Term Owner and Policy Change Form - Fidelity

Term Owner and Policy Change Form
Use this form to change the address of record, owner’s or insured’s legal name, or policy ownership. If you have questions when
filling out this form, please call us at 888-343-8376, option 3, Monday through Friday, 8 a.m. to 5 p.m. Eastern time.
HELPFUL TO KNOW
• For new beneficiary designations, you must submit a Beneficiary Form.
1 CURRENT POLICY INFORMATION
Policy Number
Owner Name Insured Name
2 CHANGE OF POLICY OWNER (skip to Section 3 on the next page if you are not changing the ownership of the policy)
Name of Trust/Corporation Tax ID Number
For trusts, a Trustee Statement and Agreement Form must also be submitted and the trust must be the beneficiary. If naming a corporation,
please attach a copy of the corporation resolution.
NEW INDIVIDUAL OWNER or TRUSTEE/OFFICER OF CORPORATION
First Name Middle Initial Last Name
Date of Birth (MM/DD/YYYY) Relationship to Current Owner Social Security/Tax ID Number
Mailing Address — Street
City State ZIP Phone Number
NEW TRUSTEE/OFFICER OF CORPORATION
First Name Middle Initial Last Name
Date of Birth (MM/DD/YYYY) Relationship to Current Owner Social Security/Tax ID Number
Mailing Address — Street
City State ZIP Phone Number
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. A contract’s financial guarantees are subject to the claims-paying ability of the issuing insurance company.
Fidelity Brokerage Services, Member NYSE, SIPC, and/or Fidelity Insurance Agency, Inc., are the distributors.
Form continues on next page ➞

3 CHANGE OWNER/INSURED ADDRESS OR NAME
If changing name, attach a photocopy of a marriage certifi cate, divorce decree, or other court document showing the new name.
4 AUTHORIZED SIGNATURES (This section must be completed for any changes.)
• I (We) authorize the preceding changes to the above-referenced policy.
• I (We) have read my (our) policy and understand the effects of these changes.
• Ownership of this policy will be transferred when this form is signed, received, and recorded at the Life Insurance Service Center.
4a CURRENT OWNER SIGNATURE (ALL Current Owners must sign.)
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SIGNATURE OF CURRENT OWNER/TRUSTEE DATE SIGNATURE OF CURRENT OWNER/TRUSTEE DATE
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Change your name Owner Insured
Former Name
Name M.I. Last Name Social Security or Taxpayer ID Number
New Name
Name M.I. Last Name
Change your address Owner Insured
Mailing Address — Street
City State ZIP Phone Number
SIGNATURE OF WITNESS DATE SIGNATURE OF WITNESS DATE
4b NEW OWNER/TRUSTEE/CORPORATE OFFICER SIGNATURE (ALL New Owners must sign. Required only for changes in policy
ownership in Section 2.)
• You must sign for income tax identification. I certify under penalties of perjury that (1) the Social Security number or tax identification number
provided is correct, and (2) the IRS has not notified me that I am subject to 20% backup withholding or has notified me that I am no longer
subject to such backup withholding. (Note: If any or all of item (2) is not true, please cross out this part before signing.)
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SIGNATURE OF NEW OWNER/TRUSTEE/OFFICER DATE SIGNATURE OF NEW OWNER/TRUSTEE/OFFICER DATE
617501.2.0
1.943930.101
Please mail this form to: Life Insurance Service Center, P.O. Box 724507, Atlanta, GA 31139-2049
Overnight mail: Fidelity Investments, Suite 300 3rd Floor, 6425 Powers Ferry Road, Atlanta, GA 30339
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