Fillable Consolidate Beneficiary /BOSTON/xinet/ Bos Work/ Jobs/34871/PIECE13/34871 05 FRM Consolidat (Fidelity Investments)

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Consolidate Beneficiary /BOSTON/xinet/ Bos Work/ Jobs/34871/PIECE13/34871 05 FRM Consolidat (Fidelity Investments)

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  • 8 check-boxes
  • 61 other fields

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Questions about your annuity? Call 800.634.9361.
Beneficiaries – Annuities
Use this form to add or change the beneficiaries of your Fidelity annuity contract, your Brighthouse Growth and Income
SM
annuity
contract, OR your MetLife Growth and Income
SM
annuity contract only. Do NOT use for non-annuity accounts like Fidelity IRA,
Retirement Plan (Keogh), or non-retirement accounts. Type on screen or print out and fill in. For best results, use CAPITAL letters and
black ink. Need more room for information or signatures? Make a copy of the relevant page or a blank sheet.
Helpful to Know
• You may want to review this document with a tax, financial, or legal advisor.
• For NY Retirement Reserves annuities (contracts that begin with 4 or 5) this form applies only to annuitant
beneficiaries. Filing this form replaces any annuitant beneficiaries, but not any owner beneficiaries. To change
owner beneficiaries, use the Beneficiaries – Retirement Reserves Annuities form.
1. Contract Owner(s)
Contract Owner Name Phone
Joint Contract Owner Name if applicable
2. Contracts Included
Annuity Contract Number Annuity Contract Number Annuity Contract Number
Annuity Contract Number Annuity Contract Number Annuity Contract Number
Trust and UGMA/
UTMA Accounts:
Provide names
of authorized
individuals in the
Contract Owner fields.
List all contracts you
want this form to apply
to. To indicate different
beneficiaries for
different contracts, use
copies of this form.
1.9865752.106 Page 1 of 3 033740301
Form continues on next page.
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3. Beneficiaries
Primary Beneficiaries
Keep the primary beneficiary designations already in place on the contract(s). Do not list beneficiaries below if box is checked.
Name of Person, Trust, or Entity Email
Address Street, City, State, ZIP Code Relationship Share Percentage
%
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Phone
Per
stirpes
Name of Person, Trust, or Entity Email
Address Street, City, State, ZIP Code Relationship Share Percentage
%
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Phone
Per
stirpes
Name of Person, Trust, or Entity Email
Address Street, City, State, ZIP Code Relationship Share Percentage
%
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Phone
Per
stirpes
Total must add up to 100%
%
Contingent Beneficiaries
Keep the contingent beneficiary designations already in place on the contract(s). Do not list beneficiaries below if box is checked.
Name of Person, Trust, or Entity Email
Address Street, City, State, ZIP Code Relationship Share Percentage
%
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Phone
Per
stirpes
Name of Person, Trust, or Entity Email
Address Street, City, State, ZIP Code Relationship Share Percentage
%
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Phone
Per
stirpes
Name of Person, Trust, or Entity Email
Address Street, City, State, ZIP Code Relationship Share Percentage
%
Social Security or Taxpayer ID Number Date of Birth or Trust MM DD YYYY Phone
Per
stirpes
Total must add up to 100%
%
If you need more room for additional primary OR contingent beneficiaries, make a copy of this page or use a blank sheet.
For each beneficiary
listing, provide all
required information.
If a beneficiary is
deceased at the
time of the contract
owner’s death and
you want that ben-
eficiary’s share to go
to his or her legal
descendants (children
born of or legally
adopted by the
beneficiary), check
“Per stirpes” (not
applicable for trust/
estate beneficiaries).
For custodial
contracts, list the
minor’s estate as the
primary beneficiary.
For jointly owned
Retirement Reserves
contracts, to continue
the contract upon
either owner’s death,
list both owners as the
primary beneficiaries.
Do NOT list
any primary
beneficiaries here.
Contingent benefi-
ciaries receive assets
if no primary benefi-
ciaries survive you.
If a beneficiary is
deceased at the
time of the con-
tract owner’s death
and you want that
beneficiary’s share
to go to his or her
legal descendants
(children born of
or legally adopted
by the beneficiary),
check “Per stirpes”
(not applicable
for trust/estate
beneficiaries).
1.9865752.106 Page 2 of 3 033740302
Signature and Date on next page.
4. Signature and Date ALL owners of the contract must sign and date below.
By signing below, you:
• Acknowledge that the information in this form
replaces any and all beneficiary information
(for NY Retirement Reserves, annuitant
beneficiary information only) that may be on
record for this annuity at the time this form is
received in good order by Fidelity.
• Acknowledge and agree to all terms in the
contract concerning beneficiaries.
• Acknowledge that only those beneficiaries
who are alive on the contract owner’s death
(“date of death”) will receive the assets of
your contract.
• Acknowledge that Fidelity has no
responsibility for the application of assets
distributed to beneficiaries.
• Agree that by checking the “per stirpes”
box next to a beneficiary’s name, any sum
payable to that beneficiary will be divided
equally among the beneficiary’s surviving legal
descendants, if the beneficiary him- or herself
is no longer living on the date of death.
• Acknowledge that “per stirpes” creates
a category of beneficiaries (for example,
the children of your daughter or son), and
therefore may end up including individuals
who are not yet born or adopted.
• Acknowledge that if no percentages are
indicated, assets will be divided equally
among primary beneficiaries that are living
or have per stirpes descendants.
• Acknowledge that listing beneficiaries
by name does NOT create a category,
and that if you later want to include other
beneficiaries (such as any children born to
or adopted by you in the future), you will
need to file a new beneficiary form with
updated names and information.
• Agree that Fidelity has no obligation to
locate any beneficiary, notify any person
of any transfer of assets to beneficiaries,
or to independently verify any information
submitted by any person claiming an
interest in your contract.
• Certify that for Fidelity-issued trust-owned
annuities (excluding charitable remainder
trusts), all beneficiaries are natural persons.
CONTRACT OWNER NAME/TRUSTEE NAME
SIGNATURE DATE MM/DD/YYYY
SIGN
X
DATE
X
JOINT CONTRACT OWNER NAME/TRUSTEE NAME
SIGNATURE DATE MM/DD/YYYY
SIGN
X
DATE
X
• Contract owner must sign and date.
• If the contract is owned by a Trust, all
Trustees must sign and date.
• If the signee is power of attorney, required
documentation must be on file granting
powers to add or change beneficiaries.
• Joint owner of the contract must sign
and date. (If needed, ownership of the
contract can be verified on your recent
quarterly annuity statement.)
Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI), and, in New York, by Empire Fidelity
Investments Life Insurance Company
®
, New York, N.Y. FILI is licensed in all states except New York. A contract’s financial guarantees
are subject to the claims-paying ability of the issuing insurance company.
Brighthouse Growth and Income
SM
annuity (Policy Form Series No. 8800 (10/09)) is issued by Brighthouse Life Insurance Company,
Charlotte, NC 28277. MetLife Growth and Income
SM
annuity (Policy Form Series No. 6800 (10/09)) is issued only in New York by
Metropolitan Life Insurance Company (MetLife), New York, NY 10166. The contract’s financial guarantees are solely the responsibility
of the issuing insurance company. Fidelity Brokerage Services LLC, Member NYSE, SIPC, and Fidelity Insurance Agency, Inc., are the
distributors; they are not affiliated with any MetLife or Brighthouse Financial company.
Fidelity Brokerage Services LLC, Member NYSE, SIPC. 726931.7.0 (12/19)
1.9865752.106 Page 3 of 3 033740303
Did you print the form and did all owners
sign it? Send the ENTIRE form to Fidelity
Investments. After the changes are
registered, you will receive a Revised
Annuity Profile.
Questions? Call 800.634.9361.
Regular Mail
Except NY Regular Mail NY only Overnight Mail
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0050
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0051
Fidelity Investments
100 Crosby Parkway, KC2Q
Covington, KY 41015
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Consolidate Beneficiary BOSTONxinet Bos Work Jobs34871PIECE1334871 05 FRM Consolidat (Fidelity Investments)

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Completed 19 July 2020

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