Exhibit 5
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APPLICATION FOR QUALIFIED GROUP ANNUITY CONTRACT
QGP 685
Exact Name: ..................
(herein called the Group Contractholder applies to Great-West Life & Annuity
Insurance Company for a Qualified Group Annuity Contract (herein called the
Group Annuity Contract) in the form of the copy attached to this Application. It
is agreed that the Group Contractholder will accept the Group Annuity Contract
when issued.
Specify the effective date of the Group Annuity Contract: (which is not
earlier than the first day of the year in which this Application has been
made)
Specify the name of the Qualified Plan: ..................
..................
This Group Annuity Contract is only available to Contractholders whose Qualified
Plan is an eligible plan described in Sections 401(a) and 401(k) of the Internal
Revenue Code of 1954, as amended.
The Insurance Company requires that a copy of the currently effective plan
document accompany this application, for its information.
PAYMENTS AND VALUES PROVIDED BY THE CONTRACT APPLIED FOR MAY BE VARIABLE AND NOT
GUARANTEED AS TO DOLLAR AMOUNT.
Group Contractholder's address:
Dated at this day of , 19 _____
Agent/Broker Name of Group Contractholder
BY
Signature
Title
Application
<PAGE>
APPLICATION FOR GROUP TAX DEFERRED ANNUITY CONTRACT
Exact Name:
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(herein called the Group Policyholder) applies to Great-West Life & Annuity
Insurance Company for a Group Tax Deferred Annuity Contract (herein called the
Group Annuity Contract) in the form of the copy attached to this Application. It
is agreed that the Group Policyholder will accept the Group Annuity Contract
when issued.
Specify the effective date of the Group Annuity Contract: (which is not
earlier than the first day of the year in which this Application has been
made)
Is the Group Policyholder: a public school? Yes. No.
or
an organization described in Section 501(c)(3) and exempt from tax under
Section 501(a) of the Internal Revenue Code of 1954? Yes. No.
The Employee Retirement Income Security Act of 1974 ("ERISA") applies to any
employee benefit plan. Certain parts of ERISA do not apply if -
(1) such plan is a governmental plan (as defined in Section 3(32) of
ERISA); or
(2) such plan is a church plan (as defined in Section 3(33) of ERISA) with
respect to which no election has been made under section 410(d) of the
Internal Revenue Code of 1954; or (3) such plan meets all of the following
requirements:
(i) employee participation is voluntary;
(ii) all rights under the annuity contract are enforceable by the employee
or the beneficiary;
(iii) the involvement of the employer is limited to permitting the
sponsor to publicize the program to employees, requesting and
summarizing relevant information in a manner which will help
employees compare various program, and collecting and
remitting payments as required by its agreements with its
employees;
(iv) the employer receives no consideration other than reasonable
reimbursement for services rendered in connection with the
employer's obligations under its agreements with its
employees; and
(v) contributions are made through a salary reduction agreement or
an agreement to forego a salary increase entered into by the
employee with the employer.
Does this Plan meet any of the above requirements (1), (2) or (3)? Yes. No.
If "no," your Plan may be subject to ERISA and, if so, a written plan document,
among other legal matters, would be required. The Insurance Company requires
that a copy of the currently effective plan document accompany this application,
for its information. You are urged to discuss the requirements of ERISA with
your legal counsel.
Specify the name of the Employee Benefit Plan, if any:
PAYMENTS AND VALUES PROVIDED BY THE CONTRACT APPLIED FOR MAY BE VARIABLE AND NOT
GUARANTEED AS TO DOLLAR AMOUNT.
Group Policyholder's address
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Dated at this
day of
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Agent/Broker Name of Group Policyholder
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Signature
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Title
Application
Group Tax Deferred Annuity
APP 192
