Common use of Right to Cancel Clause in Contracts

Right to Cancel. There is a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3

Right to Cancel. The Group Contract Holder may cancel this Contract within 10 days by returning it to the agent from whom it was purchased, or to Aetna at the address shown above. Within seven days of receiving the Contract at its home office, Aetna will return the amount of Certificate Holder Purchase Payment(s) received, plus any increase, or minus any decrease, on the amount, if any, allocated to the Separate Account fund(s). This page and the pages that follow constitute the entire Contract. Signed at the home office on the Effective Date. /s/Xxxxxx Xxxxxxx /s/Xxxxx X. Xxxxxxxxx President Secretary Group Variable, Fixed, or Combination Annuity Contract Nonparticipating ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THIS CONTRACT CONTAINS A MARKET VALUE ADJUSTMENT FORMULA. APPLICATION OF A MARKET VALUE ADJUSTMENT MAY RESULT IN EITHER AN INCREASE OR DECREASE IN THE CURRENT VALUE. THE MARKET VALUE ADJUSTMENT FORMULA DOES NOT APPLY TO A GUARANTEED TERM AT THE TIME OF ITS MATURITY. Specifications -------------------------------------------------------------------------------- Guaranteed There is a 10 day right to cancelguaranteed interest rate for Purchase Interest Rate Payment(s) held in the AG Account. If the (See Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days Schedule I). -------------------------------------------------------------------------------- Deductions from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract There will be void from deductions for mortality and expense the start, Separate risks and the Company will refund the Annuity Account Value plus any charges and administrative fees. The amount returned during the right to cancel period will not be (See Contract Account Schedule I and II). -------------------------------------------------------------------------------- Deduction from Purchase Payment(s) are subject to a Withdrawal Chargededuction for Purchase premium taxes, if any. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts (See 3.01.) Payment(s) -------------------------------------------------------------------------------- Surrender There will be paid on the same day of each frequency period according to the provisions of this Contracta charge deducted upon surrender. (See Fee Contract Schedule I). This Contract is non- participating a legal contract and not eligible constitutes the entire legal relationship between Aetna and the Contract Holder. READ THIS CONTRACT CAREFULLY. This Contract sets forth, in detail, all of the rights and obligations of both you and Aetna. THEREFORE, IT IS IMPORTANT THAT YOU READ THIS CONTRACT CAREFULLY. Contract Schedule I Accumulation Period Separate Account -------------------------------------------------------------------------------- Separate Account: Variable Annuity Account B Charges to share Separate A daily charge is deducted from any portion of the Account: Current Value allocated to the Separate Account. The deduction is the daily equivalent of the annual effective percentage shown in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Numberfollowing chart: [1234567] Effective Date: [July 1, 2012] Status Administrative Charge 0.15% Mortality Risk Charge 0.35% Expense Risk Charge 0.90% ----- Total Separate Account Charges 1.40% ALIAC Guaranteed Account (AG Account) -------------------------------------------------------------------------------- Minimum Guaranteed 3.0% (effective annual rate of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed return) Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate Separate Account and AG Account -------------------------------------------------------------------------------- Transfers: An unlimited number of Transfers are allowed during the Accumulation Period. Aetna allows 12 free Transfers in any calendar year. Thereafter, Aetna reserves the right to be Applied in Adjusting charge $10 for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3each subsequent Transfer.

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within [ 10 ] days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period more or until the death benefit is payable to a Beneficiaryless than your Purchase Payments. The THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY [ xxx.Xxxxxxxxxx.xxx ] [ 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ] ICC11-VDA-P-2006C-WW [ 12/11 ] TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant the first 8 Death Benefit 8 Payment of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the 9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Account Value as Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12

Right to Cancel. There is a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 30 days from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX303-XXX123-XXXX4567] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] [Colorado] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawnWithdrawn) W ithdrawal Withdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. ................................................................................................... 1 Section 1 DEFINITIONS............................................................................................................ 3

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned may be more or less than your Purchase Payments. THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY xxx.Xxxxxxxxxx.xxx 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ICC11-VDA-P-2006C-WW 12/11 TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant 8 Death Benefit 8 Payment of the Death Benefit 9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12 [PROTECTIVE DIMENSIONS IV VARIABLE ANNUITY SCHEDULE] CONTRACT NUMBER ISSUE DATE OWNER 1 BIRTH DATE OF OWNER 1 OWNER 2 BIRTH DATE OF OWNER 2 ANNUITANT BIRTH DATE OF ANNUITANT BENEFICIARY ANNUITY DATE As contained in our records PROTECTED LIFETIME INCOME OPTION DEATH BENEFIT AGENT INSURANCE REGULATORY AUTHORITY INITIAL PURCHASE PAYMENT TAX-QUALIFIED STATUS INTEREST RATES FOR THE GUARANTEED ACCOUNT Annual Effective Interest Rates for the FIXED ACCOUNT — Guaranteed Account on the Issue Date: DCA ACCOUNT 1 — DCA ACCOUNT 2 — Non-Forfeiture Interest Rate (NFIR) for the Guaranteed Account: The Contract’s NFIR for the Guaranteed Account was established on the Issue Date and will not change. It was determined by taking the 5-Year Constant Maturity Treasury Rate as of the January 31 prior to the May 1 — April 30 annual period during which the right Contract was issued, subtracting 1.25%, and rounding the result to cancel period the nearest 0.05%. The NFIR cannot be less than 1.00% and will not be subject more than 3.00%. Interest rates declared by the Company for the Guaranteed Account will be at least equal to a Withdrawal Chargethe Contract’s NFIR. Signed for GreatICC11-West Life & Annuity Insurance Company of New York on the issuance of this Contract. VDA-P-2006SO-1 [/s/ Xxxxxxx XxxxxxxDIMENSIONS IV 11/19] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx XxxxxxxPROTECTIVE DIMENSIONS IV VARIABLE ANNUITY SCHEDULE], [Xxxxxx X. Xxxxxxxx]continued CONTRACT LIMITATIONS, [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during FEES, AND CHARGES Maximum Issue Date: We will not issue a Contract on or after the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the oldest Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Companyor Xxxxxxxxx’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 386th birthday.

Right to Cancel. The Contract Holder may cancel this Contract within 10 days by returning it to the agent from whom it was purchased, or to Aetna at the address shown above. Within seven days of receiving the Contract at its home office, Aetna will return the amount of Certificate Holder Purchase Payment(s) received, plus any increase, or minus any decrease, on the amount, if any, allocated to the Separate Account fund(s). This page and the pages that follow constitute the entire Contract. Signed at the home office on the Effective Date. /s/Xxxxxx Xxxxxxx /s/Xxxxx X. Xxxxxxxxx President Secretary Individual Variable, Fixed, or Combination Annuity Contract Nonparticipating ALL PAYMENTS AND VALUES PROVIDED BY THE CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THIS CONTRACT CONTAINS A MARKET VALUE ADJUSTMENT FORMULA. APPLICATION OF A MARKET VALUE ADJUSTMENT MAY RESULT IN EITHER AN INCREASE OR DECREASE IN THE CURRENT VALUE. THE MARKET VALUE ADJUSTMENT FORMULA DOES NOT APPLY TO A GUARANTEED TERM AT THE TIME OF ITS MATURITY. Specifications -------------------------------------------------------------------------------- Guaranteed There is a 10 day right to cancelguaranteed interest rate for Purchase Interest Rate Payment(s) held in the AG Account. If the (See Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days Schedule I). -------------------------------------------------------------------------------- Deductions from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract There will be void from deductions for mortality and expense the start, Separate risks and the Company will refund the Annuity Account Value plus any charges and administrative fees. The amount returned during the right to cancel period will not be (See Contract Account Schedule I and II). -------------------------------------------------------------------------------- Deduction from Purchase Payment(s) are subject to a Withdrawal Chargededuction for Purchase premium taxes, if any. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts (See 3.01.) Payment(s) -------------------------------------------------------------------------------- Surrender There will be paid on the same day of each frequency period according to the provisions of this Contracta charge deducted upon surrender. (See Fee Contract Schedule I). This Contract is non- participating a legal contract and not eligible constitutes the entire legal relationship between Aetna and the Contract Holder. READ THIS CONTRACT CAREFULLY. This Contract sets forth, in detail, all of the rights and obligations of both you and Aetna. THEREFORE, IT IS IMPORTANT THAT YOU READ THIS CONTRACT CAREFULLY. Contract Schedule I Accumulation Period Separate Account -------------------------------------------------------------------------------- Separate Account: Variable Annuity Account B Charges to share Separate A daily charge is deducted from any portion of the Account: Current Value allocated to the Separate Account. The deduction is the daily equivalent of the annual effective percentage shown in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Numberfollowing chart: [1234567] Effective Date: [July 1, 2012] Status Administrative Charge 0.15% Mortality Risk Charge 0.35% Expense Risk Charge 0.90% ----- Total Separate Account Charges 1.40% ALIAC Guaranteed Account (AG Account) -------------------------------------------------------------------------------- Minimum Guaranteed 3.0% (effective annual rate of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed return) Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate Separate Account and AG Account -------------------------------------------------------------------------------- Transfers: An unlimited number of Transfers are allowed during the Accumulation Period. Aetna allows 12 free Transfers in any calendar year. Thereafter, Aetna reserves the right to be Applied in Adjusting charge $10 for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3each subsequent Transfer.

Right to Cancel. There is a The Contract Holder may cancel this Contract within 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 calendar days from the date of receiving it. If you are not satisfied with the Contract, return it by returning it to ALIAC at the Retirement Resource Operations Center address shown above, or an to the agent from whom it was purchased. Within seven calendar days of receiving the Companycancellation request at its Home Office, ALIAC will return any Contributions received, plus any increase, or minus any decrease in value, on the amount, if any, allocated to the Separate Account. The Contract Contributions to the Guaranteed Accumulation Account will be void from the startreturned, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal ChargeMarket Value Adjustment, which may be positive or negative. Signed for Great-West Life & Annuity Insurance Company of New York at the Home Office on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. /s/ Xxxxxx X. XxXxxxxxx /s/ Xxxxx Xxxxxxx-Xxxxxxx President Secretary THE VARIABLE FEATURES OF THIS CONTRACT ARE DESCRIBED IN SECTIONS 3 AND 11. ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. AMOUNTS ALLOCATED TO THE GUARANTEED ACCUMULATION ACCOUNT, IF WITHDRAWN BEFORE A GUARANTEED TERM MATURITY DATE, MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT. THE MARKET VALUE ADJUSTMENT MAY RESULT IN AN INCREASE, OR A DECREASE, IN THE INDIVIDUAL ACCOUNT VALUE. AMOUNTS ALLOCATED TO THE FIXED PLUS ACCOUNT ARE NOT AVAILABLE AS A LUMP SUM WITHDRAWAL, OTHER THAN DUE TO DEATH, SEPARATION FROM SERVICE, OR RETIREMENT, OR AS OTHERWISE ALLOWED BY THE CONTRACT. VARIABLE ANNUITY ASSUMED ANNUAL NET RETURN RATE - ANNUITY PHASE If a Variable Annuity is chosen, an assumed annual net return rate of 5.0% may be elected. If 5.0% is not elected, we will use an assumed annual net return rate of 3.5%. The daily net return rate factor for an assumed annual net return rate of 3.5% per year is 0.9999058. The daily net return rate factor for an assumed annual net return rate 5.0% per year is 0.9998663. If the portion of a Variable Annuity payment for any information on this page needs Fund is not to be changed or correcteddecrease, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuity return factor under the Separate Account for that Fund must be:

Right to Cancel. There is If you are a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, consumer client and this contract was not agreed within our office you have the right to cancel this contract within 14 days without giving any reason. The cancellation period is extended to 60 will expire after 14 days from the date of receiving itday this contract was agreed. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during To exercise the right to cancel, you must inform us of your decision to cancel period will this contract by sending us a clear statement in writing to 0X Xxx Xxxxxx, Xxxxx Xxxxx, Xxxxxx, Xxxxxx X0 0XX or emailing us at xxxx@xxxxxxxx.xxx ACCEPTANCE & VARIATION The Terms & Conditions of this Agreement may be varied by the Agent at any time or times, but only by prior written notification. You (the Landlord) authorise Anglopol Management Ltd to sign the Tenancy Agreement and tenancy renewals on your behalf until further notice (delete if not applicable) I/We confirm that we have read and agreed to the above Terms & Conditions and hereby instruct the Agent to undertake the service of Signed on behalf of the Agent Name: Xxxxx Xxxxxxxxxxxx Signature: ............................................... Position: Director LETTING SERVICE/LETTING & RENT COLLECTION (NON-MANAGEMENT) When the Landlord does not wish the Agent to undertake full management, the Agent can provide a letting service or letting & rent collection service. The letting service & rent collection includes 1 to 4 of the service as listed above and in addition requires the undertakings listed A to K above to be subject to met by the Landlord. The standard letting service is 6% + VAT Sole Agency (minimum one month Sole Agency period) or 7% + VAT Multiple Agency of a Withdrawal Chargetwelve months rental + VAT and payable at the commencement of the Tenancy. Signed for Great-West Life & Annuity Insurance Company of New York Rent Collection is an additional 2% + VAT per month. It shall be deductible from monies received by the Agent on the issuance Landlord’s behalf. A minimum fee of this Contract£500 + VAT applies, non-management deposit protection registration fee £50.00 + VAT. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during Xxxxxxxx agrees to pay referencing costs (£50.00 + VAT per person) if withdrawing from the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3agreement.

Right to Cancel. There Please read this contract carefully. You may cancel the contract before midnight of the latest of: (1) The 10th day after you first receive it; (2) The 45th day after you complete Part I of the Application; and (3) The 10th day after a notice of withdrawal right is a 10 day right mailed or delivered to cancelyou. If Do this by (1) sending or delivering written notice to Lutheran Brotherhood, 600 Xxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx, XX 00000 or to the Contract is issued as a replacement representative through whom you bought it, and (2) returning the contract. Notice given by mail and return of existing life insurance or annuity coveragethe contract by mail are effective on being postmarked, the right to cancel period is extended to 60 days from the date of receiving itproperly addressed and postage prepaid. If you are not satisfied with cancel the Contractcontract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be deemed void from the start, beginning. Within 7 days after we receive notice of cancellation and the Company returned contract, we will refund the Annuity Account Value plus any charges and feesall premiums you have paid. The amount returned during the right Life insurance payable at death. Adjustable death benefit. Flexible premiums. Return on investments reflected in contract benefits. Annual dividends payable if earned. Settlement options to cancel period will not be subject to a Withdrawal Chargeprovide retirement income. Signed for Greatthe Society at Minneapolis, Minnesota ---------------------------------------------------------------------------- President SAMPLE /s/ Rxxxxx X. Xxxxxxx ---------------------------------------------------------------------------- Secretary SAMPLE /s/ Dxxxx X. Xxxxxx ---------------------------------------------------------------------------- INSURED: JXXX XXX AGE: 35 SEX: MALE CONTRACT NUMBER: LV1234567 DATE OF ISSUE: MAY 1, 1997 INITIAL FACE AMOUNT: $ 50,000 W3-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity VC-VUL-1 (97) Contract Number: [1234567] Effective Date: [July 1LV1234567 --------------------------------------------------------------------------- Table of Contents --------------------------------------------------------------------------- Cover Page Index Contract Schedule, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Definitions Section 2 General Provisions Section 3 Membership and Ownership Section 4 Premiums and Reinstatement Section 5 Insurance Coverage Section 6 Accumulated Value and Surrender Provisions Section 7 Monthly Deduction Section 8 Loans Section 9 Variable Account and Unit Value Section 10 Exchange of Contract Section 11 Beneficiary Section 12

Right to Cancel. There is a 10 day right to cancelYOU HAVE THE RIGHT TO RETURN THIS CONTRACT. If You may end your participation in the Contract is issued as a replacement of existing life insurance within ten days after you receive it by returning the Contract and Certificate to our administrative office, or annuity coverage, to the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with the Contract, return agent who sold it to you, with a written request for cancellation. Return by mail is effective on being post-marked, properly addressed and postage pre-paid. We will promptly return the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and feesamount deducted for premium taxes. The This amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during more or less than the Accumulation Period Purchase Payments. Xxxxxxx X. Xxxx Secretary Xxxx X. Xxxxx President THIS IS A LEGALLY BINDING CONTRACT READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY 0000 Xxxxxxx 000 Xxxxx P. O. Xxx 00000 Xxxxxxxxxx, Xxxxxxx 00000-0000 (000) 000-0000 This Page Intentionally left blank. SCHEDULE CONTRACT HOLDER: {AmSouth Bank, N.A., as Trustee.} CLASS OF ELIGIBLE OWNERS: {Account holders of Broker/Dealers with selling agreements with Protective Life Insurance Company, its subsidiaries or until its affiliates.} JURISDICTION: {This Contract is governed by the death benefit laws of the State of Alabama.} CONTRACT MAINTENANCE FEE: {$30} The contract maintenance fee is payable deducted prior to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying on each Contract Anniversary, and on any day that the Owner’s Annuity Account Value according Contract is surrendered other than the Contract Anniversary. The contract maintenance fee will be deducted from the Allocation Options in the same proportion as their values are to the Payout Options provisions of this ContractContract Value. Subsequent payouts The contract maintenance fee will be paid waived by the Company in the event the Contract Value or the aggregate Purchase Payments reduced by surrenders equals or exceeds $50,000 on the same day of each frequency period according date the contract maintenance fee is to be deducted. MORTALITY AND EXPENSE RISK CHARGE: {1.25%} per annum prior to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date, and {1.25%} per annum on or after the Annuity Commencement Date. ADMINISTRATION CHARGE: [March 1, 2014] State of Delivery{0.15%} per annum. TRANSFER FEE: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: {$[0] for each Transfer 25} per transfer in excess of 12 transfers per Certificate in any Contract Year. SURRENDER CHARGE Number of Full Years Elapsed Between the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5Effective Date and the Surrender Date Surrender Charge Percentage {1 } {6 %] MISSTATEMENT } {2 } {5 %} {3 } {5 %} {4 } {4 %} {5 +} {0 %} ALLOCATION OPTIONS AVAILABLE ON THE EFFECTIVE DATE {Protective Life Guaranteed Account} {Fixed Account} {DCA Fixed Account 1} {DCA Fixed Account 2} {Xxxxxxx Xxxxx/PIC} {International Equity} {Small Cap Value} {Capital Growth} {CORE U.S. Equity} {Growth and Income} {Global Income} {Xxxxxxx Sachs} {Internet Tollkeeper} {Massachusetts Financial Services (MFS)} {New Discovery} {Emerging Growth} {Research} {Investors Growth Stock} {Utilities} {Investors Trust} {Growth Series} {OppenheimerFunds} {Aggressive Growth} {Global Securities} {Capital Appreciation} {Main Street Growth & Income} {High Income} {Strategic Bond} {Money Fund} {Xxx Xxxxxx Life Investment Trust} {Emerging Growth} {Enterprise} {Xxxxxxxx} {Growth and Income} {Strategic Stock} {Asset Allocation} {Xxxxxxx} {Social Small Cap Growth} {Social Balanced} {Xxx Xxx} {Worldwide Hard Assets} {Worldwide Real Estate} 4 TABLE OF AGE OR SEX Interest Rate to be Applied CONTENTS Definitions 7 General Provisions 8 Entire Contract 8 Modification of the Contract 8 Assignment 8 Notice 8 Error in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Gender 8 Settlement 8 Receipt of Payment 8 Protection of Proceeds 8 Premium Tax 8 Non-Participating 8 Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as Values 9 Application of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied Law 9 Reports 9 Parties to the Contract as 9 Company 9 Owner 9 Change of Owner 9 Beneficiary 9 Change of Beneficiary 9 Annuitant 9 Change of Annuitant 9 Payee 9 Purchase Payments 10 Purchase Payment 10 Allocation of Purchase Payments 10 No Default 10 Guaranteed Account 10 Guaranteed Account Value 10 Variable Account 10 General Description 10 Sub-Accounts of the date Variable Account 11 Variable Account Value 11 Accumulation Unit Values 12 Transfers 12 Surrenders 13 Free Withdrawal Amount 13 Determining the Request for payment is received, less the impact Surrender Charge 13 Suspension or Delay in Payment of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age Surrender 13 5 Death Benefit 13 Death of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as an Owner 13 Death of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuitant 13 Death Benefit 14 Suspension of Payment 14 Annuitization 14 Annuity Commencement Date 14 Annuity Income Payments 14 Fixed Income Payments 14 Variable Income Payments 15 Annuity Unit Values 15 Selection of Annuity Options 15 Annuity Options 15 Minimum Amounts 16 Guaranteed Purchase Rates 16 Fixed Annuity Tables 16

Right to Cancel. There is a 10 day right to cancel. If This Contract may be returned for any reason within [10] days after you receive it by mailing or delivering the Contract is issued as a replacement of existing life to either us or the insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving producer who sold it. If you are not satisfied with the ContractReturn of this Contract by mail is effective on being postmarked, return it to the Retirement Resource Operations Center or an agent of the Companyproperly addressed and postage prepaid. The We will promptly refund your [Contract will be void from the start, and the Company will refund the Annuity Account Value plus any fees or charges and feesdeducted under the Contract] as of the Business Day we receive your Contract. The amount returned during the right to cancel period will not Your Contract Value may be subject to a Withdrawal Chargemore or less than your Purchase Payment. VALUES AND DETERMINATION OF ANNUITY PAYMENTS PROVIDED BY THIS CONTRACT, WHEN BASED ON THE VALUE OF THE INDEX ACCOUNT OPTIONS, ARE VARIABLE, MAY INCREASE OR DECREASE, AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. INDIVIDUAL SINGLE PREMIUM DEFERRED ANNUITY CONTRACT WITH INDEX-LINKED INTEREST OPTION Signed for Great-West Symetra Life & Annuity Insurance Company of New York Company, at its Bellevue, Washington office on the issuance of this ContractIssue Date. [ ] [ ] [/s/ Xxxxxxx Margxxxx X. Xxxxxxx] [/s/ Xxxxxx Jacqxxxxxx X. XxxxxxxxXxxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], President] [Secretary] IF YOU HAVE ANY QUESTIONS, COMMENTS OR COMPLAINTS, PLEASE CONTACT SYMETRA AT [President 1-800-000-0000] XYMETRA LIFE INSURANCE COMPANY Home Office: Administrative Office: [777 000xx Xxx XX Xxxxx 0000 [PO Box 34690 Bellevue, WA 98004] Seattle, WA 98124] [Phone 1-800-000-0000] [www.xxxxxxx.xxx] XEFINITIONS Accumulation Phase The period beginning on the Contract Date shown on your Contract Data Page and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITYending on the Annuity Date. Contributions may be made only during Adjusted Index Return The Index Return, after the Accumulation Period application of the Indexed Interest Cap and either the Indexed Interest Buffer or until the death benefit Indexed Interest Floor. Allocation Date The date when the Purchase Payment is payable allocated to a Beneficiarythe Fixed Account or one or more Indexed Account(s) for the initial Interest Term. The Owner Allocation Date will be the next 7th or 21st calendar day of a month, whichever occurs first after the Contract Date. If this date is as not a Business Day, the Allocation Date will be the next Business Day. Annuitant The natural person(s) on whose life (or lives) Annuity Payments under the Contract are based and is shown on the your Contract Data Page. The Company will pay You are the Annuitant unless you designate someone else before the first of Annuity Date. If there is a joint Annuitant, the term Annuitant as used in the Contract includes the joint Annuitant named on the application, unless changed. Annuity Date The date that the Income Phase begins. Annuity Payments A series of annuity payouts periodic payments under the Contract that begins on the Annuity Commencement Date by applying and continues for a specified period of time. Base Value The amount used to calculate an Indexed Account’s (a) Interim Value, and (b) Indexed Interest at the Owner’s Annuity end of the Interest Term. On the first day of the Interest Term, the Base Value is the amount allocated to the Indexed Account. During the Interest Term the Base Value equals the amount allocated to the Indexed Account on the first day of the Interest Term reduced for any partial withdrawals from the Indexed Account based on the proportion of the Indexed Account Value according to that was withdrawn. The Base Value is not a cash value under the Payout Options provisions of this Contract. Subsequent payouts will be paid on Beneficiary The person(s) or entity (or entities), designated by the same day of each frequency period according Owner(s) to receive the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in Business Day Any day that the Death Benefit provisionsNew York Stock Exchange (“NYSE”) is open for regular trading. A Business Day ends at the same time that regular trading on the NYSE closes (typically, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 34:00 pm Eastern Time).

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within [ 10 ] days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period more or until the death benefit is payable to a Beneficiaryless than your Purchase Payments. The THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY [ xxx.Xxxxxxxxxx.xxx ] [ 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ] ICC11-VDA-P-2006C-WX [ 12/11 ] TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant the first 8 Death Benefit 8 Payment of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the 9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Account Value as Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period more or until the death benefit is payable to a Beneficiaryless than your Purchase Payments. The THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY xxx.Xxxxxxxxxx.xxx 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ICC11-VDA-P-2006C-WW 12/11 TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant the first 8 Death Benefit 8 Payment of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the 9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Account Value as Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12

Right to Cancel. There is a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, The Shrewsbury Club reserves the right to cancel period terminate your registration when one or more of the following circumstances apply: non-payment of balance 90 days overdue, violation of club policies/privileges, or at the discretion of the Owner or General Manager for any reason. Dance Class payments will not be refunded when registration is extended terminated. If damages to 60 days from the date facility/equipment occur, the participant shall be responsible for incurring any such fees. Name: Parent/Guardian’s Name: Address: City: State: Zip: Phone:( ) Email: DOB: / / First Bill Date: / / Monthly EFT Payment: $ Member /$ Non-Member Class: Day(s)/Time(s): I have read and agree to the above terms: Signature: Date: / / Printed Name: Club Representative: Date: / / Printed Name: …………………………………………………………………………………………………………………………………………………………... METHOD OF PAYMENT Card on File? Routing #: Checking Account #: Credit Card Type: Credit Card # CVV: Exp. Date: / Dance PIF Session Reg. Check one : Fall 1 ( ) Fall 2 ( ) KIDZ CLUB MAKEUP POLICY There will be no refunds for classes missed because of receiving itconflicting schedule or illness. If you wish to make up a missed class, you must schedule it prior with the instructor. Make up classes are available as long as there is reasonable availability in a similar age and rank of class. In the event of classes cancelled by The Club due to weather, facility’s inability to operate, or instructor illness; a make up class will be provided as long as there is additional space and availability in accordance with our club wide program- ming schedule. Otherwise, a club credit will be applied to your account for the cancelled class. By initialing, I agree to abide by the above policy: (int.) SESSION VOLUNTARY CANCELLATION POLICY If you are enrolled in Kidz Club programming, making payments by the session, and choose to cancel mid-session no credit or refund will be issued. By initialing, I agree to abide by the above policy: (int.) SESSION INVOLUNTARY CANCELLATION POLICY The only acceptable reasons for cancellation mid-session are listed below: •If upon a Doctor’s order you cannot physically or medically receive the services because of significant physical or medi- cal disability •If you move your residence more than twenty-five miles from the facility’s principle address •In case of life changing events: loss of job, divorce, death •If the martial arts services to be provided under this contract are not satisfied with available for more than 30 days because the Contract, return it seller fails to open a facility equipped for the services to be rendered Credit on account will be issued for the un-used portion of the session. Cancellation is complete once the client receives an email confirmation from a Shrewsbury Club Management Repre- sentative. Do not assume cancellation is complete without receiving email confirmation. Any cancellation must be deliv- ered in writing or by email to the Retirement Resource Operations Center Kidz Club or an agent Business Office by the 20th day of the Companymonth. The Contract will be void from By initialing, I agree to abide by the start, above policy: (int.) Name: Parent/Guardian’s Name: Address: City: State: Zip: Phone:( ) Email: DOB: / / Class: Day(s)/Time(s): Session Payment: $ Member /$ Non-Member I have read and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according agree to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Numberabove terms: [1234567] Effective Signature: Date: [July 1, 2012] Status of Annuity/ / Printed Name: [Non-Qualified Annuity ] Initial ContributionClub Representative: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery/ / Printed Name: [New York] Department of Insurance Telephone Number…………………………………………………………………………………………………………………………………………………………... METHOD OF PAYMENT Card on File? Routing #: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Checking Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3#:

Right to Cancel. There is a You may return this Contract within 10 day right to canceldays after you receive it. If You may return the Contract is issued as a replacement of existing life insurance by delivering or annuity coverage, the right mailing it to cancel period is extended to 60 days SBL. This Contract will then be deemed void from the date beginning. No withdrawal charge will be imposed, and we will refund your Contract Value, including any fees and/or charges for Premium tax that were deducted from that Contract Value, less the value of receiving it. If you are not satisfied with any Credit Enhancements made into the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date we receive the Request returned Contract. Signed for payment is received less Premium Tax, if any; or · the sum of Contributions applied to Security Benefit Life Insurance Company on the Contract as of Date. {J. Michael Keefer} {Kris A. Robbins} Xxxxxxxxx President A BRIEF DESCRIPTION OF THIS CONTRACT This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT. * Investment Experience is Reflected in Benefits * Variable and Fixed Accumulation Before the date Annuity Start Date; Variable and Fixed Annuity Payments Thereafter * Death Benefit Proceeds are Payable Before the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION Annuity Start Date * This Contract Data Pageis Non-Participating BENEFITS AND VALUES PROVIDED BY THIS CONTRACT MAY BE ON A VARIABLE BASIS. AMOUNTS DIRECTED INTO ONE OR MORE OF THE SUBACCOUNTS WILL REFLECT THE INVESTMENT EXPERIENCE OF THOSE SUBACCOUNTS. THESE AMOUNTS MAY INCREASE OR DECREASE AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. (SEE "CONTRACT VALUE AND EXPENSE PROVISIONS" AND "ANNUITY PAYMENT PROVISIONS" FOR DETAILS.) Security Benefit Life Insurance Company One Security Benefit Plxxx, together with Xxxxxx, XX 00000-0000 1-800-888-2461 The varixxxx xxxxxxx xovered by this Contract is the Initial Applicable Allocation Confirmation, reflects subject of a pending patent application in the information with which your Contract has been established as of the Effective DateUnited States Patent and Trademark Office. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. V6029 (11-00) -------------------------------------------------------------------------------- TABLE OF CONTENTS -------------------------------------------------------------------------------- Page CONTRACT DATA............................................................................................................. 1 Section 1 DATA PAGE................................... 25 DEFINITIONS............................................................................................................ 3.......................................... 4

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within 10 days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period more or until the death benefit is payable to a Beneficiaryless than your Purchase Payments. The THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY xxx.Xxxxxxxxxx.xxx 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ICC11-VDA-P-2006C-WW 12/11 TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant the first 8 Death Benefit 8 Payment of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the 9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Account Value as Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12 Protective Dimensions Schedule CONTRACT NUMBER ISSUE DATE OWNER 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE BIRTH DATE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3OWNER 1

Right to Cancel. There is a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance The Owner may surrender this contract by delivering or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with the Contract, return mailing it to the Retirement Resource Operations Center Company at its Servicing Office (or, if applicable, to the agent or an agent agency office through which it was delivered) within 10 days after receipt by the Owner of this contract. Receipt by the Company. The Contract Owner of this contract will be void from deemed to occur (i) on the start, and date the Company sends an electronic mail message ("e-mail") to the Owner's address as provided confirming that this contract is available to be viewed on the website used by the Company for document delivery or (ii) if applicable, on the fifth day after this contract has been placed in the U.S. Mail, first class postage prepaid, addressed to the Owner. Upon exercise of this Right to Cancel, We will refund the Annuity Account sum of (i) the Accumulated Value plus any at the end of the Valuation Period immediately preceding cancellation notice and (ii) the sum of all charges and feesmade with respect to this contract. The amount returned Any Premium(s) received during the right this Right to cancel Cancel period will not be subject allocated to a Withdrawal Chargethe Money Market Variable Investment Option. Signed for Great-West Life & the Company at Boston, Massachusetts. /s/ Xxxxxxxx X. Xxxxxxx /s/ Xxxxx Xxxxxxxxxxx ------------------- ----------------- President Secretary Flexible Premium Variable Deferred Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit Nonparticipating Initial premium is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contractin Section 1. This Contract form is non- participating a legal contract between the Applicant and not eligible to share in the Company’s divisible surplusInsurer. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1Read this contract carefully. THE BENEFITS, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1PAYMENTS AND ACCUMULATED VALUE UNDER THIS CONTRACT, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1WHEN BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT ARE VARIABLE AND NOT GUARANTEED AS TO DOLLAR AMOUNT. THE VALUES OF AGE THE VARIABLE INVESTMENT OPTIONS MAY INCREASE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death BenefitDECREASE. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if anySEE SECTION 8 FOR DETAILS. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] 00DVA VA0100 CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3PROVISIONS Numerical Guide Section

Right to Cancel. There is The Contract Holder may cancel this Contract within 10 days of receiving it by returning this Contract along with a 10 day right written notice to cancelAetna at the above address or to the agent from whom it was purchased. If Within 7 days after it receives the notice of cancellation and this Contract is issued as a replacement at its Home Office, Aetna will return the entire consideration paid plus any increase or minus any decrease in the current value of existing life insurance or annuity coverageany funds allocated to the Separate Account. This page, the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the startfollowing pages, and the Company will refund application make up the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Chargeentire Contract. Signed for Great-West Life & Annuity Insurance Company of New York at the Home Office on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected/s/ Xxxx X. Xxxxxxx /s/ Xxxxxx X. Xxxxxxx Xxxx X. Xxxxxxx Xxxxxx X. Xxxxxxx President Secretary Multiple Asset Portfolio (MAP) V-Allocated Group Annuity Contract Nonparticipating ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, please contact WHEN BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THIS CONTRACT CONTAINS MARKET VALUE ADJUSTMENT FORMULAS. APPLICATION OF A MARKET VALUE ADJUSTMENT TO THE GAA MAY RESULT IN EITHER AN INCREASE OR DECREASE IN THE CURRENT VALUE. THE MARKET VALUE ADJUSTMENT FORMULA DOES NOT APPLY TO A GUARANTEED TERM AT THE TIME OF ITS MATURITY. APPLICATION OF A MARKET VALUE ADJUSTMENT TO THE FIXED ACCOUNT MAY RESULT IN A DECREASE IN THE CURRENT VALUE. SPECIFICATIONS (continued) GUARANTEED There are guaranteed interest rates for amounts held INTEREST RATE in the Retirement Resource Operations CenterFixed Account and the Guaranteed Accumulation Account. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3(See 4.02 and 4.03(d).)

Right to Cancel. The Group Contract Holder may cancel this Contract within 10 days by returning it to the agent from whom it was purchased, or to Aetna at the address shown above. Within seven days of receiving the Contract at its home office, Aetna will return the amount of Certificate Holder Purchase Payment(s) received, plus any increase, or minus any decrease, on the amount, if any, allocated to the Separate Account fund(s). This page and the pages that follow constitute the entire Contract. Signed at the home office on the Effective Date. /s/ Xxxxxx Xxxxxxx /s/ Xxxxx X. XxXxxx President Secretary Group Variable, Fixed, or Combination Annuity Contract Nonparticipating ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THIS CONTRACT CONTAINS A MARKET VALUE ADJUSTMENT FORMULA. APPLICATION OF A MARKET VALUE ADJUSTMENT MAY RESULT IN EITHER AN INCREASE OR DECREASE IN THE CURRENT VALUE. THE MARKET VALUE ADJUSTMENT FORMULA DOES NOT APPLY TO A GUARANTEED TERM AT THE TIME OF ITS MATURITY. G-MP2(5/96) Specifications -------------------------------------------------------------------------------- Guaranteed There is a 10 day right to cancelguaranteed interest rate for Purchase Interest Rate Payment(s) held in the AG Account. If the (See Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days Schedule I). -------------------------------------------------------------------------------- Deductions from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract There will be void from deductions for mortality and expense the start, Separate risks and the Company will refund the Annuity Account Value plus any charges and administrative fees. The amount returned during the right to cancel period will not be (See Contract Account Schedule I and II). -------------------------------------------------------------------------------- Deduction from Purchase Payment(s) are subject to a Withdrawal Chargededuction for Purchase premium taxes, if any. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts (See 3.01.) Payment(s) -------------------------------------------------------------------------------- Surrender There will be paid on the same day of each frequency period according to the provisions of this Contracta charge deducted upon surrender. (See Fee Contract Schedule I). This Contract is non- participating a legal contract and not eligible constitutes the entire legal relationship between Aetna and the Contract Holder. READ THIS CONTRACT CAREFULLY. This Contract sets forth, in detail, all of the rights and obligations of both you and Aetna. THEREFORE, IT IS IMPORTANT THAT YOU READ THIS CONTRACT CAREFULLY. Contract Schedule I Accumulation Period Separate Account -------------------------------------------------------------------------------- Separate Account: Variable Annuity Account I Charges to share Separate A daily charge is deducted from any portion of the Account: Current Value allocated to the Separate Account. The deduction is the daily equivalent of the annual effective percentage shown in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Numberfollowing chart: [1234567] Effective Date: [July 1, 2012] Status Administrative Charge 0.15% Mortality Risk Charge 0.35% Expense Risk Charge 0.90% ----- Total Separate Account Charges 1.40% AICA Guaranteed Account (AG Account) -------------------------------------------------------------------------------- Minimum Guaranteed 3.0% (effective annual rate of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed return) Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate Separate Account and AG Account -------------------------------------------------------------------------------- Transfers: An unlimited number of Transfers are allowed during the Accumulation Period. Aetna allows 12 free Transfers in any calendar year. Thereafter, Aetna reserves the right to be Applied in Adjusting charge $10 for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3each subsequent Transfer.

Right to Cancel. The Contract Holder may cancel this Contract within 10 days of receiving it by returning this Contract along with a written notice to Aetna at the above address or to the agent from whom it was purchased. Within 7 days after it receives the notice of cancellation and this Contract at its Home Office, Aetna will return the entire consideration paid. This page, the following pages, and the application make up the entire Contract. Signed at the Home Office on the Effective Date. /s/Xxxxxx Xxxxxxx /s/Xxxxx X. Xxxxxxxxx President Secretary Group Variable, Fixed, or Combination Annuity Contract Nonparticipating ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THIS CONTRACT CONTAINS A MARKET VALUE ADJUSTMENT FORMULA. APPLICATION OF A MARKET VALUE ADJUSTMENT MAY RESULT IN EITHER AN INCREASE OR DECREASE IN THE CURRENT VALUE. THE MARKET VALUE ADJUSTMENT FORMULA DOES NOT APPLY TO A GUARANTEED TERM AT THE TIME OF ITS MATURITY. Specifications -------------------------------------------------------------------------------- Guaranteed There is a 10 day right to cancelguaranteed interest rate for Purchase Payment(s) Interest Rate held in the ALIAC Guaranteed Account (see Contract Schedule I). If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days -------------------------------------------------------------------------------- Deductions from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract There will be void from the start, deductions for mortality and expense risks and the Company will refund the Annuity Separate administrative fees (see Contract Schedule I and II). Account Value plus any charges and fees. The amount returned during the right to cancel period will not be -------------------------------------------------------------------------------- Deduction from Purchase Payment(s) are subject to a Withdrawal Chargededuction for premium Purchase taxes, if any (see 3.01). Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts Payment(s) -------------------------------------------------------------------------------- Surrender There will be paid on the same day of each frequency period according to the provisions of this Contracta charge deducted upon surrender (see Contract Fee Schedule I). This Contract is non- participating a legal contract and not eligible constitutes the entire legal relationship between Aetna and the Contract Holder. READ THIS CONTRACT CAREFULLY. This Contract sets forth, in detail, all of the rights and obligations of both you and Aetna. IT IS THEREFORE IMPORTANT THAT YOU READ THIS CONTRACT CAREFULLY. Contract Schedule I Accumulation Period Separate Account -------------------------------------------------------------------------------- Separate Account: Variable Annuity Account B Charges to share Separate A daily charge is deducted from any portion of the Account: Current Value allocated to the Separate Account. The deduction is the daily equivalent of the annual effective percentage shown in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Numberfollowing chart: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Administrative Charge 0.15% Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Risk Charge 0.35% Expense Risk Charge: [1.20Charge 0.90% ----- Total Separate Account Charges 1.40%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within [ 10 ] days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not may be subject to a Withdrawal Chargemore or less than your Purchase Payments. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxx X. Xxxxx /s/ Xxxxxxx XxxxxxxX. Xxxx THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY [ xxx.Xxxxxxxxxx.xxx ] [/s/ Xxxxxx X. Xxxxxxxx[ 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant the first 8 Death Benefit 8 Payment of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12 [ PRODUCT A ] SCHEDULE CONTRACT NUMBER ISSUE DATE [ VA00000001 ] [ February 1, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 32012 ]

Right to Cancel. There is a 10 day right to cancelYOU HAVE THE RIGHT TO RETURN THIS CONTRACT. If You may cancel this Contract within ten days after you receive it by returning the Contract is issued as a replacement of existing life insurance to our administrative office, or annuity coverage, to the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with agent who sold the Contract, with a written request for cancellation. Return of this Contract by mail is effective on being post-marked, properly addressed and postage pre-paid. We will promptly return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and feesamount deducted for premium taxes. The This amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period more or until the death benefit less than your Purchase Payments. Xxxxxxx X. Xxxx Secretary Xxxx X. Xxxxx President THIS IS A LEGAL CONTRACT READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY 0000 Xxxxxxx 000 Xxxxx X. X. Box 10648 Birmingham, Alabama 35202-0648 (000) 000-0000 This Page Intentionally left blank. SCHEDULE CONTRACT NUMBER PVA20000001 EFFECTIVE DATE May 15, 2001 OWNER Xxxx X. Xxx BIRTH DATE OF OWNER November 5, 1953 JOINT OWNER N/A BIRTH DATE OF JOINT OWNER N/A ANNUITANT Xxxx X. Xxx BIRTH DATE OF ANNUITANT November 5, 1953 BENEFICIARY As contained in our records ANNUITY COMMENCEMENT DATE November 5, 2043 INITIAL PURCHASE PAYMENT: {$100,000.00} ANNUAL EFFECTIVE INTEREST RATE FOR THE FIXED ACCOUNT ON THE EFFECTIVE DATE: {4.00%} ANNUAL EFFECTIVE INTEREST RATE FOR DCA FIXED ACCOUNT 1 ON THE EFFECTIVE DATE: {5.00%} ANNUAL EFFECTIVE INTEREST RATE FOR DCA FIXED ACCOUNT 2 ON THE EFFECTIVE DATE: {4.50%} BENEFIT PACKAGE: {Standard} CONTRACT MAINTENANCE FEE: $30 The contract maintenance fee is payable deducted prior to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying on each Contract Anniversary, and on any day that the Owner’s Annuity Account Value according Contract is surrendered other than the Contract Anniversary. The contract maintenance fee will be deducted from the Allocation Options in the same proportion as their values are to the Payout Options provisions of this ContractContract Value. Subsequent payouts The contract maintenance fee will be paid waived by the Company in the event the Contract Value or the aggregate Purchase Payments reduced by surrenders equals or exceeds $50,000 on the same day of each frequency period according date the contract maintenance fee is to be deducted. MORTALITY AND EXPENSE RISK CHARGE: {1.25%} per annum prior to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date, and 1.25% per annum on or after the Annuity Commencement Date. ADMINISTRATION CHARGE: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee0.15% per annum. TRANSFER FEE: $[0] for each Transfer 25 per transfer in excess of 12 in any Contract Year. SURRENDER CHARGE Number of Full Years Elapsed Between the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT Effective Date and the Surrender Date Surrender Charge Percentage 1 6 % 2 5 % 3 5 % 4 4 % 5 + 0 % ALLOCATION OPTIONS AVAILABLE ON THE EFFECTIVE DATE {Protective Life Guaranteed Account} {Fixed Account} {DCA Fixed Account 1} {DCA Fixed Account 2} {Xxxxxxx Xxxxx/PIC} {International Equity} {Small Cap Value} {Capital Growth} {CORE U.S. Equity} {Growth and Income} {Global Income} {Xxxxxxx Xxxxx} {Internet Tollkeeper} {Massachusetts Financial Services (MFS)} {New Discovery} {Emerging Growth} {Research} {Investors Growth Stock} {Utilities} {Investors Trust} {Growth Series} {OppenheimerFunds} {Aggressive Growth} {Global Securities} {Capital Appreciation} {Main Street Growth & Income} {High Income} {Strategic Bond} {Money Fund} {Xxx Xxxxxx Life Investment Trust} {Aggressive Growth} {Emerging Growth} {Enterprise} {Xxxxxxxx} {Growth and Income} {Strategic Stock} {Asset Allocation} {Xxxxxxx} {Social Small Cap Growth} {Social Balanced} {Xxx Xxx} {Worldwide Hard Assets} {Worldwide Real Estate} 4 TABLE OF AGE OR SEX Interest Rate to be Applied CONTENTS Definitions 7 General Provisions 8 Entire Contract 8 Modification of the Contract 8 Assignment 8 Notice 8 Error in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Gender 8 Settlement 8 Receipt of Payment 8 Protection of Proceeds 8 Premium Tax 8 Non-Participating 8 Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as Values 9 Application of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied Law 9 Reports 9 Parties to the Contract as 9 Company 9 Owner 9 Change of Owner 9 Beneficiary 9 Change of Beneficiary 9 Annuitant 9 Change of Annuitant 9 Payee 9 Purchase Payments 10 Purchase Payment 10 Allocation of Purchase Payments 10 No Default 10 Guaranteed Account 10 Guaranteed Account Value 10 Variable Account 10 General Description 10 Sub-Accounts of the date Variable Account 11 Variable Account Value 11 Accumulation Unit Values 12 Transfers 12 Surrenders 13 Free Withdrawal Amount 13 Determining the Request for payment is received, less the impact Surrender Charge 13 Suspension or Delay in Payment of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age Surrender 13 5 Death Benefit 13 Death of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as an Owner 13 Death of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuitant 13 Death Benefit 14 Suspension of Payment 14 Annuitization 14 Annuity Commencement Date 14 Annuity Income Payments 14 Fixed Income Payments 14 Variable Income Payments 15 Annuity Unit Values 15 Selection of Annuity Options 15 Annuity Options 15 Minimum Amounts 16 Guaranteed Purchase Rates 16 Fixed Annuity Tables 16

Right to Cancel. The Group Contract Holder may cancel this Contract within 10 days by returning it to the agent from whom it was purchased, or to Aetna at the address shown above. Within seven days of receiving the Contract at its home office, Aetna will return the amount of Certificate Holder Purchase Payment(s) received, plus any increase, or minus any decrease, on the amount, if any, allocated to the Separate Account fund(s). This page and the pages that follow constitute the entire Contract. Signed at the home office on the Effective Date. /s/ Xxxxxx Xxxxxxx /s/ Xxxxx X. XxXxxx President Secretary Group Variable, Fixed, or Combination Annuity Contract Nonparticipating ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, WHEN BASED ON INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. THIS CONTRACT CONTAINS A MARKET VALUE ADJUSTMENT FORMULA. APPLICATION OF A MARKET VALUE ADJUSTMENT MAY RESULT IN EITHER AN INCREASE OR DECREASE IN THE CURRENT VALUE. THE MARKET VALUE ADJUSTMENT FORMULA DOES NOT APPLY TO A GUARANTEED TERM AT THE TIME OF ITS MATURITY. G-MP2(5/96) <PAGE> Specifications - -------------------------------------------------------------------------------- Guaranteed There is a 10 day right to cancelguaranteed interest rate for Purchase Interest Rate Payment(s) held in the AG Account. If the (See Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days Schedule I). - -------------------------------------------------------------------------------- Deductions from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract There will be void from deductions for mortality and expense the start, Separate risks and the Company will refund the Annuity Account Value plus any charges and administrative fees. The amount returned during the right to cancel period will not be (See Contract Account Schedule I and II). - -------------------------------------------------------------------------------- Deduction from Purchase Payment(s) are subject to a Withdrawal Chargededuction for Purchase premium taxes, if any. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts (See 3.01.) Payment(s) - -------------------------------------------------------------------------------- Surrender There will be paid on the same day of each frequency period according to the provisions of this Contracta charge deducted upon surrender. (See Fee Contract Schedule I). This Contract is non- participating a legal contract and not eligible constitutes the entire legal relationship between Aetna and the Contract Holder. READ THIS CONTRACT CAREFULLY. This Contract sets forth, in detail, all of the rights and obligations of both you and Aetna. THEREFORE, IT IS IMPORTANT THAT YOU READ THIS CONTRACT CAREFULLY. <PAGE> Contract Schedule I Accumulation Period Separate Account - -------------------------------------------------------------------------------- Separate Account: Variable Annuity Account I Charges to share Separate A daily charge is deducted from any portion of the Account: Current Value allocated to the Separate Account. The deduction is the daily equivalent of the annual effective percentage shown in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Numberfollowing chart: [1234567] Effective Date: [July 1, 2012] Status Administrative Charge 0.15% Mortality Risk Charge 0.35% Expense Risk Charge 0.90% ----- Total Separate Account Charges 1.40% AICA Guaranteed Account (AG Account) - -------------------------------------------------------------------------------- Minimum Guaranteed 3.0% (effective annual rate of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed return) Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate Separate Account and AG Account - -------------------------------------------------------------------------------- Transfers: An unlimited number of Transfers are allowed during the Accumulation Period. Aetna allows 12 free Transfers in any calendar year. Thereafter, Aetna reserves the right to be Applied in Adjusting charge $10 for Misstatement of Age each subsequent Transfer. Maintenance Fee: The annual Maintenance Fee is $30. If the Account's Current Value is $50,000 or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of more on the date the Request for payment Maintenance Fee is received less Premium Taxto be deducted, if any; or · the sum Maintenance Fee is $0. <PAGE> Contract Schedule I (Continued) Accumulation Period Separate Account and AG Account (Cont'd) - -------------------------------------------------------------------------------- Surrender Fee: For each surrender, the Surrender Fee will be determined as follows: Surrender Fee (as percentage Length of Contributions applied to the Contract as Time from Deposit of the date the Request for payment is received, less the impact Net of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution Net Purchase Purchase Payment (Being W ithdrawnYears) W ithdrawal Charge % Payment) ------------------------ -------- Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 or more but less than 4 years old or older, but not yet 3 years old 6% 3 4 or more but less than 5 years old or older, but not yet 4 years old 5% 4 5 or more but less than 6 years old or older, but not yet 5 years old 4% 5 6 or more but less than 7 years old 3% 7 years or older more 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as % Systematic Withdrawal The specified payment or specified percentage may Option (SWO): not be greater than 10% of the Effective DateAccount's Current Value at time of election. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations CenterSee 1. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3GENERAL DEFINITIONS for explanations. <PAGE> Contract Schedule II

Right to Cancel. There Please read this contract carefully. You may cancel the contract before midnight of the latest of: (1) The 10th day after you first receive it; (2) The 45th day after you complete Part I of the Application; and (3) The 10th day after a notice of withdrawal right is a 10 day right mailed or delivered to cancelyou. If Do this by (1) sending or delivering written notice to Lutheran Brotherhood Variable Insurance Products Company, 600 Xxxxxx Xxxxxx Xxxxx, Xxxxxxxxxxx, XX 00000 or to the Contract is issued as a replacement representative through whom you bought it, and (2) returning the contract. Notice given by mail and return of existing life insurance or annuity coveragethe contract by mail are effective on being postmarked, the right to cancel period is extended to 60 days from the date of receiving itproperly addressed and postage prepaid. If you are not satisfied with cancel the Contractcontract, return it to the Retirement Resource Operations Center or an agent of the Company. The Contract will be deemed void from the start, beginning. Within 7 days after we receive notice of cancellation and the Company returned contract, we will refund the Annuity Account Value plus any charges and feesall premiums you have paid. The amount returned during the right Life insurance payable at death. Adjustable death benefit. Flexible premiums. Return on investments reflected in contract benefits. Nonparticipating. Settlement options to cancel period will not be subject to a Withdrawal Chargeprovide retirement income. Signed for Greatthe Company at Minneapolis, Minnesota ---------------------------------------------------------------------------- President SAMPLE /s/ Rxxxxx X. Xxxxxxx ---------------------------------------------------------------------------- Secretary SAMPLE /s/ Dxxxx X. Xxxxxx ---------------------------------------------------------------------------- INSURED: JXXX XXX AGE: 35 SEX: MALE CONTRACT NUMBER: V1234567 DATE OF ISSUE: MAY 1, 1997 INITIAL FACE AMOUNT: $ 50,000 V3-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity YC-VUL-1 (97) Contract Number: [1234567] Effective Date: [July 1V1234567 --------------------------------------------------------------------------- Table of Contents --------------------------------------------------------------------------- Cover Page Index Contract Schedule, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Definitions Section 2 General Provisions Section 3 Ownership and Beneficiary Section 4 Premiums and Reinstatement Section 5 Insurance Coverage Section 6 Accumulated Value and Surrender Provisions Section 7 Monthly Deduction Section 8 Loans Section 9 Variable Account and Unit Value Section 10 Exchange of Contract Section 11

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within [ 10 ] days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to by mail, the Retirement Resource Operations Center cancellation will be effective on the postmark date on the properly addressed and postage-paid envelope. We will promptly return your Contract Value. This amount may be more or an agent less than your Purchase Payment. In states where specifically required, we will promptly return the greater of your Purchase Payment, or the Contract Value. THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY [ xxx.Xxxxxxxxxx.xxx ] [ 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35201-1928 (000) 000-0000 ] SG-RILA-P-2017 [ 4/20 ] TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 3 Annuitant 3 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Company. The Contract will be void from 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 4 Separate Account 4 Assignment 4 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 5 Settlement 5 Receipt of Payment 5 Premium Tax 5 Notice 5 PURCHASE PAYMENT AND ALLOCATION INSTRUCTIONS 5 Purchase Payment 5 Allocation Instructions 6 Reallocating Contract Value on Maturity Dates 6 HOLDING ACCOUNT 7 Holding Account 7 Crediting Interest 7 Holding Account Value 7 THE STRATEGIES 8 Strategies, Generally 8 Strategy Elements 8 Confirming Your Strategy Elections 9 HOW WE USE THE REFERENCE INDEXES 9 Reference Index 9 Unavailability of, or Substantial Change to an Index 9 Index Performance 9 STRATEGY PERFORMANCE AND VESTING 9 Strategy Performance 9 Vesting Factor 10 STRATEGY BASE AND STRATEGY VALUE 10 General Description 10 Base (Strategy Base) 10 Value (Strategy Value) 11 XXXXXXXXXXX AND SURRENDERS 11 Withdrawals 11 Important Considerations Regarding Withdrawals 11 Market Value Adjustment (“MVA”) and Withdrawal Charge 12 MVA and Withdrawal Charge Waivers 12 Calculating Amounts Associated with a Withdrawal (or Surrender) Request 12 Prompt Payment and Suspension or Delay in Payment of Withdrawal or Surrender 13 DEATH BENEFIT 13 Death of an Owner 13 Death of the start, and Annuitant 13 Death Benefit 13 Payment of the Company will refund Death Benefit 13 INCOME PAYMENTS 14 Annuity Date 14 Income Payments 14 Selection of the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for GreatOption 14 Annuity Options 14 Minimum Amounts 15 Guaranteed Purchase Rates 15 FIXED ANNUITY TABLES 15 ENDORSEMENTS AND RIDERS following contract page 15 [ PROTECTIVE MARKET DEFENDER II ] SCHEDULE CONTRACT NUMBER ISSUE DATE [ IMG00000001 ] [ August 20, 2018 ] PURCHASE PAYMENT APPLIED ON THE ISSUE DATE TAX-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx XxxxxxxQUALIFIED STATUS [ $50,000.00 ] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [[ Non-Qualified Annuity ] Initial Contribution: [$50,000PRIMARY OWNER BIRTH DATE OF PRIMARY OWNER [ Xxxx Xxx ] Annuity Commencement Date: [March 1[ October 15, 20141952 ] State JOINT OWNER BIRTH DATE OF JOINT OWNER [ None ] [ Not Applicable ] ANNUITANT BIRTH DATE OF ANNUITANT [ Xxxx Xxx ] [ October 15, 1952 ] BENEFICIARY DEATH BENEFIT As contained in our records [ Optional — Return of Delivery: [New YorkPurchase Payment ] AGENT ANNUITY DATE [ Xxxxx Agent ] [ October 15, 2047 ] [ Brisk Financial Services ] [ 0000 Xxxx Xxxxxx ] INSURANCE REGULATORY AUTHORITY [ Anycity, Anystate 12345 ] [ Anystate Department of Insurance Telephone Number: [XXX] [ 000-XXX000-XXXX0000 ] OWNER INFORMATION Owner: [XXXX X. XXX[ 000-000-0000 ] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3[ xxxxxxx.xxx@xxxxxxxx.xxx ]

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not may be subject to a Withdrawal Chargemore or less than your Purchase Payments. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxx, President Xxxxx X. Xxxxxxxx] [, Secretary THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY xxx.Xxxxxxxxxx.xxx 0000 Xxxxxxx Xxxxxxx]000 Xxxxx, [Xxxxxx X. Xxxxxxxx]Xxxxxxxxxx, [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant the first 8 Death Benefit 8 Payment of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the 9 Suspension or Delay in Payment of Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Account Value as Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuity Option 10 Annuity Options 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12

Right to Cancel. There is YOU HAVE THE RIGHT TO RETURN THIS CONTRACT. You may cancel this Contract within [ 10 ] days after you receive it by returning it to our administrative office, or to the agent who sold it to you, with a 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itwritten request for cancellation. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent by mail, effective date of the Company. The Contract cancellation will be void from determined by the start, postmark date on the properly addressed and postage-paid return package. We will promptly return the Company will refund the Annuity Account Contract Value plus any charges and feesamounts deducted from your Purchase Payments before they were applied to this Contract. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period more or until the death benefit is payable to a Beneficiaryless than your Purchase Payments. The THIS IS A LEGALLY BINDING CONTRACT - READ IT CAREFULLY Administrative Office: PROTECTIVE LIFE INSURANCE COMPANY xxx.Xxxxxxxxxx.xxx 0000 Xxxxxxx 000 Xxxxx, Xxxxxxxxxx, Xxxxxxx 00000 P. O. Box 1928, Birmingham, Alabama 35282-8238 (000) 000-0000 ICC11-VDA-P-2006C-WX 12/11 TABLE OF CONTENTS SCHEDULE A DEFINITIONS 1 PARTIES TO THE CONTRACT 2 Company 2 Owner is as shown on 2 Change of Owner 2 Beneficiary 2 Change of Beneficiary 2 Annuitant 2 Change of Annuitant 3 Payee 3 GENERAL PROVISIONS 3 Entire Contract 3 Modification of the Contract Data Page. The Company will pay 3 Non-Participating 3 Incontestability 3 Application of Law 3 Form Approval 3 Assignment 3 Protection of Proceeds 4 Minimum Values 4 Reports 4 Error in Age or Gender 4 Settlement 4 Receipt of Payment 4 Premium Tax 4 Written Notice 4 PURCHASE PAYMENTS 5 Purchase Payments 5 Allocation of Purchase Payments 5 VARIABLE ACCOUNT 5 General Description 5 Sub-Accounts of the Variable Account 5 Variable Account Value 6 Accumulation Unit Values 6 Net Investment Factor 7 TRANSFERS 7 Transfers 7 Limitation on Frequent Transfers 7 Dollar Cost Averaging 7 SURRENDERS AND WITHDRAWALS 8 Surrenders 8 Withdrawals 8 Surrender Value 8 Suspension or Delay in Payment of Surrender or Withdrawal 8 DEATH BENEFIT 8 Death of an Owner 8 Death of the Annuitant 8 Death Benefit 8 Payment of the first Death Benefit 9 Suspension or Delay in Payment of a series Death Benefit 9 ANNUITY INCOME PAYMENTS 9 Annuity Date 9 Annuity Income Payments 9 Fixed Income Payments 9 Variable Income Payments 10 Annuity Unit Values 10 Selection of annuity payouts on the Annuity Commencement Date by applying the Owner’s Option 10 Annuity Account Value according to the Payout Options provisions 11 Minimum Amounts 11 Guaranteed Purchase Rates 11 FIXED ANNUITY TABLES 12 VARIABLE ANNUITY TABLES 12 [ PROTECTIVE VARIABLE ANNUITY INVESTORS SERIES ADV ] SCHEDULE CONTRACT NUMBER ISSUE DATE [ Contract Number ] [ Month Day, Year ] OWNER 1 BIRTH DATE OF OWNER 1 [ Owner 1 Name ] [ Month Day, Year ] OWNER 2 BIRTH DATE OF OWNER 2 [ Owner 2 Name or “None” ] [ Month Day, Year or “Not Applicable” ] ANNUITANT BIRTH DATE OF ANNUITANT [ Annuitant Name ] [ Month Day, Year ] BENEFICIARY ANNUITY DATE As contained in our records [ Month Day, Year ] DEATH BENEFIT [ “Contract Value” or “Return of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567Purchase Payments” ] Effective Date: [July 1, 2012AGENT INSURANCE REGULATORY AUTHORITY [ Agent Name ] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] [ State of Delivery: [New York] Department of Insurance Telephone Number: [XXXName ] [ Agency Name ] [ State DOI Phone ] [ Agency Street Address ] [ State DOI Email or Website ] [ Agency City State ZIP ] [ Agency Phone ] INITIAL PURCHASE PAYMENT TAX-XXXQUALIFIED STATUS [ $nnn,nnn.nn ] [ Type of Qualified Plan or “Non-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Qualified” ]

Right to Cancel. There is a The Contract Holder may cancel this Contract within 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 calendar days from the date of receiving it. If you are not satisfied with the Contract, return it by returning it to ALIAC at the Retirement Resource Operations Center address shown above, or an to the agent from whom it was purchased. Within seven calendar days of receiving the Companycancellation request at its Home Office, ALIAC will return any Contributions received, plus any increase, or minus any decrease in value, on the amount, if any, allocated to the Separate Account. The Contract Contributions to the Guaranteed Accumulation Account will be void from the startreturned, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal ChargeMarket Value Adjustment, which may be positive or negative. Signed for Great-West Life & Annuity Insurance Company of New York at the Home Office on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. /s/ Xxxxxx X. XxXxxxxxx /s/ Xxxxx Xxxxxxx Xxxxxxx President Secretary THE VARIABLE FEATURES OF THIS CONTRACT ARE DESCRIBED IN SECTIONS 3 AND 11. ALL PAYMENTS AND VALUES PROVIDED BY THE GROUP CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT GUARANTEED AS TO FIXED DOLLAR AMOUNT. AMOUNTS ALLOCATED TO THE GUARANTEED ACCUMULATION ACCOUNT, IF WITHDRAWN BEFORE A GUARANTEED TERM MATURITY DATE, MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT. THE MARKET VALUE ADJUSTMENT MAY RESULT IN AN INCREASE, OR A DECREASE, IN THE INDIVIDUAL ACCOUNT VALUE. AMOUNTS ALLOCATED TO THE FIXED PLUS ACCOUNT ARE NOT AVAILABLE AS A LUMP SUM WITHDRAWAL, OTHER THAN DUE TO DEATH, SEPARATION FROM SERVICE, OR RETIREMENT, OR AS OTHERWISE ALLOWED BY THE CONTRACT. VARIABLE ANNUITY ASSUMED ANNUAL NET RETURN RATE - ANNUITY PHASE If a Variable Annuity is chosen, an assumed annual net return rate of 5.0% may be elected. If 5.0% is not elected, we will use an assumed annual net return rate of 3.5%. The daily net return rate factor for an assumed annual net return rate of 3.5% per year is 0.9999058. The daily net return rate factor for an assumed annual net return rate 5.0% per year is 0.9998663. If the portion of a Variable Annuity payment for any information on this page needs Fund is not to be changed or correcteddecrease, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Annuity return factor under the Separate Account for that Fund must be:

Right to Cancel. There If for any reason the owner is a not satisfied with this Contract, he or she may return it to the Company within 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving itreceipt. If you are not satisfied with the Contract, return It may be returned by delivering or mailing it to the Retirement Resource Operations Center or an agent of the Company. The If returned, this Contract will shall be deemed void from the start, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data PageDate. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according refund any Purchase Payments made and allocated to the Payout Options provisions of this Contract. Subsequent payouts Fixed Account and will be paid on the same day of each frequency period according to the provisions of this Contract. This refund Separate Account Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment returned policy is received less Premium Tax, if any; by the Company. Signed for Security Benefit Life Insurance Company on the Contract Date. RXXXX X. VXXXX XXXXXX R. XXXXXX Secretary President A BRIEF DESCRIPTION OF THIS CONTRACT This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY CONTRACT. * Purchase Payments may be made until the earlier of the Annuity Start Date or · termination of the sum of Contributions applied Contract. * A Death Benefit may be paid prior to the Annuity Start Date according to the Contract as provisions. * Annuity Payments begin on the Annuity Start Date using the method specified in this Contract. * This Contract is Participating. ALL PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND MAY INCREASE OR DECREASE IN ACCORDANCE WITH THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT. THERE ARE NO GUARANTEED MINIMUM PAYMENTS OR CASH VALUES. (SEE "CONTRACT VALUE AND EXPENSE PROVISIONS" AND "ANNUITY PAYMENT PROVISIONS" FOR DETAILS.) SECURITY BENEFIT LIFE INSURANCE COMPANY A Member of the date the Request for payment is receivedThe Security Benefit Group of Companies P.O. Box 750497, less the impact Topeka, KS 66675-0497 700 XX Xxxxxxxx Street, Topeka, KS 66636-0001 1-000-000-0000 TABLE OF CONTENTS Page DEFINITIONS 4-6 GENERAL PROVISIONS 7, 8 The Contract 7 Compliance 7 Misstatement of partial withdrawalsAge 7 Evidence of Survival 7 Incontestability 7 Assignment 7 Transfers 8 Claims of Creditors 8 Nonforfeiture Values 8 Participation 8 Statements 8 OWNERSHIP, distributions, ANNUITANT AND BENEFICIARY PROVISIONS 9 Ownership 9 Joint Ownership 9 Annuitant 9 Primary and Premium Tax, if any. CHARGES: Secondary Beneficiaries 9 Ownership and Beneficiary Changes 9 PURCHASE PAYMENT PROVISIONS 10 Flexible Purchase Payments 10 Purchase Payment Limitations 10 Purchase Payment Allocation 10 Place of Payment 10 CONTRACT VALUE AND EXPENSE PROVISIONS 10-12 Contract Value 10 Fixed Account Contract Value 10 Fixed Account Interest Crediting 11 Separate Account Contract Value 11 Accumulation Unit Value 11 Determining Accumulation Units 11 Mortality and Expense Risk Charge: [1.20%] Charge 12 Premium Tax Expense 12 Administrative Charge 12 Mutual Fund Expenses 12 WITHDRAWAL CHARGES [Age PROVISIONS 12, 13 Withdrawals 12, 13 Withdrawal Value 13 Systematic Withdrawals 13 Date of Contribution Request 13 Payment of Withdrawal Benefits 13 DEATH BENEFIT PROVISIONS 14, 15 Death Benefit 14 Proof of Death 14 Distribution Rules 14, 15 ANNUITY PAYMENT PROVISIONS 15-18 Annuity Start Date 15 Change of Annuity Start Date 15 Annuity Start Amount 15 Annuity Tables 16 Annuity Payments 16 Change of Annuity Option 16 Fixed Annuity Payments 16 Variable Annuity Payments 16 Annuity Units 16, 17 Net Investment Factor 17 Alternate Annuity Option Rates 17 Annuity Options 18 ANNUITY TABLES 19 AMENDMENTS OR ENDORSEMENTS, if any DEFINITIONS (Being W ithdrawnContinued) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together SEPARATE ACCOUNT Variable Annuity Account VIII (the "Separate Account") is a separate account established and maintained by the Company under Kansas law. The Separate Account is registered with the Initial Applicable Allocation Confirmation, reflects Securities and Exchange Commission under the information with which your Contract has been Investment Company Act of 1940 as a Unit Investment Trust. It was established as by the Company to support variable annuity contracts. The Company owns the assets of the Effective Separate Account and maintains them apart from the assets of its general account and its other separate accounts. The assets held in the Separate Account equal to the reserves and other Contract liabilities with respect to the Separate Account may not be charged with liabilities arising from any other business the Company may conduct. Income and realized and unrealized gains and losses from assets in the Separate Account are credited to, or charged against, the Separate Account without regard to the income, gains or losses from the Company's general account or its other separate accounts. The Separate Account is divided into Subaccounts shown on page 3. Income and realized and unrealized gains and losses from assets in each Subaccount are credited to, or charged against, the Subaccount without regard to income, gains or losses in the other Subaccounts. The Company has the right to transfer to its general account any assets of the Separate Account that are in excess of the reserves and other Contract liabilities with respect to the Separate Account. The value of the assets in the Separate Account on each Valuation Date are determined at the end of each Valuation Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3.

Right to Cancel. There is a 10 day right You may return this Annuity to cancel. If our Office or to the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with the Contract, return representative who sold it to you for a refund within ten days after you receive it, or longer if required by applicable law or regulation. It can be mailed or delivered either to us, at our Office, or to the Retirement Resource Operations Center or an agent representative who sold it to you. Return of the Company. The Contract will be void from the startthis Annuity by mail is effective on being postmarked, properly addressed and the Company will refund the Annuity Account Value plus any charges and feespostage prepaid. The amount returned during of the right to cancel period refund will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according an amount equal to the Payout Options provisions sum of this Contract. Subsequent payouts will be paid on (i) the same day of each frequency period according difference between the Purchase Payment(s) received (including any fees or other charges deducted from gross considerations) and the amount(s) allocated to the provisions of this Contract. This Contract is non- participating Fixed Rate Options, MVA Options and not eligible to share in Sub-accounts under the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1Annuity, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of and (ii) the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date Valuation Day the Request Annuity is returned to us. Signed for payment is received less Premium TaxPruco Life Insurance Company of New Jersey: [________________________] [________________________] Secretary President INDIVIDUAL FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITY NON-PARTICIPATING SUB-ACCOUNTS, if any; FIXED RATE OPTIONS, AND MARKET VALUE ADJUSTED ("MVA") OPTIONS ALL MAY BE MADE AVAILABLE In the Accumulation Period any payments and values provided under the Sub-Accounts may increase or · the sum of Contributions applied decrease according to their investment performance and are, therefore, not guaranteed. Please refer to the Contract as of "Account Value in the date Sub-Accounts" section for a more complete explanation. In the Request for payment is received, less Accumulation Period any payments and values provided under the impact of MVA Options may be subject to a Market Value Adjustment. Such a Market Value Adjustment may increase or decrease any such payments or values. The Market Value Adjustment applies to full or partial withdrawals, distributionstransfers and amounts applied to an annuity payout option. However, such payments made by us on, or within 30 days immediately prior to, the maturity of an MVA Option, and Premium Tax, if anydeath benefits payable during the Accumulation Period are not subject to a Market Value Adjustment. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with The MVA liquidity factor may be waived during the Initial Applicable Allocation Confirmation, reflects Right to Cancel Period. Please refer to the information with which your Contract has been established as "Account Value of the Effective DateMVA Options" section for a more complete explanation. If any information on this page needs to Payout options are specified in the Annuity. Other options may be changed or corrected, please contact the Retirement Resource Operations Centermade available. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3CONTENTS

Right to Cancel. There is a 10 day right to cancel. If This Contract may be returned for any reason within [10] days after you receive it by mailing or delivering the Contract to either us or the agent who sold it. Return of this Contract by mail is issued effective on being postmarked, properly addressed and postage prepaid. We will promptly refund your Account Value, plus the sum of all fees, taxes, and charges deducted from the Purchase Payment as a replacement of existing life insurance the effective date of the Free Look on the Business Day we receive your Contract. Your Account Value may be more or annuity coverageless than your Purchase Payment. Based on the maximum yearly Asset-Based Insurance Charges, the right smallest yearly rate of investment return required to cancel period ensure that the dollar amount of variable annuity payments does not decrease is extended [4.35%]. The smallest yearly rate of investment return is equal to 60 days from the date assumed interest rate (AIR) plus the maximum yearly Asset-Based Insurance Charge during the payout phase of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center or an agent of . Signed for the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx XxxxxxxIllegible Secretary] [/s/ Xxxxxx X. XxxxxxxxIllegible President] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] ------------- ------------- 6010 (3/07) NOTICE: ------- DETAILS OF THE SEPARATE ACCOUNT PROVISIONS ON PAGE 6 INDIVIDUAL FLEXIBLE PREMIUM PURCHASE PAYMENT DEFERRED VARIABLE ANNUITYANNUITY CONTRACT NONPARTICIPATING READ YOUR CONTRACT CAREFULLY ANNUITY PAYMENTS, DEATH BENEFITS, WITHDRAWAL VALUES AND ANY OTHER CONTRACT VALUE PROVIDED BY THIS CONTRACT, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE, MAY INCREASE OR DECREASE IN ACCORDANCE WITH FLUCTUATIONS IN THE NET INVESTMENT FACTOR, AS APPLICABLE, AND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT, UNLESS OTHERWISE SPECIFIED. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution 6010 (Being W ithdrawn3/07) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3Contract Schedule........................................................... [3 Definitions................................................................. 4

Right to Cancel. There is a FREE LOOK PROVISION -- At any time within 10 day right to cancel. If the Contract is issued as a replacement of existing life insurance or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving it. If this contract you are not satisfied with the Contract, may return it to us or to the Retirement Resource Operations Center or an agent through whom it was purchased. Immediately upon our receipt, this contract will be voided as if it had never been in force. All purchase payments allocated to the General Account plus the Separate Account contract value computed at the end of the Companyvaluation period following our receipt of this contract will then be refunded within ten days. We agree to pay an annuity to the annuitant provided the annuitant is living and this contract is in force on the annuity date. We further agree to pay the death benefit prior to the annuity date upon the death of the owner or the annuitant when a death benefit is payable. Payment will be made upon our receipt of due proof of death and the return of this contract. This contract is issued in consideration of the attached application and payment of the initial purchase payment. The Contract will be void from the start, provisions on this cover and the Company will refund the Annuity Account Value plus any charges and fees. The amount returned during the right to cancel period will not be subject to a Withdrawal Chargepages that follow are part of this contract. Signed for Great-West Kempxx Xxxestors Life & Annuity Insurance Company of New York on the issuance of this Contractat its home office in Long Grove, Illinois. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx]ALL BENEFITS, [Xxxxxx X. Xxxxxxxx]PAYMENTS AND VALUES PROVIDED BY THIS CONTRACT, [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM WHEN BASED UPON THE INVESTMENT EXPERIENCE OF THE SUBACCOUNTS, ARE VARIABLE ANNUITYAND ARE NOT GUARANTEED AS TO DOLLAR AMOUNT. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this ContractREFER TO THE VARIABLE ACCOUNT AND ANNUITY PERIOD PROVISIONS FOR A DETERMINATION OF ANY VARIABLE BENEFITS. This Contract is non- participating a legal contract between the owner and not eligible to share in the Kempxx Xxxestors Life Insurance Company’s divisible surplus. READ YOUR CONTRACT CAREFULLY L-1000 (6/93) L-1000 (6/93) INDEX PAGE ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date the Request for payment is received less Premium Tax, if any; or · the sum of Contributions applied to the Contract as of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old OPTION TABLE ......................................... Follows Page 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective Date. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3

Right to Cancel. There is a 10 day right You may return this Annuity to cancel. If the Contract is issued as a replacement of existing life insurance our Office or annuity coverage, the right to cancel period is extended to 60 days from the date of receiving it. If you are not satisfied with the Contract, return it to the Retirement Resource Operations Center representative who solicited its purchase for a refund within ten days after you receive it or an agent of the Company. The Contract will be void from the start, and the Company will refund the Annuity Account Value plus any charges and feeslonger if required by applicable law or regulation. The amount returned during the right to cancel period will not be subject to a Withdrawal Charge. Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [President and Chief Executive Officer] INDIVIDUAL FLEXIBLE PREMIUM VARIABLE ANNUITY. Contributions may be made only during the Accumulation Period or until the death benefit is payable to a Beneficiary. The Owner is as shown on the Contract Data Page. The Company will pay the Annuitant the first of a series of annuity payouts on the Annuity Commencement Date by applying the Owner’s Annuity Account Value according to the Payout Options provisions of this Contract. Subsequent payouts will be paid on the same day of each frequency period according to the provisions of this Contract. This Contract is non- participating and not eligible to share in the Company’s divisible surplus. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: [New York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] OWNER INFORMATION Owner: [XXXX X. XXX] Date of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. XXX] Date of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1794] TRANSFERS Number of Free Transfers Allowed: [12] each Contract Year Transfer Fee: $[0] for each Transfer in excess of the free Transfers permitted CONTRIBUTIONS Minimum Initial Contribution Amount: $[10,000] Minimum Additional Contribution: $[500] Automatic Bank Draft Plan Minimum: $[100] Maximum Total Contributions: $[1,000,000] ANNUITY PAYMENT Minimum Annuity Payment: $50 Annuity Mortality Table: [Modified Annuity 2000 Mortality Table] Assumed Interest Rate: [2.5%] MISSTATEMENT OF AGE OR SEX Interest Rate to be Applied in Adjusting for Misstatement of Age or Sex [1%] DEATH BENEFIT: Guaranteed Minimum Death Benefit. As described in refund will equal not less than the Death Benefit provisions, the death benefit payable will be the greater of: · the Annuity Account Value as of the date we receive the Request for payment is received less Premium Taxcancellation request plus any tax charge deducted. You bear the investment risk during this period. However, if anyrequired by applicable law or regulation, the amount we refund is the greater of; or · (1) the sum of Contributions applied to Purchase Payment and (2) the Contract as current Account Value of the date the Request for payment is received, less the impact of partial withdrawals, distributions, and Premium Tax, if any. CHARGES: Mortality and Expense Risk Charge: [1.20%] WITHDRAWAL CHARGES [Age of Contribution (Being W ithdrawn) W ithdrawal Charge % Less than one year old 7% 1 year old or older, but not yet 2 years old 7% 2 years old or older, but not yet 3 years old 6% 3 years old or older, but not yet 4 years old 5% 4 years old or older, but not yet 5 years old 4% 5 years old or older 0%] CONTRACT INFORMATION This Contract Data Page, together with the Initial Applicable Allocation Confirmation, reflects the information with which your Contract has been established as of the Effective DateAnnuity plus any tax charge deducted. If any information on under applicable law we are required to return not less than the Purchase Payment, we may elect to allocate your Account Value to a money-market investment option during the period this page needs Right to be changed or correctedCancel provision applies to your Annuity. Signed for PRUDENTIAL ANNUITIES LIFE ASSURANCE CORPORATION: ------------------------------ President INDIVIDUAL DEFERRED ANNUITY NON-PARTICIPATING VARIABLE AND FIXED INVESTMENT OPTIONS IN THE ACCUMULATION PERIOD IN THE ACCUMULATION PERIOD ANY PAYMENTS AND VALUES PROVIDED UNDER THE VARIABLE INVESTMENT OPTIONS ARE BASED ON THEIR INVESTMENT PERFORMANCE AND ARE, please contact the Retirement Resource Operations CenterTHEREFORE, NOT GUARANTEED. PLEASE REFER TO THE SECTION ENTITLED "ACCOUNT VALUE IN THE SUB-ACCOUNTS" FOR A MORE COMPLETE EXPLANATION. IN THE ACCUMULATION PERIOD ANY PAYMENTS AND VALUES PROVIDED UNDER THE FIXED INVESTMENT OPTIONS MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT. SUCH A MARKET VALUE ADJUSTMENT MAY INCREASE OR DECREASE ANY SUCH PAYMENTS OR VALUES. PLEASE REFER TO THE SECTION ENTITLED "ACCOUNT VALUE OF THE FIXED ALLOCATIONS" FOR A MORE COMPLETE EXPLANATION. N-ASP/IND(04/02)-01 1 RBRND08 TABLE OF CONTENTS Page CONTRACT DATA............................................................................................................. 1 Section 1 DEFINITIONS............................................................................................................ 3................................................................ 5