
 Business Day – Any day, and during the hours, on which the New York Stock
Exchange is open for trading. Except as otherwise provided, in the event that a date falls on a non-Business Day, the date of the succeeding Business Day will be used. 
 Certificate - This document issued to the Certificate Owner which specifies the benefits, rights, privileges, and obligations of the Certificate Owner and Great-West under the Group Contract.

 Certificate Anniversary Date – The anniversary of the Certificate Election Date, or the preceding Business Day to the extent that
the Certificate Election Date is not a Business Day. 
 Certificate Contributions – Certificate Owner directed amounts received and
allocated to the Certificate Owner’s Covered Fund(s), including but not limited to Transfers from other assets in the Investment Portfolio. If the Certificate is issued in connection with a Retirement Account, Certificate Contributions may also
include rollovers as defined under Section 402 of the Code. Reinvested dividends, capital gains, and settlements arising from the Covered Fund(s) will not be considered Certificate Contributions for the purpose of calculating the Benefit Base
but will affect the Covered Fund Value. If this Certificate is issued in connection with a Non-Retirement Account, and dividends are not reinvested, it will be considered an Excess Withdrawal to the extent the distribution causes total withdrawals
in the year to exceed the GAW. 
 Certificate Election Date – The date on which the GLWB Elector or Beneficiary elects the GLWB
option in the Certificate and pursuant to the terms of the Covered Fund(s) prospectus. The Certificate Election Date shall be the date upon which the Initial Benefit Base is calculated. 

  
 3 

 Certificate Owner(s) – The person(s) named on the Certificate Data Page. The Certificate
Owner(s) is entitled to exercise all of the benefits, rights and privileges under the Certificate. The Certificate Owner must be an owner of the Investment Portfolio and the Covered Person(s) must be a natural person. 

Code – The Internal Revenue Code of 1986, as amended, and all related laws and regulations which are in effect during the term of the
Certificate. 
 Covered Fund – Interests in mutual fund(s) held in the Investment Portfolio designed for the GLWB, as follows:

  

	 	•	 	 [Maxim
SecureFoundationSM Balanced ETF Portfolio] 

  

	 	•	 	 Any other fund approved by Great-West for the GLWB 

 Covered Fund Value – The aggregate value of each Covered Fund held in the Investment Portfolio. 
 Covered Person(s) – For purposes of the Certificate, the person(s) whose age determines the Guaranteed Annual Withdrawal Percentage and on whose life the Guaranteed Annual Withdrawal Amount
will be based. If there are two Covered Persons, the Guaranteed Annual Withdrawal Percentage will be based on the age of the younger life and the Installments can continue until the death of the second life. A Joint Covered Person must be the GLWB
Elector’s spouse and the 100% primary beneficiary under the Investment Portfolio. 
 Distributions – Amounts paid from a
Covered Fund pursuant to the terms of the Investment Portfolio, including but not limited to partial and systematic withdrawals. For a Certificate issued in connection with a Non-Retirement Account, a Distribution includes dividends paid by the
Covered Fund(s) that are not reinvested. 
 Excess Withdrawal – An amount either distributed or transferred from the Covered Fund(s)
during the Accumulation Phase or any amount combined with all other amounts that exceeds the annual GAW during the Withdrawal Phase. The Excess Withdrawal reduces the Benefit Base, pursuant to Section 4.05 and Section 5.07. Neither the
Guarantee Benefit Fee nor any other fees or charges assessed to the Covered Fund Value as directed by the Financial Services Provider and as agreed to by Great-West shall be treated as a Distribution or Excess Withdrawal for this purpose.

 Financial Services Provider – An entity that offers the Investment Portfolio or a mutual fund account that offers or holds the
Covered Fund(s). 
 GLWB Elector – A Certificate Ownerwho is: (i) eligible to elect the GLWB; (ii) invested in Covered
Fund(s) pursuant to the Covered Fund prospectus; and (iii) a Covered Person. 
 Great-West – Great-West Life & Annuity
Insurance Company, located at the Administrative Offices. 
 Group Contract – The written agreement between the Group Contractholder
and Great-West. 
 Group Contractholder – The entity with ownership rights under the Group Contract. 

Guaranteed Annual Withdrawal (GAW) – The annualized withdrawal amount that is guaranteed for the lifetime of the Covered Person(s), subject
to the terms of this Certificate. 
 Guaranteed Annual Withdrawal Percentage (GAW%) – The percentage of the Benefit Base that
determines the amount of the GAW. This percentage is based on the age of the Covered Person(s) at the time of the first Installment determined by calculating the 10 Year Treasury Yield multiplied by the Age Adjustment, subject to the maximum and
minimum percentages described in Section 5.01. If there are two Covered Persons the percentage is based on the age of the younger Covered Person and the Joint Withdrawal Adjustment, pursuant to Section 5.01. 

Guarantee Benefit Fee – The fee described in Section 8 of the Certificate. 
 Guaranteed Lifetime Withdrawal Benefit (GLWB) – A payment option offered by Certificate that pays Installments during the life of the Covered Person(s). The Covered Person(s) will receive
periodic payments in 

  
 4 

 either monthly, quarterly, semiannual, or annual Installments that in total over a twelve month period equal
the GAW. 
 Initial Calculation – The calculation used to determine the GAW% on the Initial Installment Date pursuant to
Section 5.01. 
 Initial Installment Date – The date of the first Installment under the GLWB, which must be a Business Day.

 Installments – Periodic payments of the GAW made pursuant to Section 5.03. 

Installment Frequency Options – The options listed in Section 5.03. 
 Interest Rate Reset – During the Withdrawal Phase, an increase in the current GAW if the calculation described in Section 5.06 results in a greater GAW than the current GAW on the Ratchet
Date. 
 Investment Portfolio – An account of the Certificate Owner used to purchase the Certificate and Covered Fund(s) through a
Financial Services Provider. The Investment Portfolio may be either a Retirement Account or a Non-Retirement Account, which may hold investments other than the Covered Fund(s). 
 Joint Withdrawal Adjustment – The Age Adjustment of the youngest Covered Person(s) multiplied by [.90]. 
 Non-Retirement Account – An Investment Portfolio that is not intended to satisfy the requirements of Section 408 or 408A of the Code. 

Ratchet – An increase in the Benefit Base if the Covered Fund Value exceeds the current Benefit Base on the Ratchet Date, pursuant to
Section 4.04 and Section 5.05. 
 Ratchet Date – During the Accumulation Phase, the Ratchet Date is the anniversary of the
GLWB Elector’s Certificate Election Date and each anniversary thereafter. During the Withdrawal Phase, the Ratchet Date is the Initial Installment Date and each anniversary thereafter. An Interest Rate Reset may also occur on the Ratchet Date
during the Withdrawal Phase. If any anniversary is a non-Business Day, the Ratchet Date shall be the preceding Business Day for that year. 

Retirement Account – An Investment Portfolio that is intended to qualify under Sections 408 or 408A of the Code. 

Request – An inquiry or instruction in a form satisfactory to Great-West. A valid Request must be: (i) received by Great-West, at the
Administrative Office or its authorized agent in good order and (ii) submitted in accordance with the provisions of the Certificate, or as required by Great-West. The Request is subject to any action taken by Great-West before the Request was
processed. 
 Settlement Phase –The period when the Covered Fund Value has reduced to zero, but the Benefit Base is still positive.
Installments continue under the terms of the Certificate pursuant to Section 6.03. 
 Spouse – A person legally married to
another person under applicable Federal law. 
 Transfer – The transfer of all or a portion of Covered Fund Value resulting
from the purchase or sale of an interest in a Covered Fund to or from: (i) another Covered Fund; or (ii) another Investment Portfolio offered by the Financial Services Provider. 
 Withdrawal Phase – The period of time between the Initial Installment Date and the first day of the Settlement Phase. 
 SECTION 2: OWNERSHIP PROVISIONS 
  

 
 2.01 OWNERSHIP OF THE CERTIFICATE; RIGHTS OF
THE CERTIFICATE OWNER 
 The Certificate Owner is identified on the Certificate Data Page. The Certificate Owner owns the Certificate and has
certain rights and privileges as set forth in this Certificate. 

  
 5 

 2.02 NO TRANSFER OR ASSIGNMENT OF CERTIFICATE 

The interests of the Certificate Owner in the Certificate may not be transferred, sold, assigned, pledged, charged, encumbered, or in any way alienated.

 SECTION 3: GLWB ELECTION 

 
  

3.01 GLWB ELECTION 
 An individual
eligible to become a GLWB Elector makes a GLWB election by investing in a Covered Fund through a Great-West approved method and pursuant to the terms of the Covered Fund prospectus. Such individual may elect the GLWB on any Business Day as long
as he or she is younger than age 85 on the Certificate Election Date. Great-West will record a Certificate Election Date for each GLWB Elector. 
 3.02 GLWB INVESTMENT RESTRICTIONS 
 The GLWB applies only to the Covered Fund Value subject
to Section 7 of the Certificate. 
 3.03 GLWB TERMINATION DUE TO THE BENEFIT BASE REDUCING TO ZERO 

The GLWB is cancelled when the GLWB Elector causes the Covered Fund Value or Benefit Base to be reduced to zero prior to the Settlement Phase due to one
or more Excess Withdrawals. If the GLWB is cancelled, the Benefit Base, GAW and any other benefit accrued or received under the GLWB shall terminate. The GLWB Elector shall not make a subsequent Transfer or a Certificate Contribution into the same
Covered Fund until at least ninety (90) calendar days after termination of the GLWB, at which point a new Election Date would be recorded. In this situation, the Benefit Base will be based on the current Covered Fund Value on the date the new
GLWB is established. 
 SECTION 4: THE ACCUMULATION PHASE AND CALCULATION OF THE BENEFIT BASE 

 
  

4.01 INITIAL BENEFIT BASE 
 The Initial
Benefit Base is the sum of all Certificate Contributions initially allocated to the Covered Fund(s) on the Certificate Election Date. However, when there is a front-end sales load or other sales charge associated with the Covered Fund, the Initial
Benefit Base is the gross sum of all Certificate Contributions initially allocated to the Covered Fund(s) prior to deducting the sales load or other sales charge associated with the Covered Fund on the Certificate Election Date. 

4.02 RESTORATION OF THE BENEFIT BASE 
 If
the Certificate Owner invests in Covered Fund(s) with proceeds rolled over or directly transferred from the Covered Fund(s) held in another Investment Portfolio to which a Great-West approved guaranteed lifetime withdrawal product was issued, the
Certificate Owner’s Benefit Base immediately prior to distribution shall be restored within the Certificate only to the extent that the Certificate Owner: (a) invests the rollover or transfer proceeds covered by the Great-West guaranteed
lifetime withdrawal benefit product immediately prior to distribution in the Covered Fund(s); (b) invests in a Covered Fund approved by Great-West as described in the prospectus, except if the Certificate Owner is in Settlement Phase; and
(c) Requests restoration of the Benefit Base. The Certificate Owner must begin in the same phase that he or she was in at the time of the rollover or transfer after the transaction is complete. 

4.03 ADDITIONAL CERTIFICATE CONTRIBUTIONS 

Additional Certificate Contributions, of not less than [$500] per Certificate Contribution may be allocated to the Covered Fund(s) only during the
Accumulation Phase. Additional Certificate Contributions made any time after the Certificate Election Date will increase the Benefit Base dollar-for-dollar. Great-West reserves the right to refuse additional Certificate Contributions for any reason.
Great-West will provide the Certificate Owner with 30 days written notice of such refusal. If Great-West refuses additional Certificate Contributions, the GLWB Elector shall retain all other rights under the Certificate. 

4.04 ANNUAL ADJUSTMENTS TO BENEFIT BASE 

On each Ratchet Date during the Accumulation Phase, the Benefit Base automatically adjusts to the greater of: 

 

	 	(a)	the current Benefit Base; or 

  

	 	(b)	the current Covered Fund Value. 

  
 6 

 4.05 EFFECT OF DISTRIBUTIONS AND TRANSFERS DURING THE ACCUMULATION PHASE 

Any Transfer out of a Covered Fund by the GLWB Elector during the Accumulation Phase will be an Excess Withdrawal. If the GLWB Elector Transfers any asset
out of a Covered Fund, he or she shall be prohibited from making any Transfer into the same Covered Fund for at least ninety (90) calendar days. At the time of any Distribution, if the Covered Person is [59.5] years of age or older, the GLWB
Elector may elect to begin receiving Installments and establish his or her GAW% at that time. If the GLWB Elector chooses not to establish the GAW%, the Distribution will be treated as an Excess Withdrawal. If the Covered Person is not yet [59.5]
years old, then any partial or periodic Distribution will be treated as an Excess Withdrawal. The Benefit Base will be adjusted by the ratio of the Covered Fund Value after the Excess Withdrawal to the previous Covered Fund Value. 

The Certificate Owner is solely responsible for any adverse consequences that may result of any Distributions or withdrawals. The Certificate Owner
should consult with a financial advisor. 
 Numerical Example 
 Excess Withdrawals during the Accumulation Phase are illustrated as follows: 

Covered Fund Value before the Excess Withdrawal adjustment = $50,000 

Benefit Base = $100,000 
 Excess Withdrawal amount: $10,000 
 Covered Fund Value after adjustment
= $50,000 - $10,000 = $40,000 
 Covered Fund Value adjustment = $40,000/$50,000 = 0.80 

Adjusted Benefit Base = $100,000 x 0.80 = $80,000 
 4.06 DIVORCE DURING ACCUMULATION PHASE 
 If the Account is transferred or split pursuant to
a settlement agreement or a court-issued divorce decree before the Initial Installment Date, the Certificate Owner(s) must immediately notify us and provide the information that we require. 
 If the former spouse of the Certificate Owner becomes the sole Owner of the Account by a settlement agreement or a court-issued divorce decree, the Certificate Owner may request that the Certificate be
reissued with the former spouse as the sole Certificate Owner, Covered Person and GLWB Elector; otherwise the Certificate will be terminated. If the Certificate is so reissued, the current Benefit Base will be maintained. 

If the Account is divided between the Certificate Owner and the Certificate Owner’s former spouse by a settlement agreement or a court-issued
divorce decree, the Certificate Owner(s) may request that the Certificate be reissued as one new Certificate with one of the former spouses as sole Certificate Owner, Covered Person and GLWB Elector, or as two new Certificates, each with one of the
former spouses as Certificate Owner, Covered Person and GLWB Elector; otherwise the Certificate will be terminated. If the Certificate is reissued as one new Certificate, the Benefit Base will be proportionate to the share of the Covered Fund Value
allocated to the former spouse as of the date of reissuance. If the Certificate is reissued as two new Certificates, the Benefit Base will be divided in the same proportion as the respective Covered Fund Values as of the date of reissuance.

 Any election made by the Spouse Beneficiary pursuant to this section is irrevocable. 

4.07 DEATH DURING ACCUMULATION PHASE 
 If
a Certificate Owner dies before the Initial Installment Date, the GLWB will terminate and the Covered Fund Value shall be paid to the Beneficiary in accordance with the terms of the Investment Portfolio (unless an election is made by a spouse
Beneficiary as provided in this section). A Spouse Beneficiary who was legally married to the deceased Certificate Owner under applicable Federal law as of the date of death may elect to become the sole Certificate Owner and may maintain the
deceased Certificate Owner/GLWB Elector’s current Benefit Base as of the date of death. A Spouse Beneficiary also has the option to establish a new Account with a new Benefit Base based on the current Covered Fund Value on the date the Account
is established, in which case a new Certificate will be issued to the Spouse. In either situation, the Spouse Beneficiary shall become the sole Certificate Owner, Covered Person and GLWB Elector, and the Ratchet Date will be the date when his or her
Account is established. The new Certificate Owner, Covered Person and GLWB Elector will be subject to all 

  
 7 

 
terms and conditions of the Certificate, Investment Portfolio and the Code, if applicable. Any election made by a Spouse Beneficiary pursuant to this section is irrevocable. 

SECTION 5: WITHDRAWAL PHASE 
  

 
 5.01 CALCULATION OF GUARANTEED ANNUAL
WITHDRAWAL 
 The GAW is calculated by multiplying the Benefit Base by the GAW%, based on the 10 Year Treasury Yield (10YR) and the age
of the Covered Person(s) on the Initial Installment Date. If a Request is made to begin Installments, Great-West shall compare the current Benefit Base to the current Covered Fund Value on the Initial Installment Date. If the Covered Fund Value
exceeds the Benefit Base, the Covered Fund Value shall become the Benefit Base and the GAW shall be based on that amount. The Installment equals the GAW divided by the number of payments per year under the elected Installment Frequency Option, as
defined in Section 5.03. The GLWB Elector must provide information sufficient for Great-West to determine the age of each Covered Person. Installments shall not begin and an Initial Installment Date shall not be recorded until Great-West
receives appropriate information about the Covered Person(s) in good order and in manner reasonably satisfactory to Great-West. Great-West will pay the Initial Installment within [7] days from the Initial Installment Date. 

Single Covered Person: Installments may not begin until a single Covered Person attains age [59.5]. 

Joint Covered Person: If there are two Covered Persons, Installments may not begin until both Covered Persons reach age [59.5]. If the GLWB
Elector elects to declare his or her spouse as a Joint Covered Person, the election is irrevocable and the GAW% will be determined by the age of the younger life on the Initial Installment Date, and the spouse must be the GLWB Elector’s sole
Beneficiary. If the GLWB Elector’s spouse is not the sole Beneficiary, the Certificate Owner is required to change the Beneficiary designation prior to the Initial Installment Date. Installments will not begin until such change is made.

 Any Distribution taken before the youngest Covered Person attains age [59.5] shall be considered an Excess Withdrawal, pursuant to
Section 4.05. No Certificate Contributions shall be made to the Covered Fund(s) on and after the Initial Installment Date. 
 The GAW% for
a Single Covered Person is calculated by multiplying the 10YR by the Age Adjustment, subject to a minimum and maximum GAW%, based on the schedule below. The GAW% schedule is as follows: 

 

							
	 Age
Band
	  	 Age
Adjustment
	  	 Minimum
GAW%
	  	 Maximum
GAW%

	         [59.5-64]
	  	[0.7]	  	3.0%	  	5.6%
	         [65-69
	  	[1.0]	  	4.0%	  	8.0%
	         [70-74]
	  	[1.1]	  	4.5%	  	8.3%
	         [75+]
	  	[1.2]	  	5.0%	  	8.5%

 For Joint Covered Persons, the same calculation is used based on the age of the youngest Covered Person but an additional
adjustment of [.90] is applied. This rate is the Joint Withdrawal Adjustment. 
 5.02 NUMERICAL EXAMPLES OF THE GUARANTEED ANNUAL WITHDRAWAL

  

			
	 Scenario #1:
	  	72 Year Old Single Covered Person
		  	10YR = 5.0%

 Benefit Base = $80,000 
 10 YR (5.0%) x Age Adjustment [(1.10)] = 5.5% 
 GAW = $4,400 ($80,000 x 5.5%) 

 

			
	 Scenario #2:
	  	68 Year Old Joint Covered Person with a 63 Year Old Spouse
		  	10YR Rate = 6.0%

 Benefit Base = $80,000 
 10 YR (6.0%) x Age Adjustment [(.70)] x .90 = 3.78% 
 GAW = $3,024 ($80,000 x 3.78%)

  
 8 

			
	 Scenario #3:
	  	60 Year Old Single Covered Person
		  	10YR = 3.7%

 Benefit Base = $80,000 
 10 YR (3.7%) x Age Adjustment [(.70)] = 2.59%* 
 GAW =$2400 ($80,000 x 3.0%) 

* Since 2.59% is less than the minimum GAW% for a 60 year old (3.0%), the GLWB Elector would receive the minimum GAW% of 3.0%.

  

			
	 Scenario #4:
	  	71 Year Old Joint Covered Person with a 65 Year Old Spouse
		  	10YR = 3.0%

 Benefit Base = $80,000 
 10 YR (3.0%) x Age Adjustment [(1.0)] = 3.0% x .90 = 2.7%** 
 GAW =$2,880 ($80,000 x 3.6%)

 ** Since 2.7% is less than the minimum GAW% for the 65 Year Old Youngest Covered Person (3.6%), the GLWB Elector would receive
the minimum GAW% of 3.6%. 
 5.03 INSTALLMENT FREQUENCY OPTIONS 
 Installment Frequency Options are as follows: 
 (a) Annual – the GAW will be
paid on the Initial Installment Date and each anniversary annually thereafter. 
 (b) Semi-Annual – half of the GAW will be
paid on the Initial Installment Date and in Installments every 6 month anniversary thereafter. 
 (c) Quarterly – one
quarter of the GAW will be paid on the Initial Installment Date and in Installments 
 every 3 month anniversary thereafter.

 (d) Monthly – one-twelfth of the GAW will be paid on the Initial Installment Date and in Installments every monthly
anniversary thereafter. 
 If an Installment is scheduled to be made on a non-Business Day, the Installment shall be paid on the next Business
Day. 
 5.04 EFFECT OF INSTALLMENTS ON COVERED FUND VALUE 
 Installments will reduce the Covered Fund Value on a dollar-for-dollar basis. 
 5.05 ADJUSTMENT
DURING THE WITHDRAWAL PHASE 
 On the Ratchet Date, Great-West will determine the Interest Rate Reset and the Ratchet pursuant to
Section 5.06 below and determine if either of these calculations would result in a higher GAW, subject to the provisions set forth below. In the event that an Interest Rate Reset or Ratchet occurs, the GAW will automatically increase and the
Benefit Base will be adjusted to equal the current Covered Fund Value. An Interest Rate Reset may result in either a higher or lower Benefit Base than the previous year. 
 5.06 CALCULATION OF ADJUSTMENT IN WITHDRAWAL PHASE 
 On the Ratchet Date, Great-West shall
first determine if an Interest Rate Reset is applicable. If an Interest Rate Reset is applicable, the GAW will automatically increase to the higher GAW amount. Great-West will then determine if a Ratchet is applicable and results in a higher GAW. If
neither calculation results in a higher GAW, then no adjustment to the GAW will be made. 
  

	 	(1)	Interest Rate Reset – Great-West will calculate the GAW by multiplying the Covered Fund Value by the Current 10YR, subject to the Initial Calculation, and
determine if it is higher than the previous GAW. If so, the GAW will adjust to the higher amount. 

  
 9 

	 	(2)	Ratchet – Great-West will compare the Covered Fund Value to determine if it exceeds the Benefit Base. 

Numerical Example #1: When Interest Rate Reset is More Beneficial than Ratchet: 

 

			
	On Initial Installment Date:	 	70 Year Old Single Covered Person
		 	Covered Fund Value = $108,000
		 	Benefit Base = $120,000
		 	10 YR = 5%
		 	GAW% = 5.5% (10 YR of 5% x Age Adjustment of [1.10])
		 	GAW = $6,600 (GAW% of 5.5% x Benefit Base of $120,000)
		
	On 5th Anniversary of Initial Installment Date:	 	Customer is now a 75 Year Old Single Covered Person
		 	Covered Fund Value - $90,000
		 	Current 10 YR = 7%
		
	Interest Rate Reset:	 	 •        GAW% = 7.7% (10 YR of 7.7% x Age Adjustment of 70 Year Old of
[1.10])

		 	 •        Interest Rate Reset Calculation = $6,930 (GAW% of
7.7%x Covered Fund Value of $90,000)

		 	 •        Since Interest Rate Reset calculation of $6,930 is higher than
current GAW of $6,600 then the new GAW = $6,930

		
	Ratchet:	 	 •        Ratchet Calculation = $4,950 (GAW% of 5.5% x Covered Fund
Value of $90,000)

		 	 •        Since Ratchet Calculation is lower than the current GAW of $6,600
then no Ratchet

		
	Result:	 	 •        NEW GAW = $6,930

		 	 •        NEW BENEFIT BASE = $90,000

		 	 •        NEW GAW% = 7.7%

 Numerical Example #2: When Ratchet is More Beneficial than Interest Rate Reset: 

 

			
	On Initial Installment Date:	 	70 Year Old Single Covered Person
		 	Covered Fund Value = $108,000
		 	Benefit Base = $120,000
		 	10 YR = 5%
		 	GAW% = 5.5% (10 YR of 5% x Age Adjustment of [1.10])
		 	GAW = $6,600 (GAW% of 5.5% x Benefit Base of $120,000)
		
	On 5th Anniversary of Initial Installment Date:	 	Customer is now a 75 Year Old Single Covered Person
		 	Covered Fund Value - $140,000
		 	Current 10 YR = 4%
		
	Interest Rate Reset:	 	 •        GAW% = 4.4% (10 YR of 4% x Age Adjustment of 70 Year Old of
[1.10])

		 	 •        Interest Rate Reset Calculation = $6,160 (GAW% of 4.4% x
Covered Fund Value of $140,000)

		 	 •        Since Interest Rate Reset calculation of $6,160 is lower than current
GAW of $6,600 then the GAW = $6,600

		
	Ratchet:	 	 •        Ratchet Calculation = $7,700 (GAW% of 5.5% x Covered Fund
Value of $140,000)

		 	 •        Since Ratchet Value Calculation of $7,700 is higher than the current GAW
of $6,600 then the new GAW = $7,700

		
	Result:	 	 •        NEW GAW = $7,700

		 	 •        NEW BENEFIT BASE = $140,000

		 	 •        GAW% = 5.5% (no change)

  
 10 

 5.07 EFFECT OF EXCESS WITHDRAWALS DURING THE WITHDRAWAL PHASE 

After the Initial Installment Date, a Distribution or Transfer combined with all other amounts in excess of the GAW will be considered an Excess
Withdrawal. The Benefit Base will be reduced by the ratio of the new Covered Fund Value (after the Excess Withdrawal) to the previous Covered Fund Value (after the GAW). 
 If an Excess Withdrawal occurs, the GAW and current Benefit Base shall be adjusted on the next Ratchet Date. 
 Numerical Example: 
 Covered Fund Value before GAW = $55,000 

Benefit Base = $100,000 
 GAW % = 5% 

GAW Amount = $100,000 x 5% = $5,000 
 Total
annual withdrawal: $10,000 
 Excess Withdrawal = $10,000 – $5,000 = $5,000 
 Covered Fund Value after GAW = $55,000 – $5,000 = $50,000 
 Covered Fund Value
after Excess Withdrawal = $50,000 – $5,000 = $45,000 
 Covered Fund Value Adjustment due to Excess Withdrawal = $45,000/$50,000 = 0.90

 Adjusted Benefit Base = $100,000 x 0.90 = $90,000 
 Adjusted GAW Amount = $90,000 x 5% = $4,500 
 (Assuming no GAW increase on succeeding Ratchet Date)

 5.08 CHANGE OF INSTALLMENT FREQUENCY DURING WITHDRAWAL PHASE 
 The GLWB Elector may Request to change the Installment Frequency Option starting on each Ratchet Date during the Withdrawal Phase. 
 At any time during the Withdrawal Phase, the GLWB Elector receiving Installments more frequently than annually may elect to take a lump sum Distribution up to the remaining scheduled amount of the GAW for
that year. It is the GLWB Elector’s responsibility to monitor the remaining Distributions from the Investment Portfolio and suspend the remaining Installments that are scheduled to be paid during the year until the next Ratchet Date. If the
GLWB Elector fails to suspend remaining Installments for the year, an Excess Withdrawal may occur. If the GLWB Elector does not elect to recommence Installments 30 calendar days prior to the Ratchet Date, no additional Installments shall be made
until GLWB Elector notifies Great-West 30 calendar days prior to the next Ratchet Date. The GLWB Elector’s current Ratchet Date shall remain in effect while Installments are suspended. 
 The Certificate Owner is solely responsible for any adverse consequences that may result of any Distributions or withdrawals. The Certificate Owner should consult with a financial advisor prior to
making any withdrawals. 
 5.09 DIVORCE DURING WITHDRAWAL PHASE 
 If the Account is transferred or split pursuant to a settlement agreement or a court-issued divorce decree after the Initial Installment Date but before the Settlement Phase, the Certificate Owner(s) must
immediately notify Great-West and provide the information that the Company requires. 
 If the former spouse of the Certificate Owner becomes
the sole Owner of the Account, the Certificate Owner(s) may request that the Certificate be reissued as a new Certificate with the former spouse as the sole Certificate Owner, Covered Person and GLWB Elector; otherwise the Certificate will be
terminated and any remaining Covered Fund Value shall be distributed to the former spouse of the Certificate Owner in accordance with the terms of the Investment Portfolio. If the Certificate is reissued, the current Benefit Base will be maintained
but a new GAW will be computed pursuant to Section 5.01 if and when the new Certificate Owner becomes eligible to elect, and elects, to receive the GAW. A new Ratchet Date will be established for the new Certificate Owner on the date the new
Certificate is issued. 
 If the Account is divided between the Certificate Owner and the Certificate Owner’s former spouse, the
Certificate Owner(s) may request that the Certificate be reissued as one new Certificate with one of the former spouses as Certificate Owner, Covered Person and GLWB Elector, or as two new Certificates, each with one of the former spouses as
Certificate Owner, Covered Person and GLWB Elector; otherwise the Certificate will be terminated. If the Certificate is reissued as one new Certificate, the Benefit Base will be proportionate to the Certificate Owner’s share of the Covered Fund
Value as of the date of reissuance. If the Certificate is reissued as two new Certificates, the Benefit Base will be divided in the same proportion as the respective Covered Fund Values as of 

  
 11 

 
the date of reissuance. The GAWs will be calculated based on the Single Covered Person GAW% in Section 5.01 after the Accounts are split, and new Ratchet Dates will be established for each
Certificate on the date the Accounts are split. In the alternative, the former spouse of the Certificate Owner may establish a new GLWB in the Accumulation Phase with the Benefit Base based on the current Covered Fund Value on the date his or her
Account is established. Any election made by the spouse pursuant to this section is irrevocable. 
 5.10 PAYMENTS ON DEATH DURING WITHDRAWAL
PHASE 
 If a Certificate Owner Dies After the Initial Installment Date as a Single Covered Person 

If a Certificate Owner dies after the Initial Installment date without a second Covered Person, the GLWB will terminate and no further Installments will
be paid. If the death occurs before the Settlement Phase, the remaining Covered Fund Value shall be distributed to the Beneficiary in accordance with the terms of the Investment Portfolio. If permitted by the Investment Portfolio and the Code, if
applicable, the Beneficiary may elect to have a new Certificate issued with the Beneficiary as the sole Certificate Owner, Covered Person and GLWB Elector, in which event an initial Benefit Base shall be established and he or she will be subject to
all terms and conditions of the Certificate, the Investment Portfolio and the Code, if applicable. Any election made by the Beneficiary is irrevocable. 
 If a GLWB Elector Dies After the Initial Installment Date while Second Covered Person is Living 
 In the case of a Nonqualified Certificate, upon the death of a Certificate Owner after the Initial Installment Date, and while a second Covered Person who was legally married to the deceased Certificate
Owner under applicable Federal law on the date of death is still living, the surviving Covered Person may elect to become the sole Certificate Owner, Covered Person and GLWB Elector (if permitted by the terms of the Investment Portfolio and the
Code, if applicable), and he or she will acquire all rights under the Certificate and continue to receive GAWs based on the original Certificate Owner/GLWB Elector’s election. Installments may continue to be paid to the surviving Covered Person
based on the GAW% for Joint Covered Persons in Section 5.01. Installments will continue to be paid to the surviving Covered Person until his or her death and, upon death, the surviving Covered Person’s beneficiary will receive any
remaining Covered Fund Value if such death occurs before the Settlement Phase. Alternatively, the surviving Covered Person may elect to receive his or her portion of the Covered Fund Value as a lump sum Distribution. In either situation the Ratchet
Date will be the date when the Account is established. 
 To the extent to that the surviving Covered Person becomes the sole Owner, Covered
Person and GLWB Elector, he or she will be subject to all terms and conditions of the Certificate, the Investment Portfolio and the Code, if applicable. Any election made by the Beneficiary pursuant to this section is irrevocable. 

SECTION 6: SETTLEMENT PHASE 
  

 
 6.01 CERTIFICATE RIGHTS AND BENEFITS

 During the Settlement Phase, rights to receive Installments will continue but all other rights and benefits under the Certificate will
terminate. 
 6.02 FEES 
 The
Guarantee Benefit Fee described in Section 8 will not be deducted during the Settlement Phase. 
 6.03 INSTALLMENTS 

If the Covered Fund Value is less than the amount of the final Installment in the Withdrawal Phase, Great-West will pay the remaining balance of the
Installment within [7] days from the Installment Date. 
 Installments will continue in the same frequency as previously elected, and cannot be
changed during the Settlement Phase. 
 6.04 DIVORCE DURING THE SETTLEMENT PHASE 
 If a Request is made in connection with a divorce, Great-West will divide the Installment pursuant to the terms of any settlement or divorce decree, but Installments will not continue beyond the date on
which they would terminate had the divorce not occurred. 

  
 12 

 6.05 DEATH DURING THE SETTLEMENT PHASE 
 When the last Covered Person dies during the Settlement Phase, the GLWB will terminate and no additional Installments will be paid to the Beneficiary. 

SECTION 7: BENEFIT BASE CAP 
  

 
 The Benefit Base may not exceed [$5 million]. Any
value over [$5 million] will be considered excess Covered Fund Value and will not be used to calculate GAWs or the Guarantee Benefit Fee described in Section 8. A GLWB Elector may Transfer or Distribute any excess Covered Fund Value on a dollar
for dollar basis without reducing the Benefit Base. However, if the Covered Fund Value falls below [$5 million] based on Excess Withdrawals, the Benefit Base will adjust pursuant to the terms of the Certificate. 

SECTION 8: GUARANTEE BENEFIT FEE 

 
  

The amount of the annual Guarantee Benefit Fee is set forth on the Certificate Data page. The Guarantee Benefit Fee will be deducted from the GLWB
Elector’s Covered Fund Value. [One-fourth] of the Guarantee Benefit Fee is deducted on a [quarterly] basis in arrears. The Guarantee Benefit Fee will be calculated based on the GLWB Elector’s Benefit Base as of the date of the deduction.
Because the Guarantee Benefit Fee is based on the Benefit Base, the Benefit Base may increase or decrease if a Ratchet or Interest Rate Reset occurs. 
 Great-West reserves the right to change the frequency of the deduction, but will notify the GLWB Elector and the Group Contractholder in writing at least thirty (30) calendar days prior to the
change. 
 Great-West shall inform the Certificate Owner of the current percentage amount of the Guarantee Benefit Fee. The Guarantee Benefit
Fee will be divided by [four] on the date Great-West charges the fee. The Guarantee Benefit Fee is withdrawn from the Covered Fund, and Great-West is authorized to cause the Financial Services Provider to remit the Guarantee Benefit Fee when due, if
applicable. 
 The first Guarantee Benefit Fee calculated will be pro-rated based on the portion of the quarter of the Certificate Election
Date. Great-West reserves the right to change the Guarantee Benefit Fee at any time and for any reason upon thirty (30) days written notice to the GLWB Elector and Certificate Owner. Any change to the fee will affect all assets in the Covered
Fund(s). 
 Upon and termination of the Certificate, a final pro-rated Guarantee Benefit Fee will be deducted based on the portion of the last
quarter that the GLWB Certificate was in effect. 
 If Great-West does not receive the Guarantee Benefit Fee for the GLWB attributed to the GLWB
Elector, the GLWB attributed to such GLWB Elector will terminate after [45] days from the date such Guarantee Benefit Fee is due. 
 The
Guarantee Benefit Fee is not deducted during the GLWB Elector’s Settlement Phase. 
 SECTION 9: FEES ASSOCIATED WITH INVESTMENT
PORTFOLIO 
  
  

The Certificate Owner may make a withdrawal of up to 1.50% of the Covered Fund Value to pay for asset management or advisory service fees associated with
the Investment Portfolio without the withdrawal being considered an Excess Withdrawal. If these fees exceed 1.5% of the Covered Fund Value, and the entire amount of the fees are withdrawn from the Covered Fund Value, the amount withdrawn above the
1.5% limit will be considered an Excess Withdrawal and will reduce the Benefit Base, pursuant to Section 4.05 and Section 5.07 

SECTION 10: GROUP CONTRACT TERMINATION 

 
  

Unless otherwise provided in this Certificate, either Great-West or the Group Contractholder may terminate the Group Contract with
advance written notice to the other party. The Group Contract termination date shall be the [seventy-fifth
(75th)] day after the date written notice is received in
the Administrative Offices in good order. If the [seventy-fifth (75th)] day is not a Business Day, the Group Contract termination date shall be the Business Day immediately following the [seventy-fifth (75th)] day. Prior to the Group Contract termination date, Great-West and Group Contractholder may agree to an alternate
Group Contract termination date. 

  
 13 

 In addition, a GLWB Elector’s rights under the Group Contract and the Certificate terminate if the
Investment Portfolio is terminated. 
 If the Group Contractholder Terminates the Contract 

If the Group Contractholder terminates the Group Contract, all benefits, rights, and privileges provided by the Group Contract, including without
limitation, the GLWB shall terminate. GLWB Electors who are not eligible to receive Distributions under the Investment Portfolio or are eligible to receive their Distributions but do not take a Distribution prior to the Group Contract termination
date shall have the Benefit Base and Covered Fund Value reduced to zero and any and all other benefits provided under the Group Contract shall terminate on the Group Contract termination date. 

If Great-West Terminates the Contract 

If Great-West terminates the Group Contract or discontinues the availability of the Covered Fund(s), such termination or discontinuation
will not adversely affect the Certificate Owner’s rights under the Group Contract, except that additional Certificate Contributions may not be invested in the Covered Fund(s) other than reinvested dividends and capital gains. 

Other Termination 
 This Contract and the
GLWB shall automatically terminate if: (i) a Financial Services Provider discontinues the use of a Great-West approved Covered Fund and the provisions of Section 4.02 are not applicable (ii) Great-West is unable to collect the
Guarantee Benefit Fee; or (iii) Great-West cannot effectively administer the GLWB. Should the Contract terminate under this subsection, the Group Contractholder, rather than Great-West, shall be treated as having terminated the Contract.

 SECTION 11: CERTIFICATE TERMINATION 

 
  

The Certificate will terminate upon the earlier of: 
  

	(a)	the date of death of the Certificate Owner if there is no surviving Covered Person; or 

 

	(b)	the date there is no longer a Covered Person under the Certificate; 

  

	(c)	the date the Certificate is canceled as set forth in Section 3.03; 

  

	(d)	the date the Group Contract terminates subject to Section 10; or 

  

	(e)	when the Guarantee Benefit Fee is not received by the Company, subject to the provisions of Section 8. 

SECTION 12: GENERAL PROVISIONS 
  

 
 12.01 CERTIFICATE  

Great-West has issued the Certificate to the Certificate Owner setting forth in substance the benefits, rights, and privileges to which the Certificate
Owner is entitled under the Group Contract. 
 12.02 ENTIRE CERTIFICATE 
 The Certificate, including the Certificate Owner’s application, amendments, endorsements, specification page, if any, and or other riders, if any, constitutes the entire Certificate. After issue,
amendments or changes in writing and agreed to by the Company are part of the Certificate. 
 All statements in the Certificate Owner’s
application, in the absence of fraud, have been accepted as representations and not warranties. Only the President, Vice-President, or Secretary of Great-West can agree on behalf of Great-West to modify any provisions of the Certificate. 

12.03 GROUP CONTRACT MODIFICATION 

Great-West may modify the Group Contract from time to time to conform it to changes in tax or other law, including applicable regulations and rulings,
without consent of the Certificate Owner or any other person. Great-West will provide notice and a copy of any such modification to the Certificate Owner as soon as reasonably practicable. 

  
 14 

 The Group Contractholder and Great-West may, by written agreement, make other modifications to the Group
Contract, subject to the approval of the appropriate state department of insurance, if applicable. No such modification will, without the written consent of the Group Contractholder, affect the terms, provisions, or conditions of the Certificate,
which are or may be applicable to Certificate Contributions made prior to the date of such modification. 
 12.04 MODIFICATION OF COVERED
FUNDS 
 Great-West and/or the Financial Services Provider may, without the consent of the Certificate Owner or the Group Contractholder,
offer new Covered Fund(s) or cease offering Covered Fund(s). Great-West will notify the Group Contractholder whenever the Covered Fund(s) are changed. Great-West shall complete the allocations between the Covered Fund(s) as disclosed in the notice
as of the effective date of the change. Such allocation will remain in effect until the date Great-West receives a Request for a different allocation. 
 12.05 NON-PARTICIPATING 
 The Certificate is Non-Participating. The Certificate Owner is not
eligible to share in Great-West’s divisible surplus. 
 12.06 CURRENCY AND CERTIFICATE CONTRIBUTIONS 

All amounts to be paid to or by Great-West must be in currency of the United States of America. All Certificate Contributions must be made payable to
Great-West or to a designee acceptable to Great-West. 
 12.07 NOTICES OR OTHER COMMUNICATIONS 

Any notice or demand by Great-West to or upon the Group Contractholder, any GLWB Elector, Covered Person(s) or any other person, if applicable, may be
given by mailing it to that person’s last known address as stated in Great-West’s file through the United States Postal Service or last known email address or facsimile number on file. 

An application, report, Request, election, direction, notice or demand by the Group Contractholder, any GLWB Elector, or other Covered Person(s), if
applicable, will be made in a form satisfactory to Great-West. When Great-West requires it, the Certificate Owner will obtain the signature of the Covered Person(s) on forms provided by Great-West. Great-West must first approve any written materials
developed by any other person describing the Group Contract or the Certificate. 
 12.08 DISCLAIMER 

Nothing contained in the Certificate shall be construed to be tax or legal advice, and Great-West assumes no responsibility or liability for any costs,
including but not limited to taxes, penalties or interest incurred by the Investment Option, the Group Contractholder, any GLWB Elector, Covered Person(s) or any other person, if applicable, arising out of a determination of liability. Great-West
shall not be held liable for the negligence, willful misconduct, or failure to perform of any third party. 
 12.09 REPRESENTATIONS

 Great-West shall be entitled to rely and act solely on the reports, directions, proofs, notices, elections, and other information
furnished to it by the Group Contractholder or its agent, GLWB Electors, Covered Persons, Beneficiaries or their respective agents, and such acts shall be conclusive and binding as to all GLWB Electors and other persons or corporations claiming an
interest hereunder. 
 12.10 NON-WAIVER 
 Great-West may, in its sole discretion, elect not to exercise a right, privilege, or option under the Group Contract or the Certificate. Such election shall not constitute a waiver of the right to
exercise such right, privilege, or option at any subsequent time, nor shall it constitute a waiver of any provision of the Group Contract or the Certificate. 
 12.11 APPLICABLE TAX 
 An Applicable Tax may be assessed on the Covered Fund Value or any
Distribution, based on applicable state law during the term of the Group Contract or the Certificate. 
 12.12 INFORMATION 

The Certificate Owner shall furnish all information that Great-West may reasonably require for the administration of the Group Contract or the
Certificate. Great-West shall not be responsible for any obligation under the Group Contract or the Certificate until it receives all requested information in a form acceptable to Great-West. 

  
 15 

 SECTION 13: ANNUITY PAYMENT OPTIONS 

 
  

13.01 EFFECT OF ANNUITIZATION 
 If the
GLWB Elector elects to annuitize, prior to the Initial Installment Date, the GLWB will terminate for those Covered Fund assets and all previously incurred fees will not be refunded. 
 13.02 ANNUITY PAYMENT OPTIONS 
 The amount to be applied to an annuity payment option is:
(i) the portion of the Account value elected by GLWB Elector, less (ii) Applicable Tax, if any, less (iii) any fees and charges described in the Certificate. 
 The minimum amount that may be applied under the elected annuity option is $[5,000]. If any payments to be made under the elected annuity payment option will be less than $[50], Great-West may make the
payments in the most frequent interval that produces a payment of at least $[50]. 
 Great-West will issue a certificate or other statement
setting forth in substance the benefits, rights, and privileges to which such person is entitled under the Group Contract, to each Annuitant describing the benefits payable under the elected annuity payment option. 

13.03 ELECTION OF ANNUITY OPTIONS 
 An
Annuitant is required to elect an annuity payment option. The Annuitant must Request an annuity payment option or change an annuity payment option no later than 30 days prior to the Annuity Commencement Date elected by the GLWB Elector. 

The annuity payment options are: 
 Income for
Single Life Only 
 Income for Single Life with Guaranteed Period 
 Income for Joint Life Only 
 Income for Joint Life with Guaranteed Period 

Income for a Specific Period 
 Any other form
of annuity payment permitted under the law, if acceptable to Great-West. 
 The annuity option that will always be available is the Income for
Single Life Only Annuity. If this annuity option is elected, Great-West will make payments to the Annuitant at a frequency specified in the annuity certificate or other statement for the duration of the Annuitant’s lifetime. Payments will cease
pursuant to the terms of the certificate or other statement. 
 Annuity purchase rates will be the same rates that are available for a Single
Premium Immediate Annuity currently offered by Great-West at the time of annuitization. 
 SECTION 14: MISSTATEMENT OF AGE OR DEATH

  
  

Great-West may require adequate proof of the age and death of the Annuitant, GLWB Elector or Covered Person(s) before processing a Request for GAWs and
annuity payments. If the age of the Annuitant, GLWB Elector or Covered Person(s) has been misstated, the Installment or annuity payment established for him or her will be made on the basis or his or her correct age. 

If Installments or annuity payments made were too large because of a misstatement of age, Great-West may deduct the difference from the next payment or
payments with interest. If payments were too small, Great-West may add the difference to the next payment with interest. Any interest payable will be made at the rate required by law. 

  
 16Form of IRA Endorsement

 Exhibit 4.2 
 INDIVIDUAL RETIREMENT ACCOUNT ENDORSEMENT 
  

ENDORSEMENT ISSUED BY GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY AS PART OF THE CERTIFICATE TO WHICH IT IS ATTACHED. THE EFFECTIVE DATE OF THIS
ENDORSEMENT IS THE SAME AS THE ISSUE DATE OF THE CERTIFICATE. IN THE CASE OF A CONFLICT WITH ANY PROVISION IN THE CERTIFICATE, THE PROVISIONS OF THIS ENDORSEMENT WILL CONTROL. 
 This Endorsement will be issued to the Certificate Owner when the Investment Portfolio purchased in connection with the Certificate is an Individual Retirement Account (“IRA”). For purposes of
this Endorsement, an IRA is defined as the traditional, Roth or other Individual Retirement Account, if applicable, established for the Certificate Owner and the Certificate Owner’s Beneficiaries, for which a Certificate is issued. 

The Certificate is amended as follows: 
  

	(1)	The Annuitant will at all times be the Owner of the Certificate. 

  

	(2)	The entire interest of the Certificate Owner is nonforfeitable. 

  

	(3)	The Certificate is established for the exclusive benefit of the Certificate Owner and the Beneficiary. 

 

	(4)	No joint Certificate Owner may be named. Any provision of the Certificate that would allow joint ownership or that allow more than one person to share distributions is
deleted. 

  

	(5)	This Certificate is nontransferable. The Certificate Owner may not borrow any money under the Certificate or pledge the account or any portion of it as security for a
loan. Additionally, the Certificate Owner may not sell, assign or transfer this Certificate, except as provided in Section (6). 

  

	(6)	Divorce or Separation Decree. 

  

	 	(a)	Definitions. 

 Alternate
Payee – Any spouse or former spouse of a Certificate Owner who is recognized by a Decree as having a right to receive all or a portion of the benefit payable under the Investment Account with respect to such Certificate Owner. 

Decree – A divorce or separation instrument, as defined in Section 71(b)(2) of the Code, that creates or recognizes the
existence of an Alternate Payee’s right to, or assigns to an Alternate Payee the right to receive all or a portion of the benefits payable with respect to a GLWB Elector that is accepted and approved by Great-West, except as otherwise agreed.

 GLWB Elector – A Certificate Owner, Alternate Payee or Beneficiary who is: (i) eligible to elect the GLWB;
(ii) invested in Covered Fund(s) pursuant to the Covered Fund prospectus; and (iii) a Covered Person. 
  

	 	(b)	DECREE RECEIVED DURING ACCUMULATION PHASE 

 Pursuant to Section 408(d)(6) of the Code and the regulations thereunder, Great-West will make payment to the Alternate Payee and/or establish an Account on behalf of the Alternate Payee named in a
Decree received during the Accumulation Phase. The Alternate Payee shall be responsible for submitting a Request to begin Distributions in accordance with the Code. 
 If the Alternate Payee named in the Decree is the GLWB Elector’s spouse during the Accumulation Phase, he or she may elect to become a GLWB Elector, either by maintaining the current Benefit Base of
the previous GLWB Elector, divided pursuant to the terms of the Decree, or establishing a new Benefit Base based on the current Covered Fund Value on the date his or her Account is established and he or she will continue as a GLWB Elector. If the
Alternate Payee elects to maintain the current Benefit Base, the Benefit Base will be divided between the GLWB Elector and the Alternate Payee in the same proportion as their respective Covered Fund Values

  

			
	 	 	1

 
pursuant to the terms of the Decree In either situation, the Alternate Payee’s Certificate Election Date shall be the date the Account is established. 

A non-spouse Alternate Payee cannot elect to maintain the current Benefit Base, or proportionate share, but may elect to establish a new
GLWB. The Benefit Base and Certificate Election Date will be based on the current Covered Fund Value on the date his or her Account is established. 
 To the extent that the Alternate Payee becomes a GLWB Elector, she or he will be subject to all terms and conditions of the Certificate. 

Any election made by the Alternate Payee pursuant to this section is irrevocable. 

 

	 	(c)	DECREE RECEIVED DURING WITHDRAWAL PHASE 

 Pursuant to Section 408(d)(6) of the Code and the regulations thereunder, Great-West will make payment to the Alternate Payee and/or establish an Account on behalf of the Alternate Payee named in a
Decree approved during the Withdrawal Phase. The Alternate Payee shall be responsible for submitting a Request to begin Distributions in accordance with the Code. 
 Pursuant to the instructions in the Decree, if there is a single Covered Person, the Benefit Base and GAW will be divided in the same proportion as their respective Covered Fund Values as of the effective
date of the Decree. The GLWB Elector may continue to receive the proportional GAWs after the accounts are split. If the Alternate Payee is the GLWB Elector’s spouse, he or she may elect to receive his or her portion of the Covered Fund Value as
a lump sum Distribution or can separately elect to become a GLWB Elector pursuant to the provisions of Section 5.08. 

Pursuant to the instructions in the Decree, if there are two Covered Persons, the Benefit Base and GAW will be divided in the same
proportion as their respective Covered Fund Values as of the effective date of the Decree. The GLWB Elector may continue to receive the proportional GAWs after the accounts are split, based on the amounts calculated pursuant to the joint Covered
Person GAW%. If the Alternate Payee is the GLWB Elector’s spouse, he or she may elect to receive his or her portion of the Covered Fund Value as a lump sum Distribution or can separately elect to continue proportionate GAWs in the Withdrawal
Phase based on the amounts calculated pursuant to the joint Covered Persons GAW% in Section 5.01 after the accounts are split. A new Installment Anniversary Date will be established for the Alternate Payee on the date the Accounts are split.

 In the alternative, the Alternate Payee may establish a new GLWB in the Accumulation Phase with the Benefit Base based on the
current Covered Fund Value on the date his or her Account is established. 
 To the extent that the Alternate Payee becomes a
GLWB Elector, he or she will be subject to all terms and conditions of the Certificate, the terms of the IRA and the Code. 
 Any
election made by the Alternate Payee pursuant to this section is irrevocable. 
  

	 	(d)	DECREE RECEIVED DURING SETTLEMENT PHASE 

 If a Request in connection with a Decree is approved during the Settlement Phase, Great-West will divide the Installment pursuant to the terms of the Decree. Installments will continue pursuant to the
lives of each payee. 
  

	(7)	Death of the Covered Person. 

  

	 	(a)	DEATH DURING ACCUMULATION PHASE 

If a GLWB Elector dies before the Initial Installment Date, the GLWB will terminate and the Covered Fund Value shall be paid to the
Beneficiary in accordance with the terms of the Investment Portfolio (unless an election is made by a spouse Beneficiary as provided in this section). A spouse Beneficiary may elect to become a new GLWB Elector and maintain the deceased GLWB
Elector’s 

  

			
	 	 	2

 
current Benefit Base (or proportionate share if multiple Beneficiaries) as of the date of death. A spouse Beneficiary also has the option to establish a new Account with a new Benefit Base based
on the current Covered Fund Value on the date the Account is established. In either situation, the spouse Beneficiary shall become a GLWB Elector and the Ratchet Date will be the date when his or her Account is established. 

A non-spouse Beneficiary cannot elect to maintain the current Benefit Base but may elect to establish a new GLWB. The Benefit Base and
Certificate Election Date will be based on the current Covered Fund Value on the date his or her Account is established. 
 To
the extent that the Beneficiary becomes a GLWB Elector, he or she will be subject to all terms and conditions of the Certificate, Investment Portfolio and the Code, if applicable. 

Any election made by Beneficiary pursuant to this section is irrevocable. 

 

	 	(b)	DEATH DURING WITHDRAWAL PHASE 

If a GLWB Elector Dies After the Initial Installment Date as a Single Covered Person 

If the GLWB Elector dies after the Initial Installment date without a second Covered Person, the GLWB will terminate and no further
Installments will be paid. If the death occurs before the Settlement Phase, the remaining Covered Fund Value shall be distributed to the Beneficiary in accordance with the terms of the Investment Portfolio. If permitted by the Investment Portfolio
and the Code, if applicable, the GLWB Elector’s Beneficiary may elect to become a GLWB Elector in which event an initial Benefit Base shall be established and he or she will be subject to all terms and conditions of the Certificate, the
Investment Portfolio and the Code, if applicable. Any election made by the Beneficiary is irrevocable. 
 If a GLWB Elector
Dies After the Initial Installment Date while Second Covered Person is Living 
 Upon the death of an GLWB Elector after the
Initial Installment Date, and while the second Covered Person is still living, the second Covered Person/Beneficiary may elect to become a GLWB Elector (if permitted by the terms of the Investment Portfolio and the Code, if applicable) and he or she
will acquire all rights under the Certificate and continue to receive GAWs based on the original GLWB Elector’s election. Installments may continue to be paid to the surviving Covered Person based on the GAW% for Joint Covered Persons in
Section 5.01. Installments will continue to be paid to the surviving Covered Person until his or her death and, upon death, the surviving Covered Person’s beneficiary will receive any remaining Covered Fund Value. Alternatively, he or she
may elect to receive his or her portion of the Covered Fund Value as a lump sum Distribution or can separately elect to become a GLWB Elector pursuant to the provisions of Section 4.06. In either situation the Ratchet Date will be the date when
the Account is established. 
 To the extent to that the Beneficiary becomes a GLWB Elector, he or she will be subject to all
terms and conditions of the Certificate, the Investment Portfolio and the Code, if applicable. 
 Any election made by the
Beneficiary pursuant to this section is irrevocable. 
  

	(8)	Except in the case of a “rollover contribution” as permitted by sections 402(c), 402(e)(6), 403(a)(4), 403(b)(8) 403(b)(10) 408(d)(3) or 457(e)(16) of the
Code or a contribution made in accordance with the terms of a Simplified Employee Pension (SEP), as described in § 408(k), no Contributions will be accepted unless they are in cash, and the total of such Contributions shall not exceed the
maximum as Section 219(b)(5)(A) of the Code may allow, for any taxable year, regardless of whether such Contributions are deductible by the Certificate Owner under Section 219(b)(5) of the Code. 

In the case of an individual who is age 50 or older, the annual cash Contribution limit is increased by the amount as
Section 219(5)(B) of the Code may allow for any taxable year. 
 The Certificate Owner shall have the sole responsibility
for determining whether any premium payment meets applicable income tax requirements. 

  

			
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	(9)	Required Minimum Distributions (“RMDs”) made under the Certificate will only be made in a manner consistent with the required minimum distribution or other
provisions of the Code. It is the responsibility of the GLWB Elector, Alternate Payee, or Beneficiary, as applicable, to Request payments in accordance with the distribution requirements of the Code. Great-West is not responsible for any penalties
resulting from a failure to Request timely payments in the proper amount. 

 Any RMD during the Accumulation Phase
shall be considered an Excess Withdrawal. 
 During the Withdrawal Phase, RMDs are not Excess Withdrawals if the Distribution
made under the IRA causes the total Distributions to exceed GAW amount. The Benefit Base will not be reduced for a RMD Installment to the extent that the RMD Amount is attributable to the Covered Fund.  

The Certificate Owner should consult a tax advisor regarding withdrawals to satisfy his or her RMD amount. 

 

	(10)	Distributions Before Death 

 Notwithstanding any provision of the Certificate or this Endorsement to the contrary, the distribution of the individual’s interest in the IRA shall be made in accordance with the requirements of
Section 408(b)(3) of the Code and the regulations thereunder, the provisions of which are incorporated herein by reference. The Certificate Owner’s entire interest in the Certificate must be distributed, or begin to be distributed, by the
Certificate Owner’s required beginning date, which is the April 1 following the calendar year in which the Certificate Owner reaches age
70 1/2. For each succeeding year, a distribution
must be made on or before December 31. By the required beginning date, the Certificate Owner may elect to have the balance in the Certificate distributed in one of the following forms: 

 

	 	(a)	a single sum payment; 

  

	 	(b)	equal or substantially equal payments no less frequently than annually over the life of the Certificate Owner; 

 

	 	(c)	equal or substantially equal payments no less frequently than annually over the lives of the Certificate Owner and his or her designated Beneficiary;

  

	 	(d)	equal or substantially equal payments no less frequently than annually over a specified period that may not be longer than the Certificate Owner’s life expectancy;

  

	 	(e)	equal or substantially equal payments no less frequently than annually over a specified period that may not be longer than the joint life and last survivor expectancy
of the Certificate Owner and his or her designated Beneficiary. 

 All distributions made hereunder shall be made
in accordance with section 401(a)(9) of the Code, including the incidental death benefit requirements of section 401(a)(9)(G) of the Code, and the regulations thereunder, including the minimum distribution incidental benefit requirement of Q&A 1
of section 1.401(a)(9)-5 of the regulations. 
 If payment is not to be made in the form of periodic annuity payments on an
irrevocable basis (except for acceleration), the amount to be distributed each year, beginning with the first calendar year for which distributions are required and then for each succeeding calendar year shall be determined under Q&A 12 of
Section 1.401(a)(9)-6 of the regulations. 
  

	(11)	Distribution Upon Death 

  

	 	(a)	Distributions beginning before death. If the Certificate Owner dies after distribution of his or her interest has begun, the remaining portion of such interest will
continue to be distributed at least as rapidly as under the method of distribution being used prior to the individual’s death. 

  

	 	(b)	Distributions beginning after death. If the Certificate Owner dies before distribution of his or her interest begins, distribution of the individual’s entire
interest shall be completed by December 31 of the calendar year containing the fifth anniversary of the individual’s death except to the extent that an election is made to receive distribution in accordance with (1) or (2) below:

  

	 	(1)	 If the Certificate Owner’s interest is payable to a designated Beneficiary, then the entire interest of the individual may be distributed in equal
or substantially equal payments over the life or over a period certain not greater than the life expectancy of the designated Beneficiary commencing 

  

			
	 	 	4

	 	
on or before December 31 of the calendar year immediately following the calendar year in which the Certificate Owner died. 

 

	 	(2)	If the Certificate Owner’s spouse is not the named Beneficiary, the method of distribution selected will assure that at least 50% of the present value of the
amount available for distribution is paid within the Certificate Owner’s life expectancy and that such method of distribution complies with the requirements of Code section 408(b)(3) and the regulations thereunder. 

 

	 	(3)	 If the designated Beneficiary is the Certificate Owner’s surviving spouse, the date distributions are required to begin in accordance with
(1) above shall not be earlier than the later of (A) December 31 of the calendar year immediately following the calendar year in which the individual died or (B) December 31 of the calendar year in which the individual would
have attained age 70 1/2.

  

	 	(4)	If the designated Beneficiary is the Certificate Owner’s surviving spouse, the spouse may treat the Certificate as his or her own IRA. This election will be deemed
to have been made if such surviving spouse makes a regular IRA contribution to the Certificate, makes a rollover to or from such Certificate, or fails to elect any of the above provisions. 

Life expectancy is computed by use of the Single Life Table in Q&A 1 of Section 1.401(a)(9)-9 of the regulations. If
distributions are being made to a surviving spouse as the sole designated Beneficiary, such spouse’s remaining life expectancy for a year is the number in the Single Life Table corresponding to such spouse’s age in each year after the
calendar year of the Certificate Owner’s death. In all other cases, remaining life expectancy for a year is the number in the Single Life Table corresponding to the Beneficiary’s age in the year following the calendar year of the
individual’s death and reduced by 1 for each subsequent year. 
  

	(12)	Separate records will be maintained for the interest of each individual. The Company will furnish an annual calendar year report on the status of the Certificate and
such information concerning required minimum distributions as is prescribed by the Commissioner of Internal Revenue. 

  

	(13)	The Company reserves the right to amend this Endorsement at any time in order to comply with the Code and the regulations thereunder. Any such changes will be subject
to the prior approval of the appropriate state department of insurance, if applicable. 

  

			
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