Great West Life & Annuity Insurance S-1/A IPO registration (amended)

Exhibit 4.3

SecureFoundationSM
Group Fixed Deferred Annuity Certificate Election Form

    [Product Marketing Name]     [Account grouping]    

Owner Information
Last Name	First Name			MI				Social Security Number
Address – Number & Street								Email Address
City		State	Zip Code		Mo	Day	Year	q    Female     q    Male
(         )		(         )
Home Phone		Work Phone			Date of Birth

Required SignatureBy signing below, I hereby elect to purchase this Group Fixed Deferred Annuity Certificate.
SecureFoundationSM Owner Signature	Date
Owner forward to Service Provider at: [Service Address] [Phone#: 1-NNN-NNN-NNNN] [Fax#: 1-NNN-NNN-NNNN]