Non-Financial Service Request Form Page 2
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4.
Change of Beneficiary*
I (we), the present Owner(s) of the above numbered policy, hereby revoke any previous designation of beneficiaries and herewith change the
beneficiary to:
Social
% of
Name and Address
Birthdate
Relationship
Security #
Benefits
Primary
Beneficiary
Contingent
Beneficiary
*The company assumes no responsibility for validity or effect of listed changes.
% of Benefits must total 100%
5. Change of Annuity Date (Change must be received at least 30 days prior to current annuity date. Please see prospectus for limitations)
To the first day of _____________________________________________
Month
Year
Signatures
X _______________________________________________________________________________________________________________________
Owner / Trustee
Date
X _______________________________________________________________________________________________________________________
Joint Owner / Trustee
Date
Complete this section if requesting a Change of Ownership Only
X _______________________________________________________________________________________________________________________
New Owner / Trustee
Date
X _______________________________________________________________________________________________________________________
New Joint Owner / Trustee
Date
All other parties holding a legally enforceable interest under the annuity must sign here (i.e. irrevocable beneficiaries, collateral assignees, security
interest holders, court ordered interest holders)
X _______________________________________________________________________________________________________________________
Holder of Interest (i.e. irrevocable beneficiaries, collateral assignees, court ordered interest holders)
Interest Held
Signed at _______________________________________________ this _______________ day of _______________________, _________________
(city, state)
(day)
(month)
(year)
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.
Non-Financial Service Request Form
Last Updated 01/16
Page 2 of 2
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