Broker/Dealer Firm and/or Advisor Change Instructions

Broker/Dealer Firm and/or Advisor Change Instructions

Please check the following to avoid any delays in processing:

Correct Signature Please see page 4 for instructions.

State insurance license is active The appropriate state insurance license (typically a life or variable products license) is required if the plan will be purchasing a group annuity product, including a plan that invests primarily in mutual funds but which also purchases a group annuity stable value product."

Submission Instructions:

Email: RetirementAdvisorChanges@ Fax: 1-413-226-4004 For questions or help contact Workplace Retirement Compensation Phone: 1-800-471-5537 Email: RS-Commissions@empower- The new advisor will receive a confirmation email or letter upon completion.

RS-40372-01 Rev 2.21

Page 1 of 4

AgentChange

Retirement Services Commissions

Broker/Dealer Firm and/or Advisor Change Request

Note: Do not submit this form to attempt to change the compensation rate on a plan. Please contact your Empower Retirement Account Management representative if you need to discuss the compensation rate.

Email Completed Forms To: RetirementAdvisorChanges@

OR

Fax To: 1-413-226-4004

Mailing Address: Empower Retirement, 100 Bright Meadow Boulevard - MIP 225, Enfield, CT 06082

Section A - Plan Information

Plan ID/ Group Number

Plan Name

Section B - New Financial Advisor Information (Required)

Note: Split percentages must equal 100%. Advisors cannot be assigned a 0% split.

Advisor Name*

Advisor SSN

Advisor Broker/Dealer Firm Name

Split %

*Please use your registered FINRA or business name, not nicknames.

Advisor/Advisor's Office Contact Information for Questions Regarding This Request:

Name

Phone No.

Email Address

Financial Advisor Business Contact Information (CHANGES ONLY) Please complete this section ONLY if your address, email address, or phone number has changed and you would like Empower Retirement to update our

records.

1. Name

Email Address

Business Address

Phone No.

City

State

Zip Code

2. Name

Business Address City

Email Address Phone No. State

Zip Code

3. Name

Business Address City

Email Address Phone No. State

Zip Code

For questions regarding this form email RS-Commissions@empower- or call 800-471-5537.

RS-40372-01 Rev 2.21

Page 2 of 4

Section C - Required for Former Hartford Life Mutual Fund 401(k) Plans Only

Complete for Recordkeeper Plus and Corporate Plan Services (CPS) products. ? The Hartford Recordkeeper Plus and Corporate Plan Services (CPS) products are on the mutual fund platform and require a Representative Number and

Branch Number. Plan numbers typically begin with the following prefixes: 278, 281, 1105, 2205, 5505, 6605, 9905. ? If multiple advisors are servicing the plan, please provide a single Partnership Name and Representative Number to represent the group. ? Please list the names and SSNs of the individual advisors that make up the partnership in Section B (above).

Advisor/Partnership Name

Representative Number

Branch Number

Section D - Only Required for Governmental/Not for Profit Plans (Former Hartford Plans)

Some Government/Not for Profit Plans allow for advisors to be assigned to individual participants within the plan, rather than to the entire plan as a whole. Please complete the section if your plan fits this category. There are 3 different types of changes - please check the appropriate box. Explanation of Change Types ? Add new Financial Advisor to be eligible to enroll participants without changing any existing participant accounts. Check this box if you want to add an advisor to the plan for the purpose of enrolling new participants only. All existing participants will remain assigned to their current advisor.

? Individual Participant Account Change Check this box if you do not want the change to apply to all participants in the plan. If the change is for more than one participant, please attach a separate list.

? Block Transfer Check this box if you want to move all participants currently assigned to one advisor to the new advisor listed in Section B. Examples include: An advisor moving all of his/her business to a new broker/dealer firm, a complete reassignment of business from one advisor to another.

Select one:

Add new Financial Advisor to be eligible to enroll participants without changing any existing participant accounts

Individual Participant Account Change - Change advisor/firm for one or more select participants only (Complete Section 1 below).

Block Transfer - Reassign all participants in the plan from the former financial advisor/firm to the new advisor/firm (Complete Section 2 Below)

1. For Individual Participant Account Changes: Participant Name

Participant SSN

Please attach list if request is for more than one participant.

2. For Block Transfer Requests: Former Advisor Name

Former Advisor Broker/Dealer Firm Name

Page 3 of 4

Section E - Signatures

I hereby designate the above referenced Broker Dealer Firm and/or Registered Representative as the broker and/or registered representative of record for the above referenced retirement plan/account. I confirm that I understand that this designation cannot become effective before the end of a reasonable processing period after submission of this form to Empower Retirement. I understand that this will not change the compensation rate previously disclosed to me.

Empower Retirement and its affiliates are entitled to rely on my authorization and are released from any and all claims I may have, or claim to have, with respect to this authorization. I also agree to indemnify and hold harmless Empower Retirement and its affiliates from and against any loss, liability, cost, or expense (including, without limitation, counsel fees and expenses in connection with the contest or settlement of any claim) that any one of them might incur or sustain, or discover that they have incurred or sustained, by reason of any claim which may be made against any of them as a result of this designation.

Who has to sign this document?

If you are...

Then this person may sign

Changing the advisors and the broker/dealer or firm that you are registered with Or Changing the broker/dealer or firm only (advisor remains the same)

Plan Sponsor (authorized signer for Plan)

Changing the advisors the same firm

within

the

same

firm

or

changing

the

advisor

splits,

all

within

Plan Sponsor, OR Branch Manager (the signature must belong to someone than the advisor(s) who will be servicing the plan)

other

Changing the advisor when the Government or Not for Profit plan allows participants to elect a specific advisor for their individual account(s). Note: Some plans may also require the Plan Sponsor to authorize this type of request.

Complete Page 3, Section D

Plan Sponsor, OR Participant

(Required - Select one) By signing below I certify that I understand and agree that the referenced agent/broker(s) shall be named as agent/broker(s) of record to the plan/account indicated on this form. I am signing as:

Authorized Signer for Plan at Empower Retirement (Plan Sponsor) Firm Branch Manager or Authorized Registered Principal Participant

__________________________________________________________ ___________________________________________ __________________________

Signature

Printed Name

Date

Submission Instructions:

Email: RetirementAdvisorChanges@ Fax: 1-413-226-4004

For questions or help contact Workplace Retirement Compensation Phone: 1-800-471-5537 Email: RS-Commissions@empower- The new advisor will receive a confirmation email or letter upon completion.

Securities offered and/or distributed by GWFS Equities, Inc., Member FINRA/SIPC. GWFS is an affiliate of Empower Retirement, LLC; Great-West Funds, Inc.; and registered investment advisers, Advised Assets Group, LLC and Personal Capital.

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