Fidelity Security Life Insurance Company - Marketing Financial
Fidelity Security Life Insurance Company - Marketing Financial
Fidelity Security Life Insurance Company - Marketing Financial
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2609-B East Sunshine, Springfield, MO 65804 (417) 888-4389<br />
New Business Form<br />
Client Name(s): _________________________________<br />
Owner's age(s): _______________<br />
BC #/State: ____/______<br />
Writing Agent Name: _____________________________<br />
Split Commission with: (if applicable): ________________<br />
Referred by: _______________________________________<br />
Commission Split %: ________________________________<br />
Funds Info:<br />
Internal Funds (GSB)<br />
External Funds<br />
Check Enclosed: $_______________________________<br />
Qualified (CD/IRA, 401K, etc)<br />
Non-Qualified (Checking, CD, etc)<br />
Transfer(s) Approx: $_____________________________<br />
Qualified (CD/IRA, 401K, etc)<br />
Non-Qualified (Checking, Annuity, CD, etc)<br />
<strong>Company</strong> Name _________________________<br />
ex: Sagicor<br />
Product Name __________________________<br />
ex: Sage Choice SPDA<br />
Surrender Charge Period (years) ____________<br />
1035 Exchange (NQ life/annuity) Approx: $_______________________<br />
Agent Check List:<br />
New Business<br />
Non-Qualified - <strong>Life</strong>/Annuity to <strong>Life</strong>/Annuity<br />
Application<br />
1035 Exchange Form<br />
Disclosures<br />
State Replacement Form<br />
Owner's ID<br />
Original Policy or Lost Policy Affidavit<br />
Owner's OFAC<br />
Cashier's/Personal Check Payable to <strong>Company</strong> IRA Annuity to IRA Annuity<br />
IRA Trsf Form<br />
IRA Trsf/Rollover<br />
Replacement Form<br />
IRA Trsf Form<br />
Original Policy or Lost Policy Affidavit<br />
<strong>Company</strong> Specific Forms (401K) W-9 (funds coming from Lincoln Benefit <strong>Life</strong> )<br />
Agent's Report - Source of Funds: (MUST BE COMPLETED)<br />
1. Provide your detailed explanation regarding how this purchase meets the client's stated investment goal.<br />
Attach additional sheet if necessary.<br />
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___________________________________________________________________________________________<br />
___________________________________________________________________________________________<br />
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Agent Signature: ________________________________________<br />
Approver Signature (Laura M. Smith): _____________________________<br />
Date: _____________________<br />
Date: _____________________<br />
REV 05-2013
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