Exhibit 5
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[Object Omitted] If you have any questions or need help completing this
Great-West Life & Annuity Insurance Company application, call the Annuity Service Center at
1-888-560-5938 from
Mail completed application and check (if any) to: 6:00 A.M. to 4:30 P.M. Pacific time.
Great-West Life & Annuity Insurance Company
P.O. Box XXXX
Leesburg, VA XXXXX
Schwabsignature(TM)ANNUITY
Variable Annuity Application
Note: Maximum age Contract Owner: Joint Contract Owner:
of Contract Owner (Spouse only)
is 85.
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Full Legal Name Full Legal Name
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Street Address (no P.O. Box please) Street Address
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Street Address (continued) Street Address (continued)
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City, State Zip City, State Zip
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email Address email Address
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Phone - daytime Phone - daytime
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Phone - evening Phone - evening
Social Security # or Tax ID Social Security # or Tax ID
Date of Birth Date of Birth
Gender Gender
Annuitant: Contingent Annuitant:
|_| Annuitant is the same as Owner. |_| Contingent Annuitant is the same as
Owner
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Full Legal Name Full Legal Name
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Street Address Street Address
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Street Address (continued) Street Address (continued)
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City, State Zip City, State Zip
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email Address email Address
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Phone Phone
Social Security # or Tax ID Social Security # or Tax ID
Date of Birth Date of Birth
Gender Gender
J444app 1200-11319 (C) 2001 Charles Schwab & Co., Inc. Member NYSE/SIPC All Rights Reserved
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Beneficiary
If you need additional space, please use a separate sheet.
If no Beneficiary is named, the Owner's estate will be deemed to be the
Beneficiary.
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Name (first/middle/last) Birth date Percentage Relationship
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Name (first/middle/last) Birth date Percentage Relationship
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Name (first/middle/last) Birth date Percentage Relationship
Percentages must equal 100%. (Please use whole numbers; no fractional percentages)
Contingent Beneficiary
If you need additional space, please use a separate sheet. The naming of a
Contingent Beneficiary is optional.
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Name (first/middle/last) Birth date Percentage Relationship
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Name (first/middle/last) Birth date Percentage Relationship
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Name (first/middle/last) Birth date Percentage Relationship
Percentages must equal 100%. (Please use whole numbers; no fractional percentages)
Death Benefit
Select one: Mortality & Expense Charge
|_| Death Benefit Option 1 - Return of Account Value................................... .65%
|_| Death Benefit Option 2 - Guaranteed Minimum Death Benefit.......................... .70%
How will you pay for this annuity?
Minimum initial contribution: $25,000.
Subsequent minimum contributions: $500; $100 if paid through an Automatic Bank Draft.
|_| Transfer $_______________ from my Schwab brokerage account
number___________________________.
|_| Debit my checking account (Automatic Bank Draft).
|_| Transfer the entire balance from my existing annuity or life insurance
policy.
|_|______Check is attached.
Make check payable to Great-West Life & Annuity Insurance Company.
J444app 1200-11319 (C) 2001 Charles Schwab & Co., Inc. Member NYSE/SIPC All Rights Reserved
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Sub-Account
Allocation Initial premium will be allocated to the Money Market sub-account for
15 days following the date on which we deliver your contract to your Personal
Folder and/or mail it to you.
After this period, please allocate my initial purchase payment
as follows:
_____% Alger American Balanced Portfolio _____% INVESCO VIF-High Yield Fund
_____% Alger American Growth Portfolio _____% INVESCO VIF-Technology Fund
_____% Alliance Variable Product Series Growth & Income _____% J.P. Morgan Series Trust II Small Company Fund
Portfolio
_____% Alliance Variable Product Series Growth Portfolio _____% Janus Aspen Series Flexible Income Portfolio
_____% Alliance Variable Product Series Real Estate _____% Janus Aspen Series Worldwide Growth Portfolio
Investment Portfolio
_____% American Century VP International Portfolio _____% Kemper VA Series Small Cap Growth Portfolio
_____% American Century VP Income and Growth Portfolio _____% Oppenheimer Global Securities Fund/VA
_____% Berger IPT-Growth & Income Fund _____% PBHG Insurance Series Large Cap Growth
Portfolio
_____% Berger IPT-Small Company Growth Fund _____% SAFECO Resource Series Trust Equity Portfolio
_____% Delaware Group Premium Fund Small Cap Value Series _____% Schwab MarketTrack Growth Portfolio II
_____% Deutsche Asset Management VIT EAFE(R)Equity Index _____% Schwab Money Market Portfolio
Fund
_____% Deutsche Asset Management VIT Small Cap Index _____% Schwab S&P 500 Portfolio
Fund
_____% Dreyfus Variable Investment Fund Small Cap _____% Scudder VLI Fund Capital Growth Portfolio
Portfolio
_____% Dreyfus Variable Investment Fund Growth and _____% Strong VIF Mid-Cap Growth Fund II
Income Portfolio
_____% Federated International Equity Fund II _____% Strong VIF Opportunity Fund II
Total allocation must equal 100%.
You may change your allocations at any time online at
www.schwab.com or by calling the Annuity Service
Center at 1-888-560-5938 from 6:00 A.M. to 4:30 P.M. Pacific time.
J444app 1200-11319 (C) 2001 Charles Schwab & Co., Inc. Member NYSE/SIPC All Rights Reserved
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Replacement Will the proposed contract replace any existing annuity or
insurance contract (including any Great-West Life & Annuity
Insurance Company contracts)? State law requires that you
provide this information when you replace any life insurance
policy or annuity contract with another.
|_| YES, this will replace the life insurance policy or annuity listed below.
|_| NO, this will not replace another life insurance policy or annuity.
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Annuitant/Insured on Existing Policy
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Existing Company
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Policy No. Approximate Amount $
Note: Carefully consider whether a replacement is in your best
interest by making a comparison of your existing contract and
the proposed one. We encourage you to contact your current
insurance company to determine if there are any charges or
penalties that will be assessed upon replacement.
Annuitization Unless otherwise indicated, annuity payments will begin on the Annuitant's 91st birthday. You
may choose when you would like to annuitize. Note: This date can be changed at any time up to
30 days before the start of annuity payments.
I would like annuity payments to begin ---------------------------------
( month / year )
Automatic Bank
Draft From
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(optional) Bank Name ABA Number
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Bank Street Address City, State Zip
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Automatic bank draft start date Checking Account #
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Initial Amount Additional Monthly Amount I/We hereby
request and authorize the above-referenced bank (the
"Bank") to charge my/our account checks or electronic fund
transfer debits processed by and payable to the order of
Great-West Life & Annuity Insurance Company, P.O. Box
XXXX, Leesburg, Virginia XXXXX provided there are
sufficient collected funds in said account to pay the same
upon presentation. It will not be necessary for any
officer or employee of Great-West Life & Annuity Insurance
Company to sign such checks. I/We agree that the Bank's
rights in respect to each such check shall be the same as
if it were a check drawn on the Bank and signed personally
by me/us. This authority is to remain in effect until
revoked by me/us, and until the Bank actually receives
such notice, I/we agree that the Bank shall be fully
protected in honoring any such check or electronic fund
transfer debit. In addition to regular bank draft, I/we
authorize such ad hoc drafts as are requested through the
Annuity Service Center. I/We further agree that if any
such check or electronic fund transfer debit be
dishonored, whether with or without cause and whether
intentionally or inadvertently, the Bank shall be under no
liability whatsoever even though such dishonor results in
the forfeiture of insurance or investment loss to me/us.
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Signature(s) EXACTLY as shown on bank records Signature(s) EXACTLY as shown on bank records
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Print full legal name(s) Date Print full legal name(s) Date
J444app 1200-11319 (C) 2001 Charles Schwab & Co., Inc. Member NYSE/SIPC All Rights Reserved
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Fraud Warning Any person who, knowingly and with intent to
defraud any insurance company or other person, files an
application for insurance or statement of claim containing
any materially false information or conceals, for the
purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which
is a crime and subjects such person to criminal and civil
penalties.
Signatures I understand that I am applying for a Flexible Premium
Variable Annuity, Contract Form J444, 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.
I acknowledge receipt of the prospectus for the variable
annuity contract. I believe the contract is suitable for my
retirement and insurance needs. I understand that amounts
allocated to a Sub-Account are variable and are not
guaranteed as to dollar amount.
I hereby direct that my telephone instructions to the
Annuity Service Center and/or those I submit via Schwab's
Web site (www.schwab.com) 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 Annuity Service Center 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 Schwab
brokerage account is indicated in this application, I
authorize Schwab 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.
Sign Here
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Signature of Contract Owner Date Signature of Joint Contract Owner Date
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Full Name of Contract Owner Full Name of Joint Contract Owner
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Application signed at (City and State)
Annuity contracts are underwritten by:
Great-West Life & Annuity Insurance Company, 8515 East Orchard Road, Greenwood Village, Colorado, 80111
For Internal Use Only: 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
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Signature (if required) Rep Code Source Code Lead Source Date
J444app 1200-11319 (C) 2001 Charles Schwab & Co., Inc. Member NYSE/SIPC All Rights Reserved
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