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 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 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: Department of Insurance Telephone Number: [303-123-4567] 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 Withdrawn) 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. 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 30 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 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: Department of Insurance Telephone Number: [303-123-4567] 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 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 Withdrawn) 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............................................................................................................ 3each subsequent Transfer.

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 30 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: [303XXX-123XXX-4567XXXX] 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 WithdrawnW ithdrawn) Withdrawal 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 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 30 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 Richaxx Xxxxxxx], [Xxxxxx Andra X. XxxxxxxxXxxxxxx], [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. J100-ny ANNUITY INFORMATION OWNER INFORMATION Annuity Contract Number: [1234567] Effective Owner: [JOHN X. XXX] Xxfective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: Department of Insurance Telephone Number: [303-123-4567] OWNER INFORMATION Owner: [XXXX X. XXX2016] Date of Birth: [April 1, 1969] Status of Annuity: [Non-Qualified Tax ID Number: [XXX-XX-1111] Annuity ] Initial Joint Owner: [XXXX JANE X. XXX] Xxntribution: [$50,000] Date of Birth: [November 12, 1973] Annuity Commencement Date: [March 1, 2018] Tax ID Number: [XXX-XX-3333] State of Delivery: New York Department of Insurance Telephone Number: [Colorado303-100-0000] ANNUITANT INFORMATION Annuitant: [XXXX JOHN X. XXX] Joint Xoint Annuitant: [XXXX JANE X. XXX] Date Xxte 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 DAVID X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Sally Xxxxx] Date Xxte of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Sammy Xxxxx] Date Xxte 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: Asset Management Fee [1.201.5%] WITHDRAWAL CHARGES [Age of Contribution (Being Withdrawn) 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 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 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 on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Richard Xxxxxxx], [Xxxxxx Xxxretary] [Robert X. Xxxxxxxx], [Secretary] [President Xxxsident 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. ICC16-J100 ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 20122016] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 20142018] State of Delivery: Department of Insurance Telephone Number: [303-123-4567] OWNER INFORMATION Owner: [XXXX X. JOHN C. XXX] Date Xxxx of Birth: [April 1, 1969] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. JANE B. XXX] Date Xxxx of Birth: [November 12, 1973] Tax ID Number: [XXX-XX-3333] [Colorado] [303-123-4567] ANNUITANT INFORMATION Annuitant: [XXXX X. JOHN C. XXX] Joint Annuitant: [XXXX X. XXX] Date of Birth: [March 22, 1967] Date Xxxx of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] Tax ID Number: [XXX-XX-1234] Contingent Annuitant: [XXXXX X. DAVID J. XXX] Date Xxxx of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] Joint Annuitant: [JANE C. XXX] Xxxx of Birth: [March 22, 1967] Tax ID Number: [XXX-XX-1234] BENEFICIARY INFORMATION Beneficiary: [Xxxxx XxxxxSally Sxxxx] Date Xxxx of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx XxxxxSammy Sxxxx] Date Xxxx 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: Asset Management Fee [1.201.5%] WITHDRAWAL CHARGES [Age of Contribution (Being Withdrawn) 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............................................................................................................ 3ICC16-J100 1

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 30 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 Richaxx Xxxxxxx], [Xxxxxx Roberx 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- non-participating and not eligible to share in the Company’s divisible surplus. J100-ny ANNUITY INFORMATION OWNER INFORMATION Annuity Contract Number: [1234567] Effective Owner: [JOHN X. XXX] Xxfective Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: Department of Insurance Telephone Number: [303-123-4567] OWNER INFORMATION Owner: [XXXX X. XXX2016] Date of Birth: [April 1, 1969] Status of Annuity: [Non-Qualified Annuity] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX JANE X. XXX] Xxitial Contribution: [$50,000] Date of Birth: [November 12, 1973] Annuity Commencement Date: [March 1, 2018] Tax ID Number: [XXX-XX-3333] State of Delivery: [ColoradoNew York] Department of Insurance Telephone Number: [XXX-XXX-XXXX] ANNUITANT INFORMATION Annuitant: [XXXX JOHN X. XXX] Joint Annuitant: [XXXX JANE X. XXX] Date Xxte 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 DAVID X. XXX] Date of Birth: [June 6, 1989] Tax ID Number: [XXX-XX-7777] BENEFICIARY INFORMATION Beneficiary: [Xxxxx Sally Xxxxx] Date of Birth: [January 17, 1981] Tax ID Number: [XXX-XX-1789] Contingent Beneficiary: [Xxxxx Sammy 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 Withdrawn) 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 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 30 days from the date of receiving it. If for any reason you are not satisfied with the Contract, you may return this Contract within 10 days after you receive it (60 days from the date of receipt if it is a replacement contract). You may return the Contract by delivering or mailing it to the Retirement Resource Operations Center or an agent of the CompanyFSBL. The If returned, this Contract will then be deemed void from the startbeginning. No withdrawal charge will be imposed, and the Company we will refund the Annuity Account Value plus refund: (1) any charges Purchase Payments made 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 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 allocated 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 Fixed Account; and (2) 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: Department of Insurance Telephone Number: [303-123-4567] 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 returned Contract is delivered to FSBL, increased by any fees or other charges paid from Separate Account Contract Value. Signed for payment First Security Benefit Life Insurance and Annuity Company of New York on the Contract Date. Secretary President A BRIEF DESCRIPTION OF THIS CONTRACT This is received less Premium Tax, if any; 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 the Contract This Contract is non-participating and does not participate in FSBL's surplus The smallest annual net rate of return that would have to be earned on the assets of the date Separate Account so that the Request for payment dollar amount of variable Annuity Payments would not decrease is received3½%. The annual net rate of return is based upon the rate of return of the underlying mutual fund reduced by expenses of the Separate Account, less including the impact maximum mortality and expense risk charge of partial withdrawals1.45%, distributions, administrative charge of 0.15% and Premium Tax, if anyany applicable rider charges. CHARGES: Mortality Benefits and values provided by this Contract when based upon the investment experience of the Separate Account are variable. These amounts may increase or decrease and are not guaranteed as to dollar amount. (See "Contract Value and Expense Risk Charge: Provisions" and "Annuity Benefit Provisions" for details.) First Security Benefit Life Insurance and Annuity Company of New York [1.20%00 Xxxx Xxx Xxx Xxxx, Xxxxx Xxxxxx, XX 00000 0-000-000-0000] WITHDRAWAL CHARGES [Age of Contribution (Being Withdrawn) 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 If a Credit Enhancement Rider has been established as purchased, FSBL will recapture the amount of any Credit Enhancement applied during the 12 months preceding the date of the Effective DateOwner's death. If any information on this page needs to be changed or corrected, please contact the Retirement Resource Operations Center. FSB234 (5-04)U TABLE OF CONTENTS Page CONTRACT DATA................................................................................................... 1 Section 1 DEFINITIONS............................................................................................................ 3DATA PAGE 3 DEFINITIONS 4 GENERAL PROVISIONS 7 The Contract 7 Compliance 8 Misstatement of Age 8 Evidence of Survival 8 Incontestability 8 Assignment 8 Ownership of Assets 8 Transfers 8 Claims of Creditors 9 Basis of Values 9 Participation 9 Statements 9 Delay of Payment 9 OWNERSHIP, ANNUITANT AND BENEFICIARY PROVISIONS 10 Ownership 10 Joint Ownership 10 Annuitant 10 Primary and Contingent Beneficiaries 10 Ownership and Beneficiary Changes 10 PURCHASE PAYMENT PROVISIONS 11 Flexible Purchase Payments 11 Purchase Payment Limitations 11 Purchase Payment Allocation 11 Place of Payment 11 CONTRACT VALUE AND EXPENSE PROVISIONS 11 Contract Value 11 Fixed Account Contract Value 11 Fixed Account Interest Crediting 12 Separate Account Contract Value 12 Accumulation Unit Value 12 Net Investment Factor 13 Determining Accumulation Units 13 Mortality and Expense Risk Charge 13 Rider Charge 13 Method of Deducting Mortality and Expense Risk and Rider Charges 14 Administration Charge 15 Account Administration Charge 15 Premium Tax Expense 15 Withdrawal Charges 15 Free Withdrawals 16 Mutual Fund Expenses 16 WITHDRAWAL PROVISIONS 16 Withdrawals 16 Partial Withdrawals 17 Systematic Withdrawals 17 Withdrawal Value 17 DEATH BENEFIT PROVISIONS 18 Death Benefit 18 Proof of Death 18 Distribution Rules 18 ANNUITY BENEFIT PROVISIONS 19 Annuity Start Date 19 Change of Annuity Start Date 19 Annuity Options 19 Annuity Start Amount 20 Fixed Annuity Payments 20 Variable Annuity Payments 21 Annuity Tables 21 Annuity Payments 21 Annuity Units 21 Annuity Unit Value 22 Alternate Annuity Option Rates 22 ANNUITY TABLES 23 AMENDMENTS OR RIDERS, if any CONTRACT DATA PAGE OWNER NAME: [Xxxx Xxx] CONTRACT NUMBER: [123456789]

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 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 on the issuance of this Contract. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Richard Xxxxxxx], [Xxxxxx Robert 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- non-participating and not eligible to share in the Company’s divisible surplus. ICC16-J100 ANNUITY INFORMATION OWNER INFORMATION Annuity Contract Number: [1234567] Effective Owner: [JOHN C. XXX] Xxxxctive Date: [July 1, 2012] Status of Annuity: [Non-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: Department of Insurance Telephone Number: [303-123-4567] OWNER INFORMATION Owner: [XXXX X. XXX2016] Date of Birth: [April 1, 1969] Status of Annuity: [Non-Qualified Annuity] Tax ID Number: [XXX-XX-1111] Joint Owner: [XXXX X. JANE B. XXX] Xxxxial Contribution: [$50,000] Date of Birth: [November 12, 1973] Annuity Commencement Date: [March 1, 2018] Tax ID Number: [XXX-XX-3333] State of Delivery: [Colorado] ANNUITANT INFORMATION Annuitant: [XXXX X. XXX] Joint Annuitant: [XXXX X. XXX] Date Department of Birth: [March 22, 1967] Date of Birth: [March 22, 1967] Tax ID Insurance Telephone Number: [XXX303-XX-1234123-0000] 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 Withdrawn) 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............................................................................................................ 3ANNUITANT INFORMATION

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 30 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 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: Department of Insurance Telephone Number: [303-123-4567] 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 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 WithdrawnContinued) 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 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 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 30 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 as of the Company. The Contract will be void from date we receive 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 ChargeContract. Signed for Great-West Security Benefit Life & Annuity Insurance Company on the issuance of this ContractContract Date. [/s/ Xxxxxxx Xxxxxxx] [/s/ Xxxxxx X. Xxxxxxxx] [Xxxxxxx Xxxxxxx], [Xxxxxx X. Xxxxxxxx], [Secretary] [{J. Michael Keefer} {Kris A. Robbins} Xxxxxxxxx President and Chief Executive Officer] INDIVIDUAL A BRIEF DESCRIPTION OF THIS CONTRACT This is a FLEXIBLE PREMIUM DEFERRED VARIABLE ANNUITYANNUITY CONTRACT. Contributions may be made only during the * Investment Experience is Reflected in Benefits * Variable and Fixed 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 Before the Annuity Commencement Start Date; Variable and Fixed Annuity Payments Thereafter * Death Benefit Proceeds are Payable Before the Annuity Start 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 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, Xxxxxx, XX 00000-0000 1-800-888-2461 The varixxxx xxxxxxx xovered by this Contract is the subject of a pending patent application in the Company’s divisible surplusUnited States Patent and Trademark Office. ANNUITY INFORMATION Annuity Contract Number: [1234567] Effective Date: [July 1, 2012] Status of Annuity: [NonV6029 (11-Qualified Annuity ] Initial Contribution: [$50,000] Annuity Commencement Date: [March 1, 2014] State of Delivery: Department of Insurance Telephone Number: [303-123-4567] 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 Withdrawn00) 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 DATA PAGE................................... 25 DEFINITIONS............................................................................................................ 3.......................................... 4