Fidelity Security Life Insurance Company - Marketing Financial

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Fidelity Security Life Insurance Company 3130 Broadway, Kansas City, Missouri 64111-2406 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:________________________________________________________________________________________________________________ Street City State ZIP 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: ________________________________________________________________________________________________________________ First Middle Last Address:________________________________________________________________________________________________________________ Street City State ZIP 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: ________________________________________________________________________________________________________________ First Middle Last Address:________________________________________________________________________________________________________________ Street City State ZIP Social Security No. ___________________________ Date of Birth ____/____/_______ Relationship __________________________________ Contingent Beneficiary: This beneficiary designation supersedes any and all other beneficiary designations. Name: ________________________________________________________________________________________________________________ First Middle Last Address:________________________________________________________________________________________________________________ Street City State ZIP 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
Page 1 and 2: GREAT SOUTHERN FINANCIAL SERVICES 2
Page 3 and 4: 2609-B East Sunshine, Springfield,
Page 5 and 6: Fidelity Security Life Insurance Co
Page 9 and 10: Fidelity Security Life Insurance Co
Page 15 and 16: Exhibit I - Annuity Suitability Que
Page 17: Exhibit II B - Declination to Follo

Fidelity Security Life Insurance Company - Marketing Financial

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