Document:

Form of Election Form

 Exhibit 4.4 
 

 
 Group Fixed Deferred Annuity Election Form 

 
  

																							
	[Product Marketing Name]	 	[Account grouping]
	  
 Certificate Owner
Information

	 	 		 			
	 	 	 	 	 	 	 	 		 		 	 
	Last Name	 	First Name	 	MI	 	 	 		 		 	Social Security Number
		 			
	 	 	 	 		 		 	 
	Address – Number & Street	 	 	 		 		 	Email Address
		 	 			 						
	 	 	 	 	 	 	 	 	 	 	 	 		 		 		 		 		 	
	City	 	State	 	Zip Code	 	 	 		 		 		 		 		 	
		 		 		 		 		 	 	 		 		 	Mo  	 	Day  	 	Year  	 	 ̈    Female     ̈  
  Male
	(        )	 		 	(        )	 	 	 		 		 	 	 	 	 	 	 	
	Home Phone	 		 	Work Phone	 	 	 		 		 	Date of Birth	 	

  
 Required
Signature By signing below, I hereby elect to purchase this Group Deferred Annuity Certificate (“Certificate”). In doing so, I understand the following: 
  

	 	•	 	 The Certificate provides for a Guaranteed Lifetime Benefit, but only if certain specified conditions are satisfied; 

 

	 	•	 	 The Certificate has no cash value or surrender value; 

 

	 	•	 	 The Certificate does not pay dividends or death benefits; 

 

	 	•	 	 The Certificate Owner owns the Covered Fund; and 

  

	 	•	 	 The Accounts and the investments of the Covered Fund are not assets of Great-West Life & Annuity Insurance Company

 Source of Funds: 
 It is my intent to fund this Certificate with: (select only one):  
  ̈ Funds from my Individual Retirement Account (“IRA”) 

 ̈ Funds from the Roth IRA 
  ̈ Funds from other Account:
                                         
                                        

             (please specify) 

Initial Contribution: $             

 

							
	  
	 		  	  
	  	
	Certificate Owner Signature	 		  	Date	  	

 Owner forward to Service Provider at: 
 [Service Address] 
 [Phone#: 1-NNN-NNN-NNNN] 

[Fax#: 1-NNN-NNN-NNNN] 
 For Agent Use
Only: 
  

									
	  
	    	  
	    	  
	    	  
	    	  

	Signature	    	Rep Code	    	Source Code	    	Lead Source	    	Date

 GLWB-RBD-eleForm of GWLA SecureFoundation Trust Agreement

 Exhibit 10.1 
 GWLA SECUREFOUNDATION BALANCED ETF TRUST 
 TRUST AGREEMENT 

This Trust Agreement is entered into by and between Great-West Life & Annuity Insurance Company (“Settlor” and “Insurer”),
and Orchard Trust Company, LLC (“Trustee”). 
 RECITALS 

WHEREAS, the Settlor wishes to make available certain guaranteed living withdrawal benefit coverage for the benefit of persons and/or
entities who are eligible members of certain groups and qualify for such coverage; and 
 WHEREAS, Settlor wishes such persons
to have the benefit of (a) certain coverage that may only be made available on a group basis, or (b) obtaining certain coverage on a group basis; and 
 WHEREAS, Settlor wishes to establish and maintain a trust such that the Trustee will act as group contractholder for such coverage; and 

WHEREAS, Orchard Trust Company has agreed to act as trustee for such a trust in accordance with the Agreement. 

NOW, THEREFORE, in consideration mutual promises of the parties and the declaration of trust, the parties agree as follows: 

ARTICLE ONE - DEFINITIONS 
  

	1.1.	“Beneficiary” is any person or entity validly designated under the Contracts to receive benefits thereunder or determined by a court of competent jurisdiction
to receive such benefits. 

  

	1.2.	“Contracts” are the group contracts for which the Trustee is to act as group contractholder. 

 

	1.3.	“Insurer” and “Settlor” is Great-West Life & Annuity Insurance Company or its successor(s). 

 

	1.4.	“Participant” is any person or entity who, at the time such person’s or entity’s interest first takes effect, is all or does all of the following:
(a) meets the eligibility requirements for a specific group policy or group contract for which the Trustee acts as contractholder; (b) is found acceptable by the Insurer under its underwriting rules, if any, for such contract; and
(c) takes all necessary steps to effectuate coverage. Once such interest takes effect, the transferee of any interest, if allowed under the group contract, has the same rights and privileges as the Participant at the time such interest took
effect. Participants in the Contracts are not parties to this Agreement. 

  

	1.5.	“Trust” is the GWLA SecureFoundation Balanced ETF Trust. 

  
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	1.6.	“Trust Fund” is all Contracts, money and other property held by the Trustee of the Trust. 

 

	1.7.	“Trustee” is Orchard Trust Company or its successor(s). 

 ARTICLE TWO - TRUST 
  

	2.1.	The Settlor hereby creates the GWLA SecureFoundation Balanced ETF Trust. The Trustee may enter into contracts, hold property and in all matters act on behalf of the
Trust and its Participants. 

  

	2.2.	Orchard Trust Company is hereby appointed as Trustee of this Trust and Orchard Trust Company hereby accepts such appointment. 

 

	2.3.	This Trust is established to allow the Trustee to hold Contracts that make available certain guaranteed living withdrawal benefit coverage to eligible persons or
entities. 

  

	2.4.	The situs of the Trust is the State of Colorado. 

  

	2.5.	No Participant, Beneficiary, or assignee or transferee of any rights of any Participant or Beneficiary shall have any rights or claims to benefits under this Trust
except as provided under the Contracts held by the Trustee pursuant to this Agreement. 

 ARTICLE THREE - TRUST
FUND 
  

	3.1.	The Trust Fund is expected to consist of Contracts. The terms of such Contracts and the rules of eligibility in relation to such Contracts are determined by the
Insurer. Amendment or termination of such Contracts or any rights under such Contracts are subject to such Contracts’ terms and all applicable law and regulation. 

 

	3.2.	Contracts which allow for termination will end according to their terms. Contracts which do not provide for termination will end when the Insurer has satisfied all
obligations incurred under the Contracts. Once terminated, Contracts will no longer be part of the Trust Fund. 

ARTICLE FOUR - POWERS AND DUTIES OF THE TRUSTEE 
  

	4.1	From time to time the Trustee will apply to the Insurer for certain Contracts. The Trustee will maintain all Contracts issued pursuant to such applications, as well as
any amendment to such contracts. 

  

	4.2	The Trustee may agree on behalf of the Trust and its Participants to any amendments to the Contracts proposed by the Insurer in order to maintain the status of the
Contracts and status of Participants and Beneficiaries in relation to such Contracts under Federal or state law, regulation or judicial interpretation. Should any such amendment be agreed to, the Trustee shall, if required by the Insurer, present
the affected Contract(s) to the Insurer for amendment. 

  
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	4.3	The Trustee shall not assume any responsibility or liability for payment, forwarding, remittance or collection of premiums for the Contract. Premiums shall be collected
by the Insurer or its appointed agent(s). Any monies relating to the Contracts that might be forwarded to the Trustee or its agent or representative shall be promptly turned over to the Insurer. 

 

	4.4	The Trustee shall not assume any responsibility or liability for solicitation of interests in any Contracts, enrollment of Participants, issuance, administration or
termination of any certificates representing participation in Contracts, investment of assets to support such Contracts, or any other operations involved in providing the coverages afforded under the Contracts to Participants. Any correspondence
received by the Trustee relating to the operation of the Contracts or the certificates issued in relation to such Contracts shall be forwarded promptly to the Insurer. 

 

	4.5	The Insurer shall be solely responsible for handling all claims made in relation to the Contracts. The Trustee shall not assume any responsibility or liability for
payment or denial of any claim or benefit. Any correspondence received by the Trustee regarding any claim or request for payment of a benefit, or any correspondence relation thereto, shall be forwarded promptly to the Insurer.

  

	4.6	It is the intent of this Agreement that the Trustee shall have no authority, power, duty or responsibility except as expressly set forth in the Agreement which
includes, but is not limited to, no authority to file any reports or returns which may be required as a result of the creation of this Trust. 

  

	4.7	Should the Trustee be removed or resign, the Trustee shall promptly transfer the Trust Fund to any successor Trustee upon instruction of the Settlor.

  

	4.8	Settlor agrees to indemnify and hold the Trustee harmless as to any person, firm or corporation by reason of its having accepted the same or in carrying out any of its
duties hereunder, and reimburse Trustee for all its expenses including, among other things, counsel fees and court costs incurred by reason of its position hereunder or actions taken pursuant hereto, excepting, however, any expenses, losses,
including among other things, counsel fees and court costs to the extent incurred because of Trustee’s willful, wrongful acts, or gross negligence. This indemnity paragraph shall survive the term of this Agreement and survive the removal or
resignation of the Trustee. 

 ARTICLE FIVE - SETTLOR’S RIGHTS AND DUTIES 

 

	5.1	The Settlor may remove the Trustee at any time. Such removal will take effect not less than sixty (60) days after the delivery of written notice to the Trustee
unless otherwise waived in writing by the Trustee. 

  

	5.2	Should the Trustee be removed or resign, the Settlor shall appoint a successor Trustee. 

  
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 ARTICLE SIX - TRUSTEE’S RIGHTS 

 

	6.1	The Trustee shall not be liable for any action or failure to act taken in good faith or upon the instruction of the Settlor. The Trustee shall be entitled to rely upon
the information provided to it by the Settlor. No bond or other security for the faithful performance of its duties under this Agreement shall be required of the Trustee. 

 

	6.2	The Trustee shall not be liable for any action or failure to act by the Insurer in relation to the Contracts. 

 

	6.3	The Trustee shall be paid a one-time, initial $2,500 acceptance fee and a $2,500 Annual Administration fee. The Trustee shall be reimbursed for any proper disbursements
or expenses relating to the Trust. No commissions or concessions shall be paid to the Trustee relating to the premiums collected on the contracts or the assets supporting the Insurer’s liabilities under the Contracts. 

 

	6.4	The Trustee may resign at any time. Such resignation will take effect no less than sixty (60) days after delivery of written notice to the Settlor or such shorter
period as agreed in writing by the Settlor. 

 ARTICLE SEVEN - MISCELLANEOUS 

 

	7.1	Should any provision of this Agreement be held to be invalid or illegal, the remaining portions of the Agreement will continue in effect and full force unless the
objectives of the agreement can no longer be accomplished. 

  

	7.2	It is the intention of the parties that this Trust continue in effect indefinitely. The Trust and this Agreement will terminate automatically when all Contracts in the
Trust Fund terminate. 

  

	7.3	The Settlor reserves the right to amend or revoke this Agreement. Any such amendment will be delivered to the Trustee for acknowledgment. The prior written consent of
the Trustee, which may not be unreasonably withheld, is required for any amendment or revocation which in the opinion of the Trustee may affect the Trustee’s rights and duties. 

 

	7.4	Unless otherwise specified, all notices and other communications required hereunder shall be in writing and shall be hand delivered, sent by express delivery or mailed
by certified mail to the other party at the following address or such other address as each party may give notice to the other: 

 If to the Settlor and Insurer: 
 Great-West Life & Annuity Insurance Company

 8515 East Orchard Road 
 Greenwood Village, Colorado 80111 
 Attn: Beverly A. Byrne 

  
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 If to Trustee: 
 Orchard Trust Company 
 8515 E. Orchard Road 

Greenwood Village, Colorado 80111 
 Attn: Laura G. Miller , Secretary 
 IN WITNESS WHEREOF, the parties hereto have
caused this Agreement to be effective upon execution. 
  

									
	GREAT-WEST LIFE & ANNUITY	 		 	ORCHARD TRUST COMPANY, LLC
	INSURANCE COMPANY	 		 		 	
					
	By:	 	  
	 		 	By:	 	  

			
	Robert Shaw	 		 	Miles Edwards
	Executive Vice President, Ind. Markets	 		 	President
					
	Date:	 		 		 	Date:	 	

  
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