Empower Annuity Insurance Co of America Watch

from S-1 8 pages 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

from S-1 8 pages [Marketing Name] Individual Single Premium Index Linked Annuity Annuities Are Issued by Great-West Life & Annuity Insurance Company

from S-1 29 pages Please Read This Annuity Contract Carefully

from S-1 29 pages Please Read This Annuity Contract Carefully

from POS AM 1 page Great-West Life & Annuity Insurance Company a Stock Company Certificate Endorsement

from POS AM 1 page Great-West Life & Annuity Insurance Company a Stock Company Certificate Endorsement

from S-1/A ~5 pages 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

from S-1 20 pages Contract Data

from S-1 5 pages Individual Retirement Account Endorsement

from S-1 17 pages Certificate Data

from S-1/A 2 pages Amendment Rider Attached to and Forming Part of the Group Fixed Deferred Annuity Contract Group Fixed Deferred Annuity Contract Amendment

from POS AM 1 page Certificate Endorsement

from S-1 2 pages Section A. Plan Sponsor Name of Plan Sponsor Federal Tax Id # Address Situs Street City State Zip Code Telephone # Fax # Type of Entity: [O Church] [O Public School] [O Government] [O 501(c)(3) ] [O S Corp] [O Corporation] [O Partnership] [O LLC] [O Sole Proprietorship] [O Other ] Full Legal Name of Plan Section B. Contractholder Name of Contracholder, if Different Than the Plan Sponsor [Federal Tax Id #, if Applicable Address Situs, if Applicable Street City State Zip Code Telephone # Fax #] Type of Entity: [O Bank] [O Trust Company] [O Individual(s)] [O Other ] Section C. Plan Information [O 401(a) Plan] [O Erisa] [O Non-Erisa] [O 457(b) Governmental Plan] [O 401(k) Plan] [O Erisa] [O Non-Erisa] [O ] [O 403(b) Plan] [O Erisa] [O Non-Erisa] Section D. Covered Fund [O Maxim Securefoundationsm Balanced Portfolio] [O Maxim Securefoundationsm Lifetime Portfolios] [O ] Section E. Agreement and Signatures Agreement

from S-1 24 pages This Contract Has No Cash Value or Surrender Value. This Contract Does Not Pay Dividends or Death Benefits

from S-1/A ~5 pages Owner Information Last Name First Name MI Social Security Number Address – Number & Street Email Address City State Zip Code Mo Day Year Q Female Q Male ( ) ( ) Home Phone Work Phone Date of Birth

from S-1 1 page Securefoundationsm Group [Fixed] Deferred Annuity Certificate Election Form

from S-1 4 pages Great-West Life & Annuity Insurance Company a Stock Company [8515 East Orchard Road Greenwood Village, Co 80111] Master Group Fixed Deferred Annuity (The “Group Contract”) Please Read This Contract Carefully. the Group Contract Has No Cash Value or Surrender Value. the Group Contract Does Not Pay Dividends or Death Benefits. Non-Participating. Non-Assignable. Signed for Great-West Life & Annuity Insurance Company on the Issuance of This Group Contract

from S-1 4 pages Certificate Data

from S-1 ~5 pages Indenture or similar

from S-1 ~20 pages Indenture or similar