CONTRACT AMENDMENT

GREAT-WEST LIFE & ANNUITY

INSURANCE COMPANY OF NEW YORK

A Stock Company

[50 Main Street, 00xx Xxxxx

Xxxxx Xxxxxx, XX 00000]

[0-000-000-0000]

CONTRACT AMENDMENT

THIS AMENDMENT IS ISSUED BY GREAT‑WEST LIFE & ANNUITY INSURANCE COMPANY OF NEW YORK AS PART OF THE FLEXIBLE PREMIUM VARIABLE ANNUITY CONTRACT (THE “CONTRACT”) TO WHICH IT IS ATTACHED. Except as expressly aMENDED by this AMENDMENT, the terms and conditions of the contract shall remain in full force and effect. if there is any conflict between this amendment and the contract the terms of this amendment will prevail.

The definition of Payout Commencement Date in Section 1 of the Contract is deleted and replaced with the following:

Payout Commencement Date - the date on which annuity payouts or periodic withdrawals begin under a payout option. If a Payout Commencement Date is not shown on the Certificate Data Page, annuity payouts will begin on the Annuitant’s 99th birthday. The Payout Commencement Date may be changed by the Owner prior to commencement of annuity payouts.

Signed for Great-West Life & Annuity Insurance Company of New York on the issuance of the Contract.

/s/ X. Xxxxxxx                    /s/ Xxxxxx X. Xxxxxxxx

[Xxxxxxx Xxxxxxx], [Xxxxxx Xxxxxxxx],

[Secretary] [President and Chief Executive Officer]

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