EXHIBIT 1(10)
SPECIMEN APPLICATION
Application for an Individual Flexible Premium
GREAT-WEST Variable Universal Life Insurance Policy to
Life Annuity Insurance Company Great-West Life & Annuity Insurance Company
("The Company")
GENERAL INFORMATION This page must be completed for all cases.
"Insured" whenever used in this application, means "the life proposed for insurance."
INSURED OWNER OF POLICY (IF OTHER THAN INSURED)
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Name_____________________________________________ Name_____________________________________________
Address__________________________________________ Address__________________________________________
_________________________________________________ _________________________________________________
_________________________________________________ _________________________________________________
Phone #: Day ____________________________________ Phone #: Day ____________________________________
Evening _________________________________________ Evening _________________________________________
Birth Date:_____/_____/_____ SS#_____-_____-_____ Relationship to Insured__________________________
Place of Birth___________________________________ Owner's SS # or Tax ID #_________________________
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POLICY INFORMATION
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Life Insurance or Premium Applied for: Death Benefit Option (Please check one):
Total Face Amount $___________________________ Level Death ?
Coverage Plus ?
Base Face Amount $____________________________ Premium Accumulation ?
Rider Face Amount $___________________________ Please check one:
Premium $_____________________________________ Cash Value Accumlation Test ?
Guideline Single Premium Test ?
Mode of Payment_______________________________
Optional Transfer Provisions (Please check one):
Premium Payor (Owner, unless otherwise indicated)
Dollar Cost Averaging ?
Name__________________________________________ Rebalancer Option ?
Address_______________________________________
______________________________________________
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BENEFICIARY
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Beneficiary______________________________________ Contingent Beneficiary________________________
(Please Print Full Name) (Please Print Full Name)
Relationship to Insured__________________________ Relationship to Insured_______________________
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REPLACEMENT
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Will the policy applied for result in any insurance or annuity contract in this or any other Company being lapsed, surrendered,
reduced, subjected to substantial borrowing, or changed to paid-up, extended term or automatic premium loan? ? Yes ? No
If yes, details:___________________________________________________________________________________________________
Company Name:______________________________________________________________________________________________________
Policy No.:________________________________________________________________________________________________________
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J355app (99) Page 1 of 6
INVESTMENT ALLOCATION This page must be completed for all cases.
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You may choose to allocate your premium payments to one or more of the investment options listed below. Please indicate your
selections in whole percentages.
Note: During the free look period, premium payments will be allocated to the Maxim Money Market Portfolio. Please refer to the
prospectus for details. If you do not indicate your allocations below or if they do not total 100 percent, your application will
not be processed.
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American Century Variable Portfolios, Inc. Maxim Series Fund, Inc.
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% American Century VP Income & Growth % Maxim Loomis Sayles Corporate Bond Portfolio
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% American Century VP International % Maxim INVESCO ADR Portfolio
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% American Century VP Value % Maxim INVESCO Balanced Portfolio
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Dreyfus Variable Investment Fund % Maxim INVESCO Small-Cap Growth Portfolio
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% Dreyfus Capital Appreciation Portfolio % Maxim Ariel MidCap Value Portfolio
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% Dreyfus Growth & Income Portfolio % Maxim Money Market Portfolio
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% Dreyf%s Stock Index Fund % Maxim U.S. Government Securities Portfolio
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Federated Insurance Series Maxim Profile Portfolios
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% Federated American Leaders Fund II % Maxim Aggressive Profile Portfolio
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% Federated Growth Strategies Fund II % Maxim Moderately Aggressive Profile Portfolio
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% Federated High Income Bond Fund II % Maxim Moderate Profile Portfolio
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% Federated International Equity Fund II % Maxim Moderately Conservative Profile Portfolio
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INVESCO Variable Investments Fund, Inc. % Maxim Conservative Profile Portfolio
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% INVESCO VIF - High Yield Portfolio Neuberger & Berman Advisers Management Trust
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% INVESCO VIF - Industrial Income Portfolio % Guardian Portfolio Income
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% INVESCO VIF - Total Return Portfolio % Mid-Cap Growth Portfolio
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Janus Aspen Series % Partners Portfolio
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% Balanced Portfolio % Socially Responsive Portfolio
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% Flexible Income Portfolio
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% High-Yield Portfolio
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% Worldwide Growth Portfolio
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TOTAL = 100%
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COMPLIANCE INFORMATION
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The Securities Exchange Act of 1934 requires that we have reasonable grounds to believe, based upon the information provided by
you, that your selections are suitable given your objectives and financial situation. Please answer the following questions
relating to the suitability of your investment choices.
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Overall investment objective Federal income tax bracket Annual income Liquid net worth
__Conservative __15% __Less than $15,000 __Less than $15,000
__Moderately Conservative __28% __$15,000 to $24,999 __$15,000 to $49,999
__Moderate __31% or more __$25,000 to $49,999 __$50,000 to $99,999
__Moderately Aggressive __$50,000 to $99,999 __$100,000 or more
__Aggressive __$100,000 or more
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STATEMENT OF ADDITIONAL INFORMATION
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Check here if you'd like a copy of the Statement of Additional Information to the prospectus. ?
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J355app (99) Page 2 of 6
SIGNATURE This page must be completed for all cases.
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I declare and agree that:
All statements and answers to questions made in this application and any supplement to it are true and complete to the best of my
knowledge and belief. The information I have provided will be taken into consideration for and will serve as the basis of any
contract of insurance based on this application. 1) No Information or answer to any question will be deemed communicated to or
binding on The Company unless set out in this application. 2) Only the president, a vice president or the secretary of The Company
is authorized to change or waive any terms of this application or any contract of insurance issued.
Any policy issued based on this application shall not take effect until delivered and the first premium paid to The Company,
provided no change has taken place in the insurability of the Insured after the application, and any supplement to it is completed,
and all proposed Insureds are still living.
I understand that I am applying for an Individual Flexible Premium Variable Universal Life Insurance Policy, form J355, issued by
Great-West Life & Annuity Insurance Company. I declare that all statements made on this application are true to the best of my
knowledge and belief. I acknowledge receipt of the prospectus for variable universal life insurance policy. I believe the policy is
suitable for my insurance needs. I understand that all amounts are based on the investment experience of the investment divisions
and are not guaranteed as to amount; they are variable and may increase or decrease accordingly. I hereby direct that my telephone
instructions to The Company be honored for transactions unless otherwise notified by me in writing. I understand that telephone
calls may be recorded to monitor the quality of service I receive and to verify policy transaction information. I certify under
penalty of perjury that the Social Security or tax identification number listed on this application is correct. The Internal
Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid
backup withholding.
Signed at______________________________________________________________this___________________day of___________________year
City and State
___________________________________________________________________ X_________________________________________________
Name of Proposed Insured (Please Print) Signature of Proposed Insured
X__________________________________________________________________ X_________________________________________________
Witness Signature of Owner
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AGENT'S REPORT
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1. Purpose of Insurance____________________________________________ Agent's Declaration - I certify that I have asked and
have fully recored the proposed Insured's answers to all
2. Annual earned income before taxes $_____________________________ questions in this application. I know nothing that is
Above based on: ? Insured's Statement ? Other material to the insurability of this life that has not
been recored herein.
3. Do you have reason to believe the life insurance applied for will
replace any insurance or annuity with us or any other company? ____________________ X______________________________
? Yes ? No Date Signature of Agent
If yes, details:_________________________________________________
Print Agent's Name:_____________________________________
_________________________________________________________________
Agent's Number:_________________________________________
_________________________________________________________________
Phone #:________________________________________________
_________________________________________________________________
Agency/Institution:_____________________________________
_________________________________________________________________
Office:_________________________________________________
_________________________________________________________________
Address:________________________________________________
_________________________________________________________________
________________________________________________________
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J355app (99) Page 3 of 6
This section must be completed for all simplified issue and fully underwritten cases.
INSURED'S PERSONAL AND MEDICAL INFORMATION PART I
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Name:____________________________________________________ Occupation___________________________________________________
Total life insurance in force: $_____________________________Driver's License #____________________________State:__________________
1. Have you applied for insurance in the past 6 months? ___Yes ___No
2. Have you ever been refused life insurance? ___Yes ___No
3. During the past 12 months have you used tobacco or nicotine products in any form? ___Yes ___No
During the past three years have you:
4. Flown as a private pilot or do you contemplate flying as a student pilot or crew member?
(If yes, please complete the aviation questionnaire.) ___Yes ___No
5. Participated in or do you contemplate participating in any hazardous sport such as racing
(automobile, snowmobile, motorcycle, boat), scuba diving, hang gliding, mountain or rock
climbing? (If yes, please complete the hazardous sports questionnaire.) ___Yes ___No
6. Has your driver's license been suspended or have you been convicted of a moving violation? ___Yes ___No
7. Within the past 10 years, has a member of the medical profession diagnosed you as having
or treated you for Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC)? ___Yes ___No
If you answered yes to questions 1-7, provide details:_____________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
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This section must be completed simplified issue only.
INSURED'S PERSONAL AND MEDICAL INFORMATION PART II
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Height:____________________ Weight:____________________
1. Do you have a personal physician? If yes, please provide name and address: ___Yes ___No
___________________________________________________________________________________________________________________________________
2. Please provide date last seen, reason seen and results:_______________________________________________________________________
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___________________________________________________________________________________________________________________________________
3. Have any members of your immediate family died before age 60? ___Yes ___No
4. Are you currently taking any medication(s)? ___Yes ___No
5. Have you ever been hospitalized? (If yes, give details below including date(s) and reason(s)) ___Yes ___No
Within the past 10 years, has a member of the medical profession diagnosed you as having or treated you for any of the following:
7. Any permanent disease or disorder, including those requiring medical or surgical intervention
of the heart, lungs, liver, kidneys, gastrointestinal system? ___Yes ___No
8. Elevated blood pressure, stroke, paralysis, or any chronic or progressive disease or disorder
of the brain or nervous system? ___Yes ___No
9. Diabetes, cancer or malignancy? ___Yes ___No
10. Treatment for alcohol or drug use, or have you been medically advised to do so? ___Yes ___No
11. Any counseling or treatment for mental, nervous or emotional disorders? ___Yes ___No
12. Any physical impairments or diseases not listed above? ___Yes ___No
If you answered yes to questions 1-12, provide details:____________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
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J355app (99) Page 4 of 6
This page must be completed for all simplified issue and fully underwritten cases.
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
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The Company, its reinsurers, insurance support organizations, and their authorized representative, may obtain medical and other
information in order to evaluate my application for life insurance. Any physician, practitioner, hospital, clinic, other medical or
medically related facility, the Veterans Administration, the Medical Information Bureau, Inc., my employer and consumer reporting
agency, credit reporting agency or insurance company who possesses information of care, treatment or advice of me may furnish such
information to The Company upon presenting this authorization or a photocopy. This authorization includes information about drugs,
alcoholism and mental illness. The Company or its reinsurers may make a brief report regarding me to other companies to whom I have
applied or may apply. This authorization will be valid from the date signed for a period of two and one-half years. I have read
this authorization and understand I have the right to receive a copy. I have received the Notice of insurance Information Practices
and Notice Regarding Medical Information Bureau. I consent to a consumer report containing personal or credit information or both
that may be requested in connection with my application.
All statements and answers to questions made in this application and any supplement to it are true and complete to the best of my
knowledge and belief. The information I have provided will be taken into consideration for and will serve as the basis of any
contract of insurance based on this application. 1) No Information or answer to any question will be deemed communicated to or
binding on The Company unless set out in this application. 2) Only the president, a vice president or the secretary of The Company
is authorized to change or waive any terms of this application or any contract of insurance issued.
Signed at______________________________________________________________this___________________day of___________________year
City and State
___________________________________________________________________ X_________________________________________________
Name of Proposed Insured (Please Print) Signature of Proposed Insured
X__________________________________________________________________ X_________________________________________________
Witness Signature of Owner
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J355app (99) Page 5 of 6
Notice of Insurance Information Practices and Notice Regarding Medical
Information Bureau
This is to inform you that, as part of our procedure for processing your
application, an investigative consumer report may be prepared whereby
information is obtained through personal interviews with your business
associates, friends, or others with whom you are acquainted. This inquiry
includes information as to your character, general reputation, personal
characteristics, financial information and mode of living. You have the right to
make a written request within a reasonable period of time to receive additional
detailed information about the nature and scope of this investigation. You have
the right to access information upon written request. You may request
correction, amendment or deletion of any information which you believe to be
inaccurate.
In connection with your application for insurance you may receive a telephone
call from an authorized person to obtain some personal and financial
information. You may be assured that the information is considered confidential
and will be used to assess your eligibility for insurance. The interview
normally takes from five to ten minutes and will be conducted at a time
convenient for you. In the event you are not in when the interviewer calls, the
interviewer will leave his or her name and telephone number so that you can
return the call at no charge to you and supply the necessary information.
Inquiries on the above notices should be addressed to:
Great-West Life & Annuity Insurance Company
Department 690, P.O. Box 1700
Denver, CO 80201
Information regarding your insurability will be treated as confidential. The
Company, or its reinsurers, may, however, make a brief report thereon to the
Medical Information Bureau, a non-profit membership organization of life
insurance companies, which operates an information exchange on behalf of its
members. If you apply to another Bureau member company for life or health
insurance coverage, or a claim for benefits is submitted to such a company, the
Bureau, upon request, will supply such company with the information it may have
in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any
information it may have in your file. If you question the accuracy of
information in the Bureau's file, you may contact the Bureau and seek a
correction in accordance with the procedures set forth in the federal Fair
Credit Recording Act. The address of the Bureau's information office is:
Medical Information Bureau
Post Office Box 105, Essex Station
Boston, MA 02112
Phone: (617) 426-3660
The Company, or its reinsurers, may also release information in its file to
other life insurance companies to whom you may apply for life or health
insurance, or to whom a claim for benefits may be submitted.
THIS STANDARD DISCLOSURE IS REQUIRED OF ALL LIFE INSURANCE PROVIDERS. BE ASSURED
THAT GREAT-WEST'S BUSINESS PRACTICES MEET THE HIGHEST INDUSTRY STANDARDS.
J355app (99) Page 6 of 6