Deferred Variable Annuity Additional Purchase Form - Fidelity

Use this form to add additional funds to your Fidelity Retirement Reserves ® or Fidelity Personal Retirement Annuity ® contract through a check deposit or funds
transfer. If you have any questions about how to fill out this form, please call us at 800-634-9361, Monday through Friday, 8 a.m. to 8 p.m. Eastern time.
1 CONTRACT OWNER INFORMATION
Deferred Variable Annuity Additional Purchase Form
Contract Number Phone Number
Contract Owner Name
2 ADDITION BY CHECK (Complete this section if you are depositing by check.)
Enclosed is a check for $
Joint Contract Owner
Minimum $250 ($2,500 for IRA rollovers to qualified Retirement Reserves contracts)
NOTE: We do not accept starter checks, money orders, or cashier’s checks that are $10,000 or less; bank drafts; or postal money orders. Make check payable to: Fidelity Investments
Life Insurance Company. For New York residents, make check payable to: Empire Fidelity Investments Life Insurance Company.
3 ADDITION BY TRANSFER (Complete this section if you are transferring from another Fidelity Account. These exchanges can
take up to 2 days to complete if the sale of mutual funds is required.)
Transfer Amount $
From a Fidelity non-retirement account: Transfers from a brokerage account must come from the core position only.
Fidelity Non-Retirement Account Number Fidelity Fund Name or Symbol (mutual fund accounts ONLY)
4 INVESTMENT ALLOCATION (Complete this section to designate investment option.)
Specify your allocation instructions (check one):
Invest this payment per allocation on file. If you do not know your current allocation, call us at 800-634-9361.
Invest this payment as indicated below (total must equal 100%).
Change my allocation on file and my Automatic Annuity Builder service (if established) to match the allocation provided below (available only if
percentages provided).
Annuity Fund Name: Annuity Fund Number/Symbol: Dollar Amount or Percentage
For any allocations above that are deemed illegible or if the annuity fund name and number do not match, your purchase will be invested into the VIP Money Market Portfolio.
Investments withdrawn from certain funds could trigger redemption fees (see applicable fund prospectus).
Total:
011060101
Please continue

5a NON-RETIREMENT ACCOUNT OWNER SIGNATURE (If all names on both the non-retirement account and the annuity do not
match, ALL non-retirement owners must sign. Requires Medallion signature
guarantee if transfer is going to an annuity of which you are not the owner.)
SIGNATURE OF NON-RETIREMENT ACCOUNT OWNER/TRUSTEE DATE
X
MEDALLION SIGNATURE GUARANTEE
5b ANNUITY OWNER SIGNATURES (All annuity contract owners must SIGN AND DATE.)
OWNER/TRUSTEE SIGNATURE DATE JOINT OWNER SIGNATURE DATE
X X
Please mail this form to: Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0050
In New York: Empire Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0051
Overnight mail: Fidelity Investments, KC2Q, 100 Crosby Parkway, Covington, KY 41015
Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI) and, in New York, by Empire Fidelity
Investments Life Insurance Company, ® New York, N.Y. FILI is licensed in all states except New York. Products may not be available
in all states. The contract’s financial guarantees are solely the responsibility of the issuing insurance company.
493088.3.0
1.708489.119 Fidelity Brokerage Services LLC, Member NYSE, SIPC
SIGNATURE OF NON-RETIREMENT ACCOUNT OWNER/TRUSTEE DATE
X
MEDALLION SIGNATURE GUARANTEE