Term Owner and Policy Change Form - Fidelity

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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