Deferred Variable Annuity Additional Purchase Form - Fidelity

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