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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<strong>Fidelity</strong> <strong>Security</strong> <strong>Life</strong> <strong>Insurance</strong> <strong>Company</strong><br />
3130 Broadway, Kansas City, Missouri 64111-2406<br />
TaxVantage TM Annuity Application<br />
Underwritten by <strong>Fidelity</strong> <strong>Security</strong> <strong>Life</strong> <strong>Insurance</strong> <strong>Company</strong>, Kansas City, Missouri<br />
Plan Type:<br />
❏ Traditional IRA<br />
❏ Roth IRA<br />
Premium Type: ❏ Flexible Premium ❏ Single Premium<br />
Print Full Name__________________________________________________________________ SSN________________________<br />
Last First Middle<br />
Mailing Address_______________________________________________________________________________________________<br />
Street City State Zip<br />
Residential Address____________________________________________________________________________________________<br />
Street City State Zip<br />
E-Mail Address________________________________________________________________________________________________<br />
Home Phone _______________________________________<br />
Work Phone ____________________________________________<br />
Date of Birth ______/______/______ (Mo/Day/Yr) ❏ Male ❏ Female<br />
❏ Primary<br />
❏ Contingent<br />
❏ Primary<br />
❏ Contingent<br />
❏ Primary<br />
❏ Contingent<br />
❏ Primary<br />
❏ Contingent<br />
Beneficiary Allocation Relationship SS#<br />
___________________________________ ________ % ________________________ ______________________<br />
___________________________________ ________ % ________________________ ______________________<br />
___________________________________ ________ % ________________________ ______________________<br />
___________________________________ ________ % ________________________ ______________________<br />
Primary Beneficiary Allocation total must equal 100%. Contingent Beneficiary Allocation total must equal 100%.<br />
Do you have any existing annuity or life insurance contracts?<br />
❏ Yes ❏ No<br />
Is any annuity or life insurance contract being replaced with this purchase?<br />
❏ Yes ❏ No<br />
If Yes to either question, please provide the name of the insurance company(ies) and contract or policy number for each product<br />
being replaced. Please complete the replacement form.<br />
Owner Signature X______________________________________________________ Date ______/______/______ (Mo/Day/Yr)<br />
To your knowledge and belief does the applicant have any existing annuity or life insurance contracts?<br />
To your knowledge and belief is any annuity or insurance contract being replaced with this purchase?<br />
If yes, Replacement Notice must be completed.<br />
❏ Yes ❏ No<br />
❏ Yes ❏ No<br />
I have verified the applicant’s identity by viewing: ❏ Drivers License Drivers License # _______________________________<br />
❏ Other________________________________________________________<br />
Agent Signature X_______________________________________________________ Date ______/______/______ (Mo/Day/Yr)<br />
A-01142NE For Office Use Only 95-32524 #5533 0313
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