Document:

EX-4.2

 Exhibit 4.2 

 

					
	USPS First Class Mail Address:	  		  	[1786 ]
	 [ 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.

	  	  
	  	  
	  		  
	  		  
	  		  
	  		  
	  	[Marketing Name]	  

					
	
	INDIVIDUAL SINGLE PREMIUM INDEX LINKED ANNUITY
	 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.

 

									
	Qualified:	  	 ☐ Traditional IRA
	  	 ☐ Roth IRA
	  	 ☐ Inherited Traditional IRA     ☐ Inherited Roth IRA
	  	
	      or	  		  		  		  	
	Non-Qualified:	  	 ☐ Individual
	  	 ☐ Joint
	  	 ☐
Trust             [ ☐ Non-Qualified Inherited IRA    
]
	  	
	       or
	  		  		  		  	
	[ Custodial:	  	 ☐ ]

 
	  		  		  	

											
	  

  SECTION 2: OWNERSHIP INFORMATION

 

	 A. Primary Owner
  
	  		  	
	  

☐ 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)
	  		  	Email Address
	 		 
	 	  		  	 
	  
 Street Address
	  		  	  
  
  

City                           
      State                         Zip Code

	 	 	 
	 	  	 	  	 
	  
 Street Address (Line 2)
	  		  	
	 	 	 
	 	  	 	  	 

  

  

			
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  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)
	  		  	Email Address
	 		 
	 	  		  	 
	  
 Street Address
	  		  	  
  
  

City                           
      State                         Zip Code

	 	 	 
	 	  	 	  	 
	  
 Street Address (Line 2)
	  		  	
	 	 	 
	 	  	 	  	 

											
	 C. Primary Annuitant
  
	  		  	
	 ☐ Annuitant is the same as Owner

 
	  		  	
	  

☐ Male
	  	SSN/TIN	  		  	  
 Date of Birth (mm/dd/yyyy)
	  		  	  
 Phone Number

	 ☐ Female
	  	 	  		  	 	  		  	 
		  	 	  		  	 	  		  	 
	 First Name
	  		  		  	 Middle Name
	  		  	 Last Name

	 		 		 
	 	  		  	 	  		  	 
		  		  		  		  		  	

			
	Email Address	  	
	 	  	
	 	  	
	  
 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: ☐
  

		 	

 

  

			
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  SECTION 2: OWNERSHIP INFORMATION
(CONTINUED)
  
	  	  
 [1786 ]

	   D. Joint Annuitant

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

☐ Male
	  	SSN/TIN	  		  	  
 Date of Birth (mm/dd/yyyy)
	  		  	  
 Phone Number
	  	
	 ☐ Female
	  	 	  		  	 	  		  	 	  	 
		  	 	  		  	 	  		  	 	  	 
	  
 First Name
	  		  		  	  
 Middle Name
	  		  	  
 Last Name
	  	
	 		 		 	 
	 	  		  	 	  		  	 	  	 
		  		  		  		  		  		  	

			
	Email Address	  	
	 	  	
	 	  	
	  
 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
  
	  		  		 	
		  	SSN/TIN	  		  	  
 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
  
	  		  		 	
		  	SSN/TIN	  		  	  
 Birth/Trust Date (mm/dd/yyyy)
	  		  	  
 Relationship
	  		  	  
 Percentage (no fractionals)
	 	
		  	 	  		  	 	  		  	 	  		  	 	 	
		  	 	  		  	 	  		  	 	  		  	 	 	

															
	  
 First Name
	  		  		  	  
 Middle Name
	  		  	  
 Last Name
	  		  	  
 Phone Number

	 	 	 	 	 	 	 
	 	  	 	  	 	  	 	  	 	  	 	  	 

			
	  
 Street Address
	  	  

City                         
                       State                  
                          Zip Code

	 	  	 
	 	  	 

 

  

			
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  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
  
	  		  		 	
		  	SSN/TIN	  		  	  
 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
  
	  		  		 	
		  	SSN/TIN	  		  	  
 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:  
	  	 	  	Minimum Purchase Payment: [ $10,000 ]
		  	 	  	

  

													
	  
   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:
	 	 	  	
		  	 	  		 	 	  	

  

					
	☐ Check is attached for a new IRA for tax year(s):	 	 	  	
		 	 	  	

  

													
	  
   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

 

  

			
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	SECTION 5: STRATEGIES	 	 [1786 ]

	 A.
Please select an Index/Indices and Crediting Factor(s) - Total allocation must equal the 100% of the Purchase Payment
  

	 	 		 		 		 		 				 		 		 		 	 
	 	 	 For internal use
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Allocation (%)	 	 
	 	 							 	 
	 	 	     [ S&P 500 0
	 	 ]        
	 	[ S&P 500® Index: 	 	]	 	 	            [	 	 	 0% Floor	 	 ]        
	 	                             
       %    	 	 
	 	 	     [ S&P 500 -2.5
	 	 ]
	 	[ S&P 500® Index: 	 	]	 	 	            [	 	 	-2.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ S&P 500 -5.0
	 	 ]
	 	[ S&P 500® Index: 	 	]	 	 	            [	 	 	-5.0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ S&P 500 -7.5
	 	 ]
	 	[ S&P 500® Index: 	 	]	 	 	            [	 	 	.-7.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ S&P 500 -10
	 	 ]
	 	[ S&P 500® Index: 	 	]	 	 	            [	 	 	-10% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ S&P 500 -10b
	 	 ]
	 	[ S&P 500® Index: 	 	]	 	 	            [	 	 	-10% Buffer	 	 ]
	 	                             
       %    	 	 
	 	 							 	 
	 	 	     [ MSCI EAFE 0
	 	 ]
	 	[ MSCI EAFE Index:	 	]	 	 	            [	 	 	0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ MSCI EAFE -2.5
	 	 ]
	 	[ MSCI EAFE Index:	 	]	 	 	            [	 	 	-2.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ MSCI EAFE -5.0
	 	 ]
	 	[ MSCI EAFE Index:	 	]	 	 	            [	 	 	-5.0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ MSCI EAFE -7.5
	 	 ]
	 	[ MSCI EAFE Index:	 	]	 	 	            [	 	 	.-7.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ MSCI EAFE -10
	 	 ]
	 	[ MSCI EAFE Index:	 	]	 	 	            [	 	 	-10% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ MSCI EAFE -10b
	 	 ]
	 	[ MSCI EAFE Index:	 	]	 	 	            [	 	 	-10% Buffer	 	 ]
	 	                             
       %    	 	 
	 	 							 	 
	 	 	     [ Russell 2000 0
	 	 ]
	 	[ Russell 2000® Index:	 	]	 	 	            [	 	 	0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Russell 2000 -2.5
	 	 ]
	 	[ Russell 2000® Index:	 	]	 	 	            [	 	 	-2.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Russell 2000 -5.0
	 	 ]
	 	[ Russell 2000® Index:	 	]	 	 	            [	 	 	-5.0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Russell 2000 -7.5
	 	 ]
	 	[ Russell 2000® Index:	 	]	 	 	            [	 	 	.-7.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Russell 2000 -10
	 	 ]
	 	[ Russell 2000® Index:	 	]	 	 	            [	 	 	-10% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Russell 2000 -10b
	 	 ]
	 	[ Russell 2000® Index:	 	]	 	 	            [	 	 	-10% Buffer	 	 ]
	 	                             
       %    	 	 
	 	 							 	 
	 	 	     [ NASDAQ 0
	 	 ]
	 	[ NASDAQ-100® Index:	 	]	 	 	            [	 	 	0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ NASDAQ -2.5
	 	 ]
	 	[ NASDAQ-100® Index:	 	]	 	 	            [	 	 	-2.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ NASDAQ -5.0
	 	 ]
	 	[ NASDAQ-100® Index:	 	]	 	 	            [	 	 	-5.0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ NASDAQ -7.5
	 	 ]
	 	[ NASDAQ-100® Index:	 	]	 	 	            [	 	 	.-7.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ NASDAQ -10
	 	 ]
	 	[ NASDAQ-100® Index:	 	]	 	 	            [	 	 	-10% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ NASDAQ -10b
	 	 ]
	 	[ NASDAQ-100® Index:	 	]	 	 	            [	 	 	-10% Buffer	 	 ]
	 	                             
       %    	 	 
	 	 							 	 
	 	 	     [ Custom Index 0
	 	 ]
	 	[ Custom Index:	 	]	 	 	            [	 	 	0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Custom Index -2.5
	 	 ]
	 	[ Custom Index:	 	]	 	 	            [	 	 	-2.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Custom Index -5.0
	 	 ]
	 	[ Custom Index:	 	]	 	 	            [	 	 	-5.0% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Custom Index -7.5
	 	 ]
	 	[ Custom Index:	 	]	 	 	            [	 	 	.-7.5% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Custom Index -10
	 	 ]
	 	[ Custom Index:	 	]	 	 	            [	 	 	-10% Floor	 	 ]
	 	                             
       %    	 	 
	 	 	     [ Custom Index -10b
	 	 ]
	 	[ Custom Index:	 	]	 	 	            [	 	 	-10% Buffer	 	 ]
	 	                             
       %    	 	 
	 	 				 	 
	 	 	 	 	 	 	  

Total (must equal 100%):
  
	 	 	 	
                         
           %    
  
	 	 
	 	 		 		 		 		 				 		 		 		 	 
	 
	B. Rebalancer Option
	 
	Do you elect to automatically rebalance the percentage allocations among
Strategies?                                 
☐  Yes        ☐  No
	 
	
The percentage allocation rebalancer will be triggered on each Strategy Term Start Date and based on the most recent allocations elected. The amount
allocated to each Strategy will increase or decrease at different rates depending on the investment experience and structure of each Strategy including applicable Caps, Floors and Buffers. Please see the Contract for additional details. This option
can be cancelled at any time by contacting the [Retirement Resource Operations Center (RROC)].
  

  

			
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	 	 	 	 	 	 	 	[1786]	 
	  

[S&P 500® Price Index-*The Standard & Poor’s 500 Composite
Stock Price Index (S&P 500). “Standard & Poor’s®”, “S&P®”, “S&P 500®”, “Standard & Poor’s 500®” are trademarks of the McGraw-Hill Companies, Inc. and have been licensed for use by
Great-West Life & Annuity Insurance Company. This Product is not sponsored, endorsed, sold or promoted by Standard & Poor’s and Standard & Poor’s makes no representation regarding the advisability of investing in
the Product. The S&P 500 Index does not include dividends paid by the underlying companies.]
  

[MSCI EAFE Price Index - The MSCI EAFE Price Return Index is a free float-adjusted market capitalization index that is designed to
measure the equity market performance of developed markets, excluding the US and Canada. As of the date of this prospectus, the MSCI EAFE consists of the following 21 developed market country indices: Australia, Austria, Belgium, Denmark, Finland,
France, Germany, Hong Kong, Ireland, Israel, Italy, Japan, the Netherlands, New Zealand, Norway, Portugal, Singapore, Spain, Sweden, Switzerland, and the United Kingdom. The MSCI EAFE Price Return Index does not include dividends declared by any of
the companies included in this Index.]
  
 [The
Russell 2000® Price Return Index (the “Index”) is a trademark of Frank Russell Company (“Russell”) and have been licensed for use by Great-West Life & Annuity
Insurance Company. “The [Great-West Capital Market ProtectorTM Select-Advisor] is/are not in any way sponsored, endorsed, sold or promoted by Russell or the London Stock Exchange Group
companies (“LSEG”) (together the “Licensor Parties”) and none of the Licensor Parties make any claim, prediction, warranty or representation whatsoever, expressly or impliedly, either as to (i) the results to be obtained
from the use of the Index (upon which the [Great-West Capital Market ProtectorTM Select-Advisor] is based), (ii) the figure at which the Index is said to stand at any particular time on any
particular day or otherwise, or (iii) the suitability of the Index for the purpose to which it is being put in connection with the [Great-West Capital Market ProtectorTM Select-Advisor]. None
of the Licensor Parties have provided or will provide any financial or investment advice or recommendation in relation to the Index to Great-West Life & Annuity Insurance Company or to its clients. The Index is calculated by Russell or its
agent. None of the Licensor Parties shall be (a) liable (whether in negligence or otherwise) to any person for any error in the Index or (b) under any obligation to advise any person of any error therein.]

 
 [NASDAQ-100® Price Index - The NASDAQ-100 Price Return Index® includes 100 of the largest domestic and international non-financial securities listed on
The Nasdaq Stock Market based on market capitalization. The Index reflects companies across major industry groups including computer hardware and software, telecommunications, retail/wholesale trade and biotechnology. It does not contain securities
of financial companies including investment companies. The NASDAQ-100 Price Return Index® does not include dividends declared by any of the companies included in this Index.]

 
 [Custom Index - This section reserved for Custom
Index text / disclosure]
  
	 
  
 
  

  
 

 
 
  

	SECTION 6: THIRD PARTY
AUTHORIZATION	 
	 		 
	    Do you consent to Third Party Authorization?	 	 	☐  YES	 	 	 	☐  NO	 
	  

This consent will remain in effect until the authorization is revoked by contacting the [Retirement Resource Operation Center
(RROC)]. If no election is made, [RROC] will default to “NO.”
  

By selecting “YES,” I (we) authorize Great-West Life & Annuity Insurance Company to provide information related to
the policy to the Producer listed in Section 10. This may include my personal and policy information, including but not limited to Social Security Number (SSN),Tax Identification Number (TIN), account values and interest rates, as applicable.
Information provided by Great-West Life & Annuity Insurance Company to the Producer listed in Section 10 is no longer subject to the Great-West Life & Annuity Insurance Company privacy and information security policies and
procedures. Policy Owner(s) acknowledge that Great-West Life & Annuity Insurance Company is not responsible for any breach or unauthorized dissemination of personally identifiable or financial information after it is transmitted to any
authorized third party.
  
 Great-West
Life & Annuity Insurance Company is authorized to accept the following instructions from or provide the following information to the Producer listed in Section 10:

 
 The allocation and transfer of amounts in or among
the Index Option(s) when such allocations and transfers are allowed, updating or changing mailing addresses and/or phone numbers, and providing electronic copies of confirmations and statements.

 
	 

 
 

 
 

 
 

 
 

	SECTION 7: REPLACEMENT	 
	 		 
	    Do you have any life insurance or annuity contracts in force?	 	 	☐  YES	 	 	 	☐  NO	 
	 		 
	
    Will the purchase of this annuity result in the replacement, termination, or change in value of any
existing life insurance or annuity contract(s)?
  
	 	   
	☐   YES 
	   
	 	   
	☐   NO 
	   

  

			
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	  SECTION 8: ELECTRONIC DELIVERY 	  	 	[1786 ]	 
			
	     Do you consent to Electronic Delivery?.
	  	☐  YES	  	 	☐  NO    	 

 Subject to Great-West Life & Annuity Insurance Company’s ability, I
authorize that all statements, prospectuses, reports, and other documents be provided to me in an electronic format. The owner may revoke this authorization at any time by contacting the [Retirement Resource Operations Center (RROC)]. By providing
an email address, I am confirming that I have access to the Internet for purposes of accepting electronic delivery. 
     Email Address 

					
		 	 	  	

 This consent will remain in effect until I revoke my authorization by contacting the
[Retirement Resource Operation Center (RROC)]. I may request a paper copy of the information provided electronically at any time for no charge. I will provide the [Retirement Resource Operation Center (RROC)] a current e-mail address if my e-mail
address changes. 
  

			
	SECTION 9: CLIENT SIGNATURES

 I understand that I am applying for a Single Premium Annuity contract, issued by
Great-West Life & Annuity Insurance Company. I declare that all statements made on this application are true to the best of my knowledge and belief. 
  

	 	☐	 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. 

 I hereby
direct that my telephone instructions to the [Retirement Resource Operation Center (RROC)] and/or those I submit via any Internet site and/or e-mail address as identified in the prospectus, be honored for transactions unless otherwise notified by me
in writing. I understand that telephone calls may be recorded to monitor the quality of service I receive and to verify contract transaction information. The [Retirement Resource Operation Center (RROC)] will use reasonable procedures to confirm
that instructions communicated by telephone or electronically are genuine. If such procedures are followed, Great-West Life & Annuity Insurance Company will not be liable for any losses due to unauthorized or fraudulent instructions. If a
transfer from my brokerage account is indicated in this application, I authorize my broker to transfer the amount specified. I certify under penalty of perjury that the taxpayer identification numbers listed on this application are correct and that
I am not subject to backup withholding. The Internal Revenue Service does not require my consent to any provision of this document other than the certifications required to avoid backup withholding. 

FRAUD WARNING 

[Alabama:] [Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.]  

[Colorado:] [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. ] 
 [District of
Columbia:] [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 is guilty of a crime and may be subject to fines and confinement
in prison.]  
 [Florida] Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. 

[Maine:] 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 subject to fines and confinement in prison, and denial of insurance benefits, depending on state law.] 

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

[New Jersey:] [Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.] 
 [Ohio:] [Any person who, with intent to defraud or
knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.] 

[Pennsylvania:] [Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or a 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
subjects such person to criminal and civil penalties.] 
  

  

  

			
	 ILAapp-RIA-Core
	  	(07/17)        Page 7 of 8

  

			
		  	[1786] 

 All other states: [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 subject to fines and confinement in prison, and denial of insurance benefits, depending on state
law.] 
 I acknowledge receipt of the prospectus for the annuity contract. I understand that amounts allocated to a
Strategy(ies) and are not guaranteed as to dollar amount. I understand that amounts payable under this contract may be subject to a market value adjustment. 
  

													
		 	Print Name of Contract Owner	 		 	Signature of Contract Owner	 		 	Date Signed (mm/dd/yyyy)	 	
		 	 	 		 	 	 		 	 	 	
		 		 		 		 		 		 	
		 	Print Name of Joint Contract Owner	 		 	Signature of Joint Contract Owner	 		 	Date Signed (mm/dd/yyyy)	 	
		 	 	 		 	 	 		 	 	 	

  

					
	 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
	 		 	Date Signed (mm/dd/yyyy)	 		 		 	
		 	 	 		 	 	 		 	 	 		 	%	 	
		 		 		 		 		 		 		 		 	
		 	 License Number
	 		 		 		 		 		 		 	
		 	 	 		 		 		 		 		 		 	

 If more than one Producer is selecting a Comp Option, please provide name and percentage
for each. Total percentage must equal 100%. 
  

																	
		 	Producer Printed Name #2	 		 	Producer Signature #2	 		 	Date Signed (mm/dd/yyyy)	 		 		 	
		 	 	 		 	 	 		 	 	 		 	%	 	
		 		 		 		 		 		 		 		 	
		 	Producer Printed Name #3	 		 	Producer Signature #3	 		 	Date Signed (mm/dd/yyyy)	 		 		 	
		 	 	 		 	 	 		 	 	 		 	%	 	

  

									
		 	Client Brokerage Account	 		 	Broker/Dealer Name	  	
		 	 	 		 	 	  	

  

  

			
	 ILAapp-RIA-Core
	  	(07/17)        Page 8 of 8Exhibit

Exhibit 10.1
EXECUTION VERSION

AMENDMENT NO. 8 TO INTERIM ASSESSMENT AGREEMENT
This eighth amendment (this “Amendment”) to the Interim Assessment Agreement dated as of March 29, 2017 (as amended, the “Interim Assessment Agreement”),1 by and among Georgia Power Company, for itself and as agent for Oglethorpe Power Corporation, Municipal Electric Authority of Georgia and The City of Dalton, Georgia, acting by and through its Board of Water, Light and Sinking Fund Commissioners (collectively, “GPC”), and Westinghouse Electric Company LLC, WECTEC Staffing Services LLC, and WECTEC Global Project Services, Inc. f/k/a Stone and Webster (collectively, the “Debtors” and, together with GPC, the “Parties”), is entered into as of the 20th day of July, 2017.
RECITALS
WHEREAS, as of March 29, 2017, GPC and the Debtors entered into the Interim Assessment Agreement to set forth the relative rights and obligations of the Parties with respect to the Vogtle Project during the Interim Assessment Period; and
WHEREAS, on March 30, 2017, the Bankruptcy Court entered an order (D.I. 68) in the Debtors’ bankruptcy cases permitting them to enter into and perform under the Interim Assessment Agreement; and
WHEREAS, section 2 of the Interim Assessment Agreement permits the Interim Assessment Period to be extended by agreement of all of the Parties; and
WHEREAS, on April 28, 2017, May 12, 2017, June 3, 2017, June 5, 2017, June 9, 2017, June 22, 2017, and June 28, 2017, the Parties entered into Amendment No. 1, Amendment No. 2,

________________________________
1 Capitalized terms not otherwise defined herein have the meanings given to them in the Interim Assessment Agreement.

Amendment No. 3, Amendment No. 4, Amendment No. 5, Amendment No. 6, and Amendment No. 7, respectively, to the Interim Assessment Agreement pursuant to which the Parties amended the Interim Assessment Agreement to, among other things, extend the Interim Assessment Period; and
WHEREAS the Parties desire to amend the Interim Assessment Agreement to further extend the Interim Assessment Period.
AGREEMENT
NOW THEREFORE, in consideration of the recitals, the Parties, each intending to be legally bound hereby, agree to amend the Interim Assessment Agreement as follows:
1.Paragraph 2 of the Interim Assessment Agreement shall be deleted and replaced in its entirety to read as follows: “This Agreement shall extend from the Effective Date to and through the earlier of (a) July 27, 2017 at 5:00 p.m. (Eastern Time), (b) the effective date of that certain Amended and Restated Services Agreement, entered into amongst the Parties, and (c) termination of the Interim Assessment Agreement by any Party upon five (5) business days’ notice (the “Interim Assessment Period”). The Interim Assessment Period may be extended by agreement of all the Parties.”
2.This Amendment shall be construed in connection with and as part of the Interim Assessment Agreement, and all terms, conditions, and covenants contained in the Interim Assessment Agreement, except as herein modified, shall be and shall remain in full force and effect. The Parties hereto agree that they are bound by the terms, conditions, and covenants of the Interim Assessment Agreement as amended hereby.

2

3.The Parties hereto agree that the terms of this Amendment shall be deemed effective as of the date hereof.
4.This Amendment may be executed simultaneously in two or more counterparts, each of which shall be deemed an original, but both of which together shall constitute one and the same instrument.
5.This Amendment shall be governed by the laws of the State of New York, without regard to the application of New York’s conflict of law principles. Each Party consents to the exclusive jurisdiction of the Bankruptcy Court to resolve any dispute arising out of or relating to this Amendment.
6.Except as expressly provided for in this Amendment, the Interim Assessment Agreement remains unchanged.

3

IN WITNESS WHEREOF, the Parties have duly executed this Amendment as of the date first above written.

	
		
	GEORGIA POWER COMPANY, FOR ITSELF AND AS AGENT FOR OGLETHORPE POWER CORPORATION, MUNICIPAL ELECTRIC AUTHORITY OF GEORGIA AND THE CITY OF DALTON, GEORGIA, ACTING BY AND THROUGH ITS BOARD OF WATER, LIGHT AND SINKING FUND COMMISSIONERS

By:  /s/Chris Cummiskey

Date:  July 20, 2017
	WESTINGHOUSE ELECTRIC COMPANY, LLC

By:  /s/David C. Durham

Date:  July 20, 2017

	 
	 

	 
	WECTEC GLOBAL PROJECT SERVICES, INC.

By:  /s/David C. Durham

Date:  July 20, 2017

	 
	 

	 
	WECTEC STAFFING SERVICES LLC

By:  /s/David C. Durham

Date:  July 20, 2017

4

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