Varifund Automatic Dollar-Cost Averaging (Dca) Authorization Form
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1
2Regular Mail to:
Overnight Mail to:
Great-West Life & Annuity Insurance
Great-West Life & Annuity Insurance
Company of New York
Company of New York
Attn: RROC
Attn: RROC
PO Box 173921
8515 E Orchard Road 8T2
Denver, CO 80217-3920
Greenwood Village, CO 80111
Phone: (800) 905-1959
Phone: (800) 905-1959
Fax: (866) 745-5766
Fax: (866) 745-5766
VARIFUND AUTOMATIC DOLLAR-COST AVERAGING (DCA) AUTHORIZATION
Owner Name ______________________________________________
Group _________________________________
Owner
Annuity
Social Security No.____________________________Ext ___________
Number _______________________________
Owner Address:
Street ____________________________________________________
City___________________ State________ Zip _____________
Owner Phone Numbers:
Daytime __________________________________________________
Evening _______________________________
PLEASE READ BEFORE COMPLETING THIS FORM - NOTE “I”, “YOU” MEANS THE POLICYOWNER/TRUSTEE(S)
A transfer under this Automatic Dollar-Cost Averaging Program (the “Program”) may be from the 1st—28th of the month, once this
1.
form is received and accepted by the Company. To allow adequate time for delivery and processing, the start date you choose
should be at least one month from the date you complete and mail this form. Subsequent transfers will occur on the same day of
the month as the selected start date.
2.
To qualify for the Program, a minimum of $5,000 must be allocated to any one of the variable sub-accounts or the one year
guarantee period of the fixed account (known as the “Disbursement Sub-Account”) AND A MINIMUM OF $250 MUST BE
TRANSFERRED AT EACH PERIODIC INTERVAL. (The company reserves the right to amend its administrative procedures.)
TM
3.
If you are submitting this form at the same time you apply for a 1035 exchange to VariFund
, we must receive the check from the
other insurance company before we can begin the Program.
INSTRUCTIONS:
To
initiate or
modify the Program, complete sections A, B, C, D, E and G below. To terminate an existing program,
complete sections F and G. Please complete and sign below.
A. Select a Dollar Amount
Transfer a total dollar amount of $ __________________ (Minimum of $250 per transactions).
B. Select the Disbursement Sub-Account or 1 year Fixed Account _____________________.
C. Select the Destination Sub-Account(s). This section must be completed before the DCA can be set up.
Please select the sub-accounts to which you would like the funds transferred. Total must equal 100%.
% Alger Large Cap Growth I-2
% Fidelity VIP High Income Portfolio
% Seligman VA Global Technology
% Alger Capital Appreciation I-2
% Fidelity VIP Index 500 Portfolio
% Seligman VA Smaller Cap Value
% Van Eck VIP Worldwide Multi-Managers
% Alger Mid Cap Growth I-2
% Fidelity VIP Investment Grade Bond Portfolio
Alternatives Fund
% Alger Small Cap Growth I-2
% Fidelity VIP Money Market Portfolio
% Van Eck VIP Emerging Markets Fund
% Dreyfus VIF Appreciation Init
% Fidelity VIP Overseas Portfolio
% Van Eck VIP Global Hard Assets Fund
% Dreyfus VIF Growth & Income Init
% Goldman Sachs VIT Structured US Equity
% Fixed Account (1yr)
% Dreyfus Socially Responsible Growth Init
% Goldman Sachs VIT Strategic Growth
% Fixed Account (3yr)
% Fidelity VIP II Asset Manager Portfolio
% Goldman Sachs VIT Large Cap Value
% Fixed Account (5yr)
% Fidelity VIP II ContraFund Portfolio
% NVIT Developing Markets II
% Fixed Account (7yr)
% Fidelity VIP Growth Portfolio
% Janus Aspen Overseas Instl
% Fixed Account (10yr)
% Fidelity VIP III Growth Opportunities Portfolio
% Seligman Communications & Information
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY OF NEW YORK
The principal underwriter is GWFS Equities, Inc., a wholly owned subsidiary of Great-West Life & Annuity Insurance Company and an
affiliate of Great-West Life & Annuity Insurance Company of New York.
Varifund Dollar Cost Averaging Form
Last Updated 01/2016
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