Trillium Automatic Dollar-Cost Averaging (Dca) Authorization Form
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1
2Overnight Mail to:
Regular Mail to:
Great-West Life & Annuity Insurance
Great-West Life & Annuity Insurance
Company of New York
Company of New York
Attn: RROC
Attn: RROC
8515 E Orchard Road 8T2
PO Box 173921
Greenwood Village, CO 80111
Denver, CO 80217-3920
Phone: (800) 905-1959
Phone: (800) 905-1959
Fax: (866) 745-5766
Fax: (866) 745-5766
TRILLIUM 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 on any given day 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, or if that date is not a business day, the next business day.
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.)
3.
If you are submitting this form at the same time you apply for a 1035 exchange to Trillium™, 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 Periodic Interval and Start Date
I would like funds transferred: (Check One)
Monthly
Quarterly
Semi-Annually
Annually
I would like the first transfer on _______________________________
Month/Day/Year
B. Select a Dollar Amount
Transfer a total dollar amount of $ __________________ (Minimum of $250 per transactions).
C. Select the Disbursement Sub-Account or 1 year Fixed Account _____________________.
D. 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%.
% Maxim Bond Index
% Seligman VA Global Technology Class 1
% Fixed Account (1yr)
% Maxim MFS International Growth
% Seligman VA Smaller Cap Value Class 1
% Fixed Account (3yr)
% Maxim Money Market Fund
% Seligman VA Large - Cap Value
% Fixed Account (5yr)
% Seligman VA Capital Class 1
% Fixed Account (7yr)
% Seligman VA Communications and Information
% Fixed Account (10yr)
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.
Trillium Dollar Cost Averaging Form
Last Updated 01/2016
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