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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
Fidelity Brokerage Services LLC, Member NYSE, SIPC. 580832.7.0 (06/19)
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.
Regular Mail Overnight Mail
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0051
100 Crosby Parkway, KC2Q
Covington, KY 41015
5. Signature and Date Required. ALL Contract owners must sign and date.
By signing below, you:
• Acknowledge that the information in this
form replaces any and all beneficiary
information 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
• 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.
PRINT CONTRACT OWNER/TRUSTEE NAME
CONTRACT OWNER/TRUSTEE SIGNATURE DATE MM/DD/YYYY
PRINT JOINT CONTRACT OWNER NAME
JOINT CONTRACT OWNER SIGNATURE DATE MM/DD/YYYY