Exhibit 5
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
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A Stock Company
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0000 Xxxx Xxxxxxx Xxxx Xxxxxxxxx Xxxxxxx, XX 00000
For service, call 0-000-000-0000 (extension 73343)
APPLICATION FOR GROUP ANNUITY CONTRACT
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SECTION A. EMPLOYER/GROUP CONTRACTHOLDER
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NAME OF EMPLOYER EMPLOYER FEDERAL TAX ID #
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ADDRESS STATE OF SITUS
STREET CITY STATE ZIP CODE
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TELEPHONE # FAX # TYPE OF ENTITY:
Church Public School
Government 501(c)(3) S Corp
Corporation Partnership LLC
Sole Proprietorship
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FULL LEGAL NAME OF PLAN
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NAME OF GROUP CONTRACTHOLDER IF OTHER THAN THE EMPLOYER FEDERAL TAX ID #, IF ANY
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ADDRESS STATE OF SITUS
STREET CITY STATE ZIP CODE
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TELEPHONE # FAX # TYPE OF ENTITY:
Church Public School
Government 501(c)(3) S
Corp
Corporation Partnership LLC
Sole Proprietorship
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SECTION B. PRODUCT INFORMATION
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Fixed Annuity Fixed-Variable Annuity
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Effective Date of Group Annuity Contract: Month____________ Day _______ Year _______
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SECTION C. PLAN INFORMATION
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401(a) Plan 403(b) Plan 415(m) Governmental Excess
ERISA Non-ERISA ERISA Benefit Arrangement
401(k) Plan Non-ERISA Corporate Excess Benefit Plan
ERISA Non-ERISA 457(b) Governmental Plan Deemed XXX ___ Plan
NQDC Plan 457(b) Non-governmental Plan Xxxx Traditional
457(f) Plan
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SECTION D. DEFAULT INVESTMENT OPTION
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Maxim Money Market Portfolio
Other Investment Option: _________________
No Default Investment Option (Money returned to payee as required by law)
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SECTION E. FIXED ACCOUNTS
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Guaranteed Fixed Fund Guaranteed Certificate Fund
Guaranteed Portfolio Fund 36-month Term 84-month Term
Guaranteed Portfolio Fund II 60-month Term ______-month Term
Daily Interest Guaranteed Fund Other _________________
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SECTION F. SERIES ACCOUNTS SECTION G. SEPARATE ACCOUNTS
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FutureFunds I Series Account Guaranteed Government Fund
FutureFunds II Series Account Stable Asset Fund
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SECTION H. AGREEMENT AND SIGNATURES
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AGREEMENT:
By signing this Application, I acknowledge that the Group Contractholder understands, accepts, and
otherwise agrees to the provisions of the attached Group Annuity Contract. I warrant that the
information contained on this application is true and correct. I further acknowledge that the Group
Contractholder hereby agrees to notify the Company of any changes to the information provided
above.
Signature on behalf of Group Contractholder Date
(month/day/year)
_
Title
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GAC A2-02 Page 1 of 2
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GAC A2-02 Page 1 of 2
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