Fidelity Security Life Insurance Company - Marketing Financial

GREAT SOUTHERN FINANCIAL SERVICES 

2609-B East Sunshine, Springfield, MO 65804 (417) 888-4389 

Annuity Processing Procedures 

Please contact the following with product info, rate questions, or insurance rate quotes. 

Marketing Financial ~ Alan Lockhart, Stacey Douglas, Caleb Smith (417) 831-4431 or (800) 677-1087 

Please contact the following with annuity processing questions. 

Great Southern Investment Dept ~ Laura Smith (417) 888-4385 or Tabatha Wynn (417) 888-4389 

BEFORE YOU WRITE NEW BUSINESS: 

If you are unsure if you are appointed with a particular company, you may not be. 

Most companies require pre-appointment & product training prior to presenting their products. 

Anti-Money Laundering Training is a requirement. Please contact Tabatha Wynn 

Please call Laura, Tabatha or Marketing Financial prior to dating any annuity company forms if you're unsure. 

REQUIREMENTS: 

Please use the Investment Dept address/phone # for all agent/BC contact info. 

NEW BUSINESS FORM – GSB doc 

CUSTOMER INVESTMENT & SUITABILITY CONFIRMATION WORKSHEET – GSB doc 

GSB DISCLOSURE FORM if applicable – GSB doc 

ANNUITY COMPANY FORMS when in doubt fill it out – or contact one of us. 

OFAC printed the day of the application – OFAC signed & dated by agent. 

Owner(s) IDs -- 2 current forms of 1 primary/1secondary owner(s) must be provided to 

GSB Investment Dept. with all applications (please follow GSB identification guidelines). 

ANNUITY COMPANY TRANSFER FORM 

Provide a copy to Great Southern CD/IRA Dept (if funds are from a GSB CD/IRA). 

SPRINGFIELD, MO LOCATIONS: 

Dispatch all required documents to the Investment Dept. – Attn: New Business. 

ALL OTHER LOCATIONS: 

PLEASE DO NOT USE WHITE OUT ON ANY COMPANY FORMS. 

HAVE OWNER’S INITIALS & DATE ALL CORRECTIONS. 

Dispatch all required documents to Investments for business written the day of your dispatch pick up. 

Mail all required documents via overnight UPS or FedEx to Investments. 

Please drop in the nearest UPS or FedEx store or drop box if possible. 

UPS Account # 8W4W69 

FedEx Account # 383706599 

Shipping account numbers are to be used for investment dept new annuity business only. 

Please contact Tabatha or Laura for pre-printed labels & all other shipping questions. 

Please note: pre-printed UPS labels with barcodes may be associated to the wrong UPS account. 

Please review regularly for rate changes, etc. http://www.marketingfinancial.com/gsannuities/ 

REV Aug. '13


New Business Form 

Client Name(s): _________________________________ 

Owner's age(s): _______________ 

BC #/State: ____/______ 

Writing Agent Name: _____________________________ 

Split Commission with: (if applicable): ________________ 

Referred by: _______________________________________ 

Commission Split %: ________________________________ 

Funds Info: 

Internal Funds (GSB) 

External Funds 

Check Enclosed: $_______________________________ 

Qualified (CD/IRA, 401K, etc) 

Non-Qualified (Checking, CD, etc) 

Transfer(s) Approx: $_____________________________ 

Qualified (CD/IRA, 401K, etc) 

Non-Qualified (Checking, Annuity, CD, etc) 

Company Name _________________________ 

ex: Sagicor 

Product Name __________________________ 

ex: Sage Choice SPDA 

Surrender Charge Period (years) ____________ 

1035 Exchange (NQ life/annuity) Approx: $_______________________ 

Agent Check List: 

New Business 

Non-Qualified - Life/Annuity to Life/Annuity 

Application 

1035 Exchange Form 

Disclosures 

State Replacement Form 

Owner's ID 

Original Policy or Lost Policy Affidavit 

Owner's OFAC 

Cashier's/Personal Check Payable to Company IRA Annuity to IRA Annuity 

IRA Trsf Form 

IRA Trsf/Rollover 

Replacement Form 

IRA Trsf Form 

Original Policy or Lost Policy Affidavit 

Company Specific Forms (401K) W-9 (funds coming from Lincoln Benefit Life ) 

Agent's Report - Source of Funds: (MUST BE COMPLETED) 

1. Provide your detailed explanation regarding how this purchase meets the client's stated investment goal. 

Attach additional sheet if necessary. 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

___________________________________________________________________________________________ 

Agent Signature: ________________________________________ 

Approver Signature (Laura M. Smith): _____________________________ 

Date: _____________________ 

Date: _____________________ 

REV 05-2013


Date: 

Owner Name: 

Joint Owner Name: 

Company/Product: 

Owner(s) Initials 

Disclosures 

Not FDIC Insured. 

Not a deposit or other obligation of Great Southern Bank. 

It is understood that if the contract is prematurely ended by the client, 

surrender charges will apply for the first ______ years. 

Any money taken out of this contract in excess of the penalty free 

withdrawal amount provided in the contract during the surrender 

charge period will incur a penalty. 

The minimum guaranteed interest rate for the contract is ______%. 

The first year rate is ______ % which includes a bonus of ______%. 

(Does not apply to indexed annuities) 

If there are any surrender charges or penalties of any kind associated 

with the money used to purchase this annuity please list the amount of 

penalty: $______. 

This contract was purchased with Qualified or Non-Qualified funds. 

(Please circle which applies) 

Signatures 

Owner: 

Joint Owner: 

Representative: 

REV 05-2013

Fidelity Security Life Insurance Company 

3130 Broadway, Kansas City, Missouri 64111-2406 

TaxVantage TM Annuity Application 

Underwritten by Fidelity Security Life Insurance Company, Kansas City, Missouri 

Plan Type: 

❏ Traditional IRA 

❏ Roth IRA 

Premium Type: ❏ Flexible Premium ❏ Single Premium 

Print Full Name__________________________________________________________________ SSN________________________ 

Last First Middle 

Mailing Address_______________________________________________________________________________________________ 

Street City State Zip 

Residential Address____________________________________________________________________________________________ 


E-Mail Address________________________________________________________________________________________________ 

Home Phone _______________________________________ 

Work Phone ____________________________________________ 

Date of Birth ______/______/______ (Mo/Day/Yr) ❏ Male ❏ Female 

❏ Primary 

❏ Contingent 

❏ Primary 


❏ Primary 


❏ Primary 


Beneficiary Allocation Relationship SS# 

___________________________________ ________ % ________________________ ______________________ 

___________________________________ ________ % ________________________ ______________________ 

___________________________________ ________ % ________________________ ______________________ 

___________________________________ ________ % ________________________ ______________________ 

Primary Beneficiary Allocation total must equal 100%. Contingent Beneficiary Allocation total must equal 100%. 

Do you have any existing annuity or life insurance contracts? 

❏ Yes ❏ No 

Is any annuity or life insurance contract being replaced with this purchase? 


If Yes to either question, please provide the name of the insurance company(ies) and contract or policy number for each product 

being replaced. Please complete the replacement form. 

Owner Signature X______________________________________________________ Date ______/______/______ (Mo/Day/Yr) 

To your knowledge and belief does the applicant have any existing annuity or life insurance contracts? 

To your knowledge and belief is any annuity or insurance contract being replaced with this purchase? 

If yes, Replacement Notice must be completed. 



I have verified the applicant’s identity by viewing: ❏ Drivers License Drivers License # _______________________________ 

❏ Other________________________________________________________ 

Agent Signature X_______________________________________________________ Date ______/______/______ (Mo/Day/Yr) 

A-01142NE For Office Use Only 95-32524 #5533 0313



TaxVantage TM Annuity Application 

Underwritten by Fidelity Security Life Insurance Company, Kansas City, Missouri 

Plan Type: 

❏ Non-Qualified 

❏ Other _________________________ 

Premium Type: ❏ Flexible Premium ❏ Single Premium 

OWNER INFORMATION (Natural Person): 





Residential Address____________________________________________________________________________________________ 


E-Mail Address________________________________________________________________________________________________ 

Home Phone _______________________________________ 

Work Phone ____________________________________________ 


❏ Primary 


❏ Primary 


❏ Primary 


❏ Primary 


Beneficiary Allocation Relationship SS# 

___________________________________ ________ % ________________________ ______________________ 

___________________________________ ________ % ________________________ ______________________ 

___________________________________ ________ % ________________________ ______________________ 

___________________________________ ________ % ________________________ ______________________ 

Primary Beneficiary Allocation total must equal 100%. Contingent Beneficiary Allocation total must equal 100%. 

OWNER INFORMATION: (Non-natural Person for Non-qualified plans only): 

Trust* Name_________________________________________________________________________________________________ 



Tax ID Number _____________________________________ Date of Trust ___________________________________________ 

Name of Trustee(s)____________________________________________________________________________________________ 



Phone Number _____________________________ Email Address ___________________________________________________ 

IMPORTANT: A copy of the Trust title page and signature page must be submitted with the application. 


JOINT OWNER INFORMATION: 





E-Mail Address________________________________________________________________________________________________ 

Home Phone _______________________________________ 

Work Phone ____________________________________________ 


ANNUITANT INFORMATION (if different from the Owner): 





E-Mail Address________________________________________________________________________________________________ 

Home Phone _______________________________________ 

Work Phone ____________________________________________ 


Do you have any existing annuity or life insurance contracts? 


Is any annuity or life insurance contract being replaced with this purchase? 


If Yes to either question, please provide the name of the insurance company(ies) and contract or policy number for each product 

being replaced. Please complete the replacement form. 

Owner Signature X______________________________________________________ Date ______/______/______ (Mo/Day/Yr) 

Joint Owner Signature X__________________________________________________ Date ______/______/______ (Mo/Day/Yr) 

To your knowledge and belief does the applicant have any existing annuity or life insurance contracts? 

To your knowledge and belief is any annuity or insurance contract being replaced with this purchase? 

If yes, Replacement Notice must be completed. 



I have verified the applicant’s identity by viewing: ❏ Drivers License Drivers License # _______________________________ 

❏ Other________________________________________________________ 

Agent Signature X_______________________________________________________ Date ______/______/______ (Mo/Day/Yr) 



3130 Broadway 

Kansas City, MO 64111 

Direct Rollover/Transfer Form 

Please read and complete sections 1 - 6 of this form, then sign and date where indicated. You may give the form to your agent or mail it directly to 

Fidelity Security Life at the address shown at the top of this form. Make sure you first complete all forms required by the employer maintaining your plan. 

Part 1: Name and Address Information (Please Print) 

Name ____________________________________________________ Social Security Number ________________________________ 

Address __________________________________________________ Your Home Phone ____________________________________ 

City _____________________________ State ______ ZIP__________ Your Work Phone ____________________________________ 

Part 2: Your Existing Account/Plan (Current Company/Custodian) 

Name of Company __________________________________________ 

Address __________________________________________________ 

________________________________________________________ 

City _____________________________ State ______ ZIP__________ 

Account/Plan Number __________________________________ 

Plan Name __________________________________________ 

Plan Administrator Name ________________________________ 

Contact Number ______________________________________ 

Part 3: FROM Account Type (check one): ❑ IRA ❑ 403(b) ❑ 401(k) ❑ 401(a) ❑ 457 

❑ Roth IRA ❑ Roth 403(b) ❑ Roth 401(k) ❑ Other____________________ 

Part 4: TO Account Type (check one): ❑ IRA ❑ 403(b) ❑ 401(k) ❑ 401(a) ❑ 457 

❑ Roth IRA ❑ Roth 403(b) ❑ Roth 401(k) ❑ Other____________________ 

Part 5: Select Type: ❑ Plan to Plan Transfer ❑ Direct Rollover ❑ Vendor to Vendor 

Qualification for Direct Rollover (check one): 

❑ Age 59 1 ⁄2 (70 1 ⁄2 for 457) ❑ Retirement ❑ Separation from Service 

Part 6: TO: (Resigning Company/Custodian) How Much to Rollover/Transfer: 

❑ 

❑ 

The entire balance of my account; or 

A partial surrender of $ ____________________ or ___________ % from my Account/Plan. 

Owner Signature X ________________________________________________________________ Date ____/____/_______ 

Employer/Third Party Administrator X ____________________________________________________ Date ____/____/_______ 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Part 7: Instructions to Current Carrier: 

Please make proceeds payable to: 

Fidelity Security Life Insurance Company FBO ________________________________________________________ and forward to: 

Fidelity Security Life Insurance Company • Attn: Annuity Department • P.O. Box 418131 • Kansas City, MO 64141-8131 

ACCEPTANCE BY FIDELITY SECURITY LIFE INSURANCE COMPANY (FSL) 

This is to certify that Fidelity Security Life Insurance Company (FSL) has an approved contract and that we hereby accept the Transfer or Direct 

Rollover of assets requested above. Please send the funds to the address listed directly above. 

Authorized (FSL) Signature X ____________________________________ 

Title __________________________ Date ____/____/_______ 

Agent/Advisor Signature 

X ____________________________________________________________________ Date ____/____/_______ 

95-32284 #4347 1109


3130 Broadway 

Kansas City, MO 64111 

1035 Exchange Form 

(Non-Qualified Annuity to Annuity) 

Please read and complete sections 1 - 5 of this form, then sign and date where indicated. You may give the form to your agent or mail it directly to 

Fidelity Security Life at the address shown at the top of this form. Make sure you first complete all forms required by the employer maintaining 

your plan. 

Part 1: Name and Address Information (Please Print) 

Name ____________________________________________________ Social Security Number ________________________________ 

Address __________________________________________________ Your Home Phone ____________________________________ 

City _____________________________ State ______ ZIP__________ 

Part 2: Your Existing Account/Plan (Current Company/Custodian) 

Name of Company __________________________________________ 

Address __________________________________________________ 

________________________________________________________ 

City _____________________________ State ______ ZIP__________ 

Part 3: To (Resigning Company/Custodian): 

Please Liquidate: 

q 

q 

The entire balance of my account; or 

A partial surrender of $ ____________________ or ___________ % from my Account/Plan. 

Part 4: *If age 85 has been attained: 

q 

q 

Please process my Required Minimum Distribution prior to exchange. 

I will satisfy my Required Minimum Distribution from another non-qualified source. 

Your Work Phone ______________________________________ 

Account/Plan Number __________________________________ 

Plan Name __________________________________________ 

Plan Administrator Name ________________________________ 

Contact Number ______________________________________ 

I hereby irrevocably assign the contract or certificate represented in exchange for a new non-qualified annuity contract or certificate issued by 

Fidelity Security Life, as part of a single integrated exchange of annuity contracts intended to satisfy the requirements under section 1035(a) of 

the Internal Revenue Code. 

Owner Signature X ________________________________________________________________ Date ____/____/_______ 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Part 5: Instructions to Current Carrier: 

Please provide cost basis information and make proceeds payable to: 

Fidelity Security Life Insurance Company FBO ________________________________________________________ and forward to: 

(name of account holder) 


Attn: Annuity Administration Department 

P.O. Box 418131 

Kansas City, MO 64141-8131 

ACCEPTANCE BY FIDELITY SECURITY LIFE INSURANCE COMPANY 

This is to certify that Fidelity Security Life Insurance Company has an approved contract and hereby accept the assets requested above. 

Authorized Signature X ____________________________________________ Title ________________________________________ 

Date ____/____/_______ 

95-32283 #5529 611



TaxVantage TM Annuitization Request Form 

1 Please provide personal information: Please print in ink or type all answers. 

Name: 

________________________________________________________________________________________________________________ 

First Middle Last 

Address:________________________________________________________________________________________________________________ 

Street City State ZIP 

ID No. ______________________________________________________ Contract(s)________________________________________________ 

Social Security No. ___________________________ Date of Birth ____/____/_______ Telephone No. ( ______ ) ________________________ 

❑ Check here if this is a new address. If address is different from above, please indicate where you would like your payments mailed. 

Address:________________________________________________________________________________________________________________ 


For direct bank deposits, please enclose a voided check from the account to which you would like payment deposited. 

Please be sure to complete the beneficiary designation information on the back of this form. 

In accordance with the terms of the Annuity Contract and with respect to the Annuity Option, I hereby request — in lieu of all benefits otherwise 

payable to me — the option checked below. If any prior request or election has been made as to optional retirement benefits, I hereby revoke and 

cancel any such prior request or election. 

2 Please check only one option: 

❑ Life Annuity — Annuity payable to the Annuitant for as long as he/she lives. 

❑ Certain Annuity — Annuity payable for 5 through 20 years certain. Upon death of the Annuitant prior to the end of the certain period, any 

payments for the balance of such period will be paid to his/her beneficiary. Number of years desired __________. 

❑ Certain and Life Annuity — annuity payable for 5, 10, 15, or 20 years certain as long thereafter as the Annuitant is living. Upon the death of the 

Annuitant prior to the end of the certain period, any payments for the balance of such period will be paid to his/her beneficiary. Number of years 

desired __________. 

❑ Survivorship Annuity — Annuity payable to the Annuitant for as long as he/she lives. Upon his/her death, payment will continue at 100%, 75%, 

or 50% to the contingent (second) Annuitant for the life of the contingent (second) Annuitant. Please complete the section on the back for 

contingent Annuitant information. Percentage desired __________. 

If you chose any annuity except the Certain Annuity, please enclose a certified or notarized copy of your birth certificate. If you chose the Survivorship Annuity, 

please enclose certified or notarized copies of both your birth certificate and that of the contingent Annuitant. 

3 Please complete this section: 

❑ Full ❑ Partial Annuitization. If Partial, indicate amount $___________ OR ______% Date to begin receiving first payment ____/____/_______ 

If Full Annuitization, your last contribution will be for the payroll period ending ____/____/_______ 

❑ Do 

❑ Do Not withhold federal income tax from any annuity payment I receive. 

Annuity Income to be Paid ❑ Monthly ❑ Quarterly ❑ Semiannually ❑ Annually

4 For the Survivorship Annuity, complete this section: 

Please provide information on the contingent (second) Annuitant, and enclose a certified or notarized copy of his/her birth certificate. 

Name: 

________________________________________________________________________________________________________________ 


Address:________________________________________________________________________________________________________________ 


Social Security No. ___________________________ Date of Birth ____/____/_______ Relationship 

Telephone No. ( _______ ) ___________________________________________ 

__________________________________ 

5 For all other annuity options (except Life or Survivorship), complete this section: 

Beneficiary Designation: Print full names and entire addresses. 

I hereby request the beneficiary under the numbered contract shown on the front to take effect in accordance with the contract provisions as follows: 

Primary Beneficiary: This beneficiary designation supersedes any and all other beneficiary designations. 

Name: ________________________________________________________________________________________________________________ 


Address:________________________________________________________________________________________________________________ 


Social Security No. ___________________________ Date of Birth ____/____/_______ Relationship __________________________________ 

Contingent Beneficiary: This beneficiary designation supersedes any and all other beneficiary designations. 

Name: ________________________________________________________________________________________________________________ 


Address:________________________________________________________________________________________________________________ 


Social Security No. ___________________________ Date of Birth ____/____/_______ Relationship __________________________________ 

It is understood and agreed that proceeds will be paid in equal shares, unless otherwise designated, to any surviving beneficiaries; but if none survives, 

proceeds will be paid in equal shares to any surviving contingent (second) beneficiaries. 

6 Please sign here: 

I agree that the benefits as elected above are accepted in full settlement and complete satisfaction of any and all rights and benefits with respect to 

me under said Annuity Contract. 

Owner Signature X ________________________________________________________________________________ 

Date ____/____/_______ 

Witness 

________________________________________________________________________________________ 

Annuitant Spouse’s Signature if Community Property state ________________________________________________ 

For Fidelity Security Life Home Office Use Only: 

Completed by ____________________________________________________________________________________ 

Date ____/____/_______ 

Attention Annuitant: Notify Fidelity Security Life Insurance Company if this copy does not contain your desired requests or if it is incorrect in any way. 

As indicated by signature in this section, Fidelity Security Life has recorded your requested changes. 

93-32131 #6136 1112

Exhibit I – Annuity Suitability Questionnaire 

Yes, I agree to answer the questions below and I understand that my responses will be used to evaluate the suitability of an 

annuity contract. I understand that FSL may elect not to issue the annuity contract being applied for based on a 

reasonable determination that the product may not be suitable for me. 

Proposed Annuitant Primary Financial Objectives (Check all that apply) 

Name: Preservation of Capital Future Income 

Address: Wealth Accumulation Charitable Giving 

Tax Deferral 

Education Planning 

Home Phone No.: 

Social Security No.: 

Age at Last Birthday: 

Immediate Income 

Inheritance 

Time Frame for this Investment 

When will you need the money you are investing in this 

Marital Status: Married Single annuity? (Circle One) 

Widowed 

Divorced 

1 year or less 7 – 10 years 

Occupation: 1 – 3 years 10 years or more 

3 – 7 years Never (money is for 

charity/inheritance) 

Financial Information 

Annual Household Income $ 

Existing Accounts 

Are you considering using funds from existing life 

insurance policies, annuity contracts, or certificates of 

Liquid Net Worth $ deposit to purchase this annuity? 

(Excluding residence and furnishings) Yes No 

Source of Income: (Check all that apply) 

How long has that policy(ies), contract(s), or certificate 

Employment Retirement Plans of deposit(s) been in force? 

Investments Other # of Years 

Social Security 

Are there any surrender charges associated with the 

Tax Bracket: (Check one) 

above-mentioned existing policy(ies), contract(s), or 

10% 15% 25% 28% 33% 35% certificates of deposit? 

Yes No Not Applicable 

Proposed Annuity represents % of Net my Worth 

Do you have any funds available to you in case of 

emergency? 

If yes, what is/are the current surrender charge(s)? 

Other relevant information (financial constraints, health 

concerns, long-term care considerations, etc.) 

OWNER ACKNOWLEDGEMENT 

By signing below, I acknowledge that I reviewed with my agent the product-specific disclosure form and that I 

understand the costs and features of the annuity I am purchasing. In addition, I acknowledge the information I 

provided is complete and accurate to the best of my knowledge. I further acknowledge that neither Fidelity Security 

Life Insurance Company nor its representatives offer legal or tax advice. I have been advised to consult my 

personal tax advisor or lawyer with any questions or concerns. I believe the annuity I am applying for is suitable 

based on my insurance needs and financial objectives. 

Owner Signature 

Date 

AGENT ACKNOWLEDGEMENT 

By signing below, I acknowledge that based on the information the Owner provided and based on all the 

circumstances known to me at the time the recommendation was made, the annuity being applied for is suitable 

based on insurance needs and financial objectives of the Owner. In addition, I have verified the identity of the 

Owner and believe that the identity information the Owner provided to me is true and accurate. 

Agent Signature 

Date 

N-00261 93-33293 

Shaded information indicates new material 08/01/12 

Page 7 SPM 100

Exhibit II A – Waiver of Annuity Suitability 

IMPORTANT! 

Your Coverage cannot be issued without your signature on either the Waiver below, 

or the attached Suitability Questionnaire. 


3130 Broadway, Kansas City, MO 64111 

Waiver of Annuity Suitability 

We appreciate your interest in an annuity contract from Fidelity Security Life Insurance Company ("FSL"). We are required 

by various states to ask for information that will help determine whether an annuity contract is suitable for your investment 

goals and financial situation. The questions pertain to your personal situation at the time of this application, and to your 

understanding of the features of the product for which you are applying. This information will not be used for any other 

purpose and will remain confidential. 

You have the legal right to decline to provide this information. If this is your wish, please read the following 

statement, sign, date, and return this form with your Application for Annuity. 

WAIVER of Annuity Suitability Questionnaire 

No, I will not answer the questions on the attached sheet, and I take full responsibility for determining whether the 

proposed annuity is suitable for me. 

(The Proposed Annuitant must sign in the "Signature" space below. Your policy cannot be issued without your signature on 

either this WAIVER or the attached Annuity Suitability Questionnaire.) 

Proposed Annuitant Signature 

Date 

N-00262 93-33294 


Page 9 SPM 100

Exhibit II B – Declination to Follow Recommendation 

IMPORTANT! 

Your Coverage cannot be issued without your signature on both the Declination below 

and the attached Suitability Questionnaire. 


3130 Broadway, Kansas City, MO 64111 

Declination to Follow Recommendation 

We appreciate your interest in an annuity contract from Fidelity Security Life Insurance Company ("FSL"). We are required 

by various states to ask for information that will help determine whether an annuity contract is suitable for your investment 

goals and financial situation. The questions pertain to your personal situation at the time of this application, and to your 

understanding of the features of the product for which you are applying. This information will not be used for any other 

purpose and will remain confidential. 

You also have the legal right to not follow any recommendation made. If this is your wish, please read the 

following statement, sign, date and return this form with your Application for Annuity. 

DECLINING to Follow Recommendation 

Based upon the information on the attached sheet, the annuity transaction was not recommended. I take full 

responsibility for determining whether the proposed annuity is suitable for me. 

(The Proposed Annuitant must sign in the "Signature" space below. Your policy cannot be issued without your signature on 

both this DECLINATION and the attached Annuity Suitability Questionnaire.) 

Proposed Annuitant Signature 

Date 

N-00260 93-33292 


Page 10 SPM 100

Fidelity Security Life Insurance Company - Marketing Financial

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