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Legal / Residential Address
Address
City State/Province ZIP/Postal Code Country
Mailing Address
Same as legal / residential address.
Address
City State/Province ZIP/Postal Code Country
Duplicate Materials
Send account statements, trade confirmations, and related prospectuses to authorized agent.
6. Authorized Agent Signature and Date Named authorized agent must sign and date.
By signing below, you:
• Agree to be bound by the current and
future terms of all agreements, and by any
applicable disclosures, between the con-
tract owner(s) and Fidelity.
• State that you are familiar with and
understand the investment objectives of
the contract owner(s) and will use only
trading strategies that are consistent with
these objectives.
• Certify that all information you provided is
correct to the best of your knowledge.
• Grant us permission to obtain credit
information, verify information you have
provided, and perform a background check
on you.
• Acknowledge that we may refuse to
approve you as authorized agent, or may
remove you as authorized agent from this
or any other contract, at any time and for
any reason.
• Certify that you will not be paid for the
investment management related to
the contract(s).
PRINT AUTHORIZED AGENT NAME
AUTHORIZED AGENT SIGNATURE DATE MM/DD/YYYY
SIGN
X X
7. Contract Owner Signatures and Dates ALL account owner(s) must sign and date.
By signing below, you:
• Acknowledge that you have read, under-
stand, and accept all the terms described in
this form.
• Authorize Fidelity to act on all instructions
given on this form.
• Designate the individual identified in this
form as your authorized agent, granting
that individual the ability to place all orders
exchanged in your contract.
• Certify that you are not adding an indi-
vidual who will be paid for his or her
investment management of the contract(s).
• Certify that you are the registered owner(s)
of the contract identified in Section 1, and
that all information you provided is correct
to the best of your knowledge.
• Agree that once granted to an authorized
agent, trading authority will remain in effect
until any of the following occurs:
– We receive written notice signed by all
owner(s) withdrawing trading authority.
– We receive notice of resignation from the
authorized agent.
– We receive notice of the death or
incapacity of the last surviving contract
owner or the authorized agent.
– We become aware of sufficient cause,
in our judgment, to remove the
authorized agent.
• Indemnify Fidelity and its agents, affiliates,
successors, and employees from any
loss, expense, or cost arising out of any
action or failure to act on the part of the
authorized agent.
CONTRACT OWNER NAME JOINT CONTRACT OWNER NAME
SIGNATURE DATE MM/DD/YYYY SIGNATURE DATE MM/DD/YYYY
SIGN
X X
SIGN
X X
Provide the address
used for tax
reporting. Cannot
be a PO Box, mail
drop, or c /o.
Initial here to confirm that you will not be
paid for the investment management of
the contract(s).
Authorized Agent Initials
Required
5. Add Authorized Agent, continued
Form continues on next page.
