State of Tennessee
Participant Enrollment Form
401(k) and 457(b) Plans
98986-01 & 02
Participant Information
Plan and Deferral Election
Last Name First Name MI Social Security Number
Address - Number & Street E- Mail Address
City State Zip Code
Home Phone Work Phone Date of Birth
I elect to enroll and participate in the following plan(s) and authorize the state to deduct and defer the amounts shown. Effective date must be at
least 30 days after completion of the agreement. Deferral amount minimum is $20.00 per plan, per month.
401(k) plan Deduct $ _____________________ 401(k) pre-tax from my gross per pay period salary.
401(k) plan ROTH Deduct $ _____________________ 401(k) designated ROTH after-tax from my gross per pay period salary.
457(b) plan Deduct $ _____________________ 457(b) pre-tax from my gross per pay period salary.
Effective ___ / ___ / 20___ Total: $
Department Name: ______________________ Paid: Monthly
Note: Your annual deferral cannot exceed the lesser of 100% of your eligible compensation or $16,500 per plan for the 2009 calendar year. State and
Higher Education employees may enroll in both plans. 401(k) Plan deferral may be eligible for employer match, subject to annual appropriation.
Investment Option Information - Please refer to your marketing communication materials for investment option descriptions.
401(k) 457(b) Select Investment Options Code
__________% __________% Allianz NFJ Large Cap Institutional * INGALG
__________% __________% Calvert Income CINCX
__________% __________% Columbia Acorn Z * INGCAC
__________% __________% Columbia Midcap Value Z * INGCMC
__________% __________% DFA International Value DFIVX
__________% __________% Fidelity Contra Fund FCNTX
__________% __________% Fidelity International Discovery FIGRX
__________% __________% Fidelity Magellan Fund FMAGX
__________% __________% Fidelity OTC Portfolio FOCPX
__________% __________% Fidelity Puritan Fund FPURX
__________% __________% Fidelity Retirement Government Money Market FGMXX
__________% __________% Fidelity Small Cap Independence FDSCX
__________% __________% ING Fixed Plus Account AEF-FX
__________% __________% Morgan Stanley Inst US Small Cap Value Inst * INGMSC
__________% __________% State Street S&P 500 Flagship Series C SV-SPC
__________% __________% Regions Bank UP-UPB
__________% __________% Vanguard Total Bond Market Index VBTSX
Vanguard Target Date Funds
__________% __________% Vanguard Target Retirement Income VTINX
__________% __________% Vanguard Target Retirement 2010 VTENX
__________% __________% Vanguard Target Retirement 2015 VTXVX
__________% __________% Vanguard Target Retirement 2020 VTWNX
__________% __________% Vanguard Target Retirement 2025 VTTVX
__________% __________% Vanguard Target Retirement 2030 VTHRX
__________% __________% Vanguard Target Retirement 2035 VTTHX
__________% __________% Vanguard Target Retirement 2040 VFORX
__________% __________% Vanguard Target Retirement 2045 VTIVX
__________% __________% Vanguard Target Retirement 2050 VFIFX
* Indicates separate account funds offered through ING
Total % % Percentages must be whole numbers and columns must add up to 100%
Employer: TBR
Reset Form
Investment Options - I understand and acknowledge that all payments and account values, when based on the experience of the investment options, may not be
guaranteed and may fluctuate, and upon redemption, shares may be worth more or less than their original cost. I understand that I may obtain current prospectuses from my
registered representative or online. The State of Tennessee shall be liable only to pay amounts equal to that which would have been available under the products or
contracts described above and shall not be responsible for any loss due to the investment of funds and assets in said Deferred Compensation Plan account, nor shall the
State of Tennessee be required to replace any loss whatsoever which may result from said investments. I acknowledge that investment option information, include
prospectuses, disclosure documents and Fund Profile sheets, have been made available to me and I understand the risks of investing.
Plan Beneficiary Designation
This designation is effective at the time it is recorded into my account by the State’s record keeper, Great-West Retirement Services. I have the right to change the
beneficiary election. If any information is missing, additional information may be required prior to recording my beneficiary designation. Under the terms of the Plan
Document, if I name more than one beneficiary in either category, the surviving beneficiary(ies) in that category will share equally, unless otherwise indicated. If my
primary and contingent beneficiaries predecease me or I fail to designate beneficiaries, amounts will be paid first to an existing spouse, and if there is none, to my estate.
If designating a minor beneficiary, I will note the name of the guardian or parent, if other than myself. Designated ROTH, 401(k) and 457 deferrals are subject to different
distribution limits.
Participation Agreement
I have received a copy of the Deferred Compensation Plan and understand the terms and provisions thereof.
The Deferred Compensation Plan is incorporated into this Participation Agreement and that these together constitute my entire rights and obligations under the Plan.
This form is a legally binding contract - I understand that by signing and submitting this Participant Enrollment form for processing, I am requesting to have investment
options established under the Plan(s) specified on the first page of this form. I understand that this account is subject to the terms of the Plan Document.
Account balances shall only be distributed under the terms of the Plan Document, which prohibits any payouts as long as I continue in employment with the State except
in the case of financial hardship as defined by applicable 401(k) plan regulations or at age 59 1/2. Special penalty and limitations may apply to 401(k) distribution and
designated Roth 401(k) deferrals. Limits on 457 hardships are more restrictive than 401(k). Requirements vary by plan.
Compliance with the Internal Revenue Code - I understand that the maximum annual limit on contributions is determined under the Plan Document and/or the Internal
Revenue Code. I understand that it is my responsibility to monitor my total annual limit on contributions to ensure that I do not exceed the amount permitted. If I exceed the
contribution limit, I assume sole liability for any tax, penalty, or cost that may be incurred. I understand that Federal income tax is deferred on allowable pre-tax contributions
and the earnings thereon, until such amounts are distributed. I understand that Roth 401(k) contributions, earnings, and distributions are treated differently.
I understand that in the event my Participant Enrollment form is incomplete, or it is not received by Benefits Administration in Nashville, Tennessee prior to the receipt of
any deposits, I consent to Great-West retaining all monies received and allocating them to the default investment option which is selected by my Plan. Once my account has
been established, I understand that I must call KeyTalk in order to transfer monies from the default investment option. Also, I understand all contributions received after my
account is established will be applied to the investment options I selected. I also understand that it is my obligation to review my confirmations and quarterly statements and
inform Great-West of any discrepancies or errors within 90 calendar days of the date of such confirmation or statement.
Plan Fees - I understand that fees may apply under this plan. The fees vary by fund, and can be found on the IOAG performance sheet or by visiting the State's website.
401(k) and 403(b) share a single contribution limit of $16,500 for 2009 - I understand that I am responsible for any excess contributions and taxes thereon.
__________________________________________________________ ____________________________
Last Name First Name MI Social Security Number
Designate Whole
Primary Beneficiary Name(s) Relationship Social Security Number Date of Birth Percentage
_________________________________ __________________ ____________________ _______________ ______________
_________________________________ __________________ ____________________ _______________ ______________
_________________________________ __________________ ____________________ _______________ ______________
Designate Whole
Contingent Beneficiary Name(s) Relationship Social Security Number Date of Birth Percentage
_________________________________ __________________ ____________________ _______________ ______________
_________________________________ __________________ ____________________ _______________ ______________
_________________________________ __________________ ____________________ _______________ ______________
List beneficiary(ies) below. If you are participating in both plans, the below beneficiary elections will apply to both plans, unless you complete separate
beneficiary change forms. Designated percentages must be whole numbers and must add up to 100% for primary and 100% for contingent beneficaries.
Required Signature - I have completed, understand, and agree to all pages of this participant enrollment form.
Participant Signature: _______________________________________________ Date: _________________________
This Participant Enrollment form is considered unsolicited unless accompanied be a signed Participant
Suitability Profile form completed in the presence of a GWRS Equities, Inc. Registered Representative during a
one-on-one meeting.
Solicited. Representative met with individual participant to solicit Plan enrollment and hasied suitability
of the participant’s investment allocation per the Participant Suitability Profile form. (Representative and
Principal must sign and check box for solicited business only, and must be accompanied by a completed
and signed Participant Suitability Profile form.)
___________________________________________ ___________________________
Registered Representative Signature Date
___________________________________________ ___________________________
Registered Principal Signature Date
For more information regarding the 401(k) and
457 plans, visit: or
call Great-West Retirement Services at
1-800-922-7772, Option 2
Send Completed Forms to:
Benefits Administration
Floor Tennessee Tower
312 Rosa L. Parks Avenue
Nashville, TN 37243
Also provide a copy to your payroll officer.
Rev. 02/09