Application for an Individual Flexible Premium Variable
Universal Life Insurance Policy to
First Great-West Life & Annuity Insurance Company
(“the Company”)
Administrative office: 8525 East Orchard Road,
Greenwood Village, CO 80111

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)

Name

Address

Phone #: Day

( ) -

Phone #: Day

( ) -

Evening

( ) -

Evening

( ) -

Birth Date:

/ /

SS #

- -

Relationship to Insured

Place of Birth

Owner’s SS # or Tax ID #

POLICY INFORMATION

Life Insurance or Premium Applied for:

Total Face Amount $____________________________

Base Face Amount $____________________________

Rider Face Amount $____________________________

Premium $____________________________________

Mode of Payment______________________________

Premium Payor (Owner, unless otherwise indicated)

Name_______________________________________

Address_____________________________________

____________________________________________

Death Benefit Option (Please check one):

Level Death [ ]

Coverage Plus [ ]

Premium Accumulation [ ]

Please check one:

Cash Value Accumulation Test [ ]

Guideline Single Premium Test [ ]

Transfer Provisions (Optional):

Dollar Cost Averaging [ ]

-OR-

Rebalancer Option [ ]

REPLACEMENT

Do you have any existing insurance policies or annuity contracts? [ ]Yes [ ] No

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.:____________________________________________________________________________________

J355app3mmf-NY

(8/06)

Page 1 of 7

BENEFICIARY
a. [ ]Employer: If employer is the beneficiary, the employer certifies, represents and warrants that: a.) The employer has a lawful and substantial economic interest in the life, health and bodily safety of each proposed insured; b.) The services of each such proposed insured are such that the employer expects to realize either: • A substantial monetary gain through the continued life of the proposed insured; or • A substantial monetary loss in the event of the proposed insured’s death. • Please confirm understanding of the above by initialing here: _____ b. [ ] Trust created by the employer c. [ ] Trust created by the Insured d. [ ] Insured e. [ ] Other [ ] See attached Schedule of Insureds.
CITIZENSHIP STATUS
Is each individual named on this application a citizen of the United States? [ ]Yes [ ] No If “No,” give details below for each individual who is not a U.S. citizen. Foreign Residency & Travel Details (1) In the past 2 years, have you resided in the United States as a U.S. citizen or with a permanent resident visa? [ ] Yes [ ] No If “No,” provide details of residency and citizenship. ___________________________________________________________________________________ ___________________________________________________________________________________ (2) Do you plan to travel or reside outside the United States in the next two years? [ ] Yes [ ] No If “Yes,” provide details to include city & country, dates, duration, and purpose. ___________________________________________________________________________________ ___________________________________________________________________________________

J355app3mmf-NY

(8/06)

Page 2 of 7

INVESTMENT ALLOCATION		This page must be completed for all cases.
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.
[AIM Variable Insurance Fund (Series I Shares)			%	Janus Aspen Flexible Bond Portfolio
%	AIM V.I. Global Health Care Fund		%	Janus Aspen Forty Portfolio
%	AIM V.I. International Growth Fund		%	Janus Aspen International Growth
American Century Variable Portfolios, Inc. (Class I Shares)			Maxim Series Fund, Inc.
%	American Century VP Ultra ® Fund		%	Maxim Ariel Small-Cap Value Portfolio
%	American Century VP Value Fund		%	Maxim INVESCO ADR Portfolio
%	American Century VP Vista SM Fund		%	Maxim Loomis Sayles Bond Portfolio
Davis Variable Account Fund, Inc.			%	Maxim Loomis Sayles Small-Cap Portfolio
%	Davis Financial Portfolio		%	Maxim Money Market Portfolio
%	Davis Value Portfolio		%	Maxim T. Rowe Price Equity/Income Portfolio
Dreyfus Investment Portfolios (Initial Shares)			%	Maxim T. Rowe Price MidCap Growth Portfolio
%	Dreyfus IP Emerging Leaders Portfolio		%	Maxim U.S. Government Securities Portfolio
%	Dreyfus IP MidCap Stock Portfolio		Maxim Profile Portfolios
%	Dreyfus IP Technology Growth Portfolio		%	Maxim Aggressive Profile I Portfolio
Dreyfus Stock Index Fund, Inc. (Initial Shares)			%	Maxim Conservative Profile I Portfolio
%	Dreyfus Stock Index Fund		%	Maxim Moderately Aggressive Profile I Portfolio
Dreyfus Variable Investment Fund (Initial Shares)			%	Maxim Moderately Conservative Profile I Portfolio
%	Dreyfus VIF Appreciation Portfolio		%	Maxim Moderate Profile I Portfolio
%	Dreyfus VIF International Equity Portfolio		Neuberger Berman Advisers Management Trust
%	Dreyfus VIF International Value Portfolio		%	Neuberger Berman AMT Fasciano Portfolio (S)
DWS Variable Series I (A Shares)			%	Neuberger Berman AMT Partners Portfolio (I)
%	DWS Global Opportunities VIP		%	Neuberger Berman AMT Regency (I)
DWS Variable Series II (A Shares)			%	Neuberger Berman AMT Socially Responsive (I)
%	DWS Dreman High Return Equity VIP		PIMCO VIT (Administrative Shares)
%	DWS Dreman Small Mid Cap Value VIP		%	PIMCO VIT High Yield Portfolio
Federated Insurance Series (Primary Shares)			%	PIMCO VIT Low Duration Portfolio
%	Federated High Income Bond Fund II		%	PIMCO VIT Real Return Portfolio
%	Federated Mid Cap Growth Strategies Fund II		%	PIMCO VIT Total Return Portfolio
Fidelity Variable Insurance Products (VIP) (Svc 2 Shares)			Royce Capital Fund (Service Class Shares)
%	Fidelity VIP Contrafund® Portfolio		%	Royce Micro-Cap
%	Fidelity VIP Equity-Income Portfolio		%	Royce Small-Cap
%	Fidelity VIP Investment Grade Bond Portfolio		STI Classic Variable Trust
%	Fidelity VIP Mid Cap Portfolio		%	STI Classic VT Capital Appreciation Fund
Janus Aspen Series (Institutional Shares)			%	STI Classic VT Small Cap Value Equity Fund]
%	Janus Aspen Balanced Portfolio			TOTAL = 100%
COMPLIANCE INFORMATION
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 complete the following relating to the suitability of your investment choices.
Do you understand that, under this policy, all payments and values including cash values and the death benefit are based on the investment experience of the Investment Divisions and are variable? Yes [ ] No [ ] Do you believe that this policy will meet your objectives and anticipated financial needs? Yes [ ] No [ ] I have received a copy of the current product prospectus for this Flexible Premium Variable Universal Life Policy. Yes [ ] No [ ]

J355app3mmf-NY

(8/06)

Page 3 of 7

SIGNATURE

This page must be completed for all cases.

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. This application will be attached to and made part of the policy. 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 Insured’s are still living.

I understand that I am applying for an Individual Flexible Premium Variable Universal Life Insurance Policy, form
J355NY, issued by First 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 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

Name of Proposed Insured (Please Print)

Signature of Proposed Insured

Witness

Signature of Owner

STATEMENT OF ADDITIONAL INFORMATION

Check here if you’d like a copy of the Statement of Additional Information to the prospectus. [ ]

AGENT’S REPORT

1. Purpose of Insurance ________________________

2. Annual earned income before taxes $____________

Above based on: [ ]Insured’s Statement [ ]Other

3. Does the applicant have existing life insurance policies or annuity contracts? [ ]Yes [ ] No

4. Do you have reason to believe the life insurance applied for will replace any insurance or annuity with us or any other company? [ ]Yes [ ] No

If yes, details:__________________________________

_____________________________________________

Agent’s Declaration - I certify that I have asked and
have fully recorded the proposed Insured’s answers to
all questions in this application. I know nothing that is
material to the insurability of this life that has not been
recorded herein.

____________ X ________________________

Date Signature of Agent

Print Agent’s Name:___________________________

Agent’s Number:______________________________

Phone #: (____)_______-_______________________

Agency/Institution:_____________________________

Office:______________________________________

Address:____________________________________

___________________________________________

J355app3mmf-NY

(8/06)

Page 4 of 7

This section must be completed for all fully underwritten cases.

INSURED’S PERSONAL AND MEDICAL INFORMATION PART I

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. In the past three years, have you been charged with driving under the influence of alcohol or drugs

(DUI), or have you had your driver’s license suspended or revoked? [ ]Yes [ ] No

7. In the past 10 years, have you been diagnosed or treated for Acquired Immune Deficiency Syndrome (AIDS)

or AIDS Related Complex (ARC) by a member of the Medical profession)? [ ]Yes [ ] No

If you answered yes to questions 1-7, provide details:

This section must be completed for all fully underwritten cases.

INSURED’S PERSONAL AND MEDICAL INFORMATION PART II

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:_____________________________________________

_________________________________________________________________________________________

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:

6. Any permanent disease or disorder, including those requiring medical or surgical intervention

of the heart, lungs, liver, kidneys, gastrointestinal system? [ ]Yes [ ] No

7. Elevated blood pressure, stroke, paralysis, or any chronic or progressive disease or disorder of

the brain, spinal cord or central nervous system? [ ]Yes [ ] No

8. Blood disorders including chronic anemia? [ ]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: (Use an additional sheet of paper if necessary)______________

_______________________________________________________________________________________________

This page must be completed for all fully underwritten cases.

J355app3mmf-NY

(8/06)

Page 5 of 7

AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
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 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

J355app3mmf-NY

(8/06)

Page 6 of 7

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. This inquiry includes information as to your character, general reputation, personal characteristics, 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:

First Great-West Life & Annuity Insurance Company

Administrative Office

P.O. Box 1470

Denver, CO 80201-9606

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 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 Reporting Act.

Please contact MIB at:

Medical Information Bureau

Post Office Box 105, Essex Station

Boston, MA 02112

Phone: 866-692-6901 (TTY 866-346-3642)

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 FIRST GREAT-WEST’S BUSINESS PRACTICES MEET THE HIGHEST INDUSTRY STANDARDS.

First Great-West Life & Annuity Insurance Company, Home Office: White Plains, New York

J355app3mmf-NY

(8/06)

Page 7 of 7