Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Form

Transcription

1 Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Form Participant Information: Plan Name: Name of Participant: SSN: Fidelity BrokerageLink Account Number: Daytime Phone: Use this form to grant trading authority to a third party on the Fidelity BrokerageLink account listed above. Do not use this form to add an individual who will be paid for the investment management of your account. Read all instructions carefully and please use a pen and print clearly. Complete the Participant Information section above and complete Section 1. The third party to whom you grant trading authority ( Authorized Agent ) must complete Section 2. Please submit a separate original form for each Authorized Agent added to your BrokerageLink account. Return the completed form to Fidelity Investments, P.O. Box , Cincinnati, OH If you have any questions, please contact Fidelity using your plan s toll-free number. This form cannot be used to add an individual who will be paid for the investment management of your account. To establish a Registered Investment Advisor relationship, please contact Fidelity Institutional Wealth Services at Participant Authorization to be completed by the Participant Powers You Give Your Authorized Agent: This Limited Third-Party Trading Authorization and Indemnification Form allows your Authorized Agent to have the ability to invest in and dispose of the same range of securities that you have access to through your BrokerageLink account ( Account ), for and at your risk. Your Authorized Agent is bound by all terms and conditions set forth in all agreements relating to the above-referenced Account. Your Authorized Agent can trade to the same extent that you can. If your Authorized Agent engages in covered writing, purchase of long options, and long equity spreads and straddles, you, the Participant, recognize the inherent risks involved and are fully prepared financially to undertake such risks. This Limited Third-Party Trading Authorization and Indemnification Form does not allow your Authorized Agent to withdraw or disburse money or assets from your Account (including the delivery of securities from your Account). Fidelity assumes no responsibility for reviewing or monitoring any investment decision or activity of your Authorized Agent. You, the Participant, have been furnished and have carefully read this form in its entirety, including the attached Participant s Fidelity BrokerageLink Terms and Conditions, and agree to be bound by these documents as they currently exist and as they may be modified in the future, and hereby designate the Authorized Agent listed in Section 2 to act as your agent and attorney in fact to exercise all rights and powers set forth herein with respect to your Account. You authorize Fidelity Brokerage Services LLC, Fidelity Service Company, Inc., Fidelity Distributors Corporation and their affiliates (together Fidelity ), and any other person whom Fidelity may instruct to act in connection with your Authorized Agent s instructions, to rely on your Authorized Agent s instructions without further approval or direction from you. You understand that a commission will be charged to your Account each time a trade is effected. This trading authorization applies to a retirement account ( Plan ) for which Fidelity Management Trust Company ( FMTC ) or its affiliate and/or any successor acts as trustee, custodian, or recordkeeper. This authorization shall allow the Authorized Agent to provide instructions to Fidelity, and to execute such directions with respect to the Plan. Such directions shall be limited to purchase, exchange, and sell orders; transfers back into the standard plan options; future automatic contribution allocations in any investment permitted by the terms of the Plan; and any other incidental transactions subject to the limitations described herein, provided such transactions do not result in a distribution from the Plan. The Authorized Agent shall have no authority to designate a beneficiary or establish a new Plan. It is also understood that with respect to the Plan, FMTC merely acts as custodian or trustee, and has no discretionary fiduciary authority or responsibility. Accordingly, the suitability of any investments or actions that the Authorized Agent may direct, and any adverse consequences arising from such an investment or action, is solely and ultimately your responsibility and neither the Plan Sponsor nor the plan administrator is responsible for monitoring your Account or the activities of your Authorized Agent. Once granted to an authorized agent, trading authority will remain in effect until any of the following occurs: We receive written notice signed by you withdrawing authority. We receive written notice of resignation from the authorized agent. We receive written notice of the death or incapacity of you or the authorized agent. We decide, at any time and for any reason, to remove the authorized agent. By signing this form, you certify that you are not adding an individual who will be paid for his or her investment management of your account. Check here if you would like to replace all existing Authorized Agent(s) on the Fidelity account(s) identified above with the Authorized Agent indicated in Section 2. Your Authorized Agent may trade in and view your Account(s) at Fidelity.com. Check the following if you wish to have copies of your trade confirmations or periodic account statements sent to your Authorized Agent by mail. Duplicate Confirmations Duplicate Statements Authorized Agent s Name: Participant s Signature: 1

2 2 Authorized Agent Information to be completed by Authorized Agent Complete this section to grant authority to an individual other than the retirement plan Participant. NOTE: Authorized agents who are being paid for their investment management of the Account are not permitted. Name of Agent: Relationship to Participant: Employed Self-employed Agent s Occupation: Agent s Employer: Agent s Employer s Address: Retired Not employed Source of Income (Pension, investments, spouse, etc.): Agent s SSN: Date of Birth: Street Address: City, State, ZIP: Daytime Phone: Initial here to confirm that you will not be paid for the investment management of the Account. Citizenship Indicate your citizenship status: U.S. citizen Foreign citizen Information in this box must be completed. Permanent U.S. resident Non-permanent U.S. resident Nonresident of U.S. Country of Citizenship Country of Tax Residency Only applicable to nonresidents of the U.S. City, State/Province, and Country of Birth Check one and attach a copy of a valid and unexpired government ID showing number and photo. Passport DHS Permanent Resident Card Employment Authorization Document Foreign National Identity Document Associations If you are employed by or associated with a broker-dealer, stock exchange, exchange member firm, the Financial Industry Regulatory Authority (FINRA), a municipal securities dealer, or other financial institution, or are the spouse or an immediate family member residing in the same household of someone who meets the aforementioned employment criteria, provide the company s name and address below. By providing this information and completing this form, you hereby authorize Fidelity to provide the associated person s employer with duplicate copies of confirmations and statements, or the transactions data contained therein, for your account(s) and any accounts you choose to have on a consolidated statement for purposes of their compliance review. As a person associated with a member firm, you are obligated to receive consent from that firm. Fidelity has existing consent agreements with many firms for their employees to maintain accounts with Fidelity and to deliver transactional data. If your firm is not one of them, Fidelity will attempt to contact your firm s compliance office. Company Name Company Address City State/Province ZIP/Postal Code Country If you are, or an immediate family/household member is, a director, corporate officer, or 10% shareholder of a publicly held company, or a control person of a publicly traded company under SEC Rule 144, you must provide the information below. Company Name Trading Symbol or CUSIP Duplicate Materials If the authorized agent works for a member firm, additional copies will be sent to that firm as well as to the agent. I, the Authorized Agent, have been furnished with and have read this form in its entirety, including the attached Authorized Agent s Fidelity BrokerageLink Terms and Conditions, and agree to be bound by these documents as they currently exist and as they may be modified in the future. I also agree to be bound by all terms and conditions set forth in any agreements relating to the Participant s BrokerageLink account. I understand the investment objectives and trading plans of the Participant and will design my trading strategies to meet those objectives. I represent and warrant that if I have not completed the section titled Associations, I am not associated with or employed by a stock exchange or a broker-dealer, and that I am not a control person or associate of a public company under SEC Rule 144 (such as a director, a 10% shareholder, or a policy-making officer), or an immediate family or household member of such a person. I acknowledge that Fidelity may refuse to approve me as authorized agent, or may remove me as authorized agent from this or any other account, at any time and for any reason. I further acknowledge that individuals who provide investment advice to others may be subject to regulation by federal and state regulators and I agree to be responsible for determining whether and what type of registration is required. I further certify that I will not be paid for the investment management related to the account. If I am looking to establish a Registered Investment Advisor relationship, I will contact Fidelity Institutional Wealth Services. 2

3 To help the government fight financial crimes, federal regulation requires Fidelity to obtain your name, date of birth, address, and a government-issued ID number before opening your account, and to verify the information. In certain circumstances, Fidelity may obtain and verify comparable information for any person authorized to make transactions in an account. Your account may be restricted or closed if Fidelity cannot obtain and verify this information. Fidelity will not be responsible for any losses or damages (including, but not limited to, lost opportunities) that may result if your account is restricted or closed. This account is governed by a predispute arbitration clause, which is located on the last page of the attached Authorized Agent s Terms and Conditions. I acknowledge receipt of the predispute arbitration clause. Authorized Agent s Signature: Date: Fidelity Brokerage Services LLC, Member NYSE, SIPC P.O. Box , Cincinnati, OH FMR LLC. All rights reserved. 3

4 Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Terms and Conditions Participant s Terms and Conditions This agreement is between Fidelity ( Fidelity means Fidelity Management Trust Company, Fidelity Brokerage Services LLC, National Financial Services LLC, Fidelity Service Company, Inc., Fidelity Distributors Corporation, and their respective employees, agents, representatives, and affiliates) and me, the Participant. If I have appointed two or more Authorized Agents, I authorize each of them to act alone (severally) and without the consent of any other Authorized Agent, with respect to each power granted above. In addition, I acknowledge that Fidelity has the right to restrict my BrokerageLink account from further activity in the event that my Authorized Agents enter conflicting or inconsistent instructions. I understand that my BrokerageLink account at Fidelity may remain restricted until written instructions are received from me or until joint written instructions are submitted by all my Authorized Agents, or until receipt of a court order instructing Fidelity how to proceed. I hereby ratify and confirm any and all transactions, trades, or dealings effected in and for my Account(s) by my Authorized Agent. I have granted my Authorized Agent limited third-party trading authorization. I have granted my Authorized Agent the ability to invest in and dispose of the same range of securities that I myself have access to through my BrokerageLink account, for and at my risk. The Authorized Agent is bound by all terms and conditions set forth in all customer agreements relating to the BrokerageLink account listed above. My Authorized Agent can trade to the same extent that I can. If my Authorized Agent engages in covered call option transactions, I, the Participant, recognize the inherent risks involved and am fully prepared financially to undertake such risks. Fidelity s Role Fidelity will execute transactions as directed by my Authorized Agent. Fidelity assumes no responsibility for reviewing or monitoring any investment decision or other activity of my Authorized Agent. I alone am responsible for monitoring my Account and determining whether any investment, security, or strategy is appropriate or suitable for me based on my investment objectives and financial situation, and Fidelity will not give me or my Authorized Agent any tax, legal, or investment advice or recommendations. I select my Authorized Agent at my own risk. Fidelity has no responsibility for selecting, investigating, or monitoring the activities of my Authorized Agent in connection with my BrokerageLink account. Fidelity may, but is not obligated to, perform a background check of my Authorized Agent on its own behalf, and has the right to reject my Authorized Agent as a result of such a check or for any other reason at any time. Release and Indemnification I agree to indemnify and to hold Indemnified Persons ( Indemnified Persons means Fidelity, its control persons, officers, and directors, the Plan, the Plan Sponsor, and the Plan Fiduciaries [including but not limited to the plan administrator, the plan administrative committee, and investment committee]) harmless from, and to pay the Indemnified Persons promptly upon demand for, any and all losses, liabilities, claims, and costs (including reasonable attorney s fees) that may be brought against Indemnified Persons that arise from the acts or omissions of my Authorized Agent with respect to my BrokerageLink account. This Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Form is in addition to, and in no way restricts, any rights that may exist at law or under any other agreement(s) between Fidelity and me. Governing Law This Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Form shall be construed, administered, and enforced according to the laws of the Commonwealth of Massachusetts. Successors and Assigns This Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Form shall inure to the benefit of Fidelity and any successor firm or firms, and to the benefit of the affiliates and assigns of Fidelity or any successor firm. This agreement and indemnification will be binding upon my successors, assignees, heirs, executors, and administrators. Authorized Agent s Terms and Conditions This agreement is between Fidelity ( Fidelity means Fidelity Management Trust Company, Fidelity Brokerage Services LLC, National Financial Services LLC, Fidelity Service Company, Inc., Fidelity Distributors Corporation, and their affiliates) and me, the Authorized Agent. Fidelity s Role Fidelity will execute transactions as I, the Authorized Agent, direct, consistent with this authorization and all limitations placed upon the BrokerageLink account by the Plan Sponsor. Fidelity assumes no responsibility for reviewing or monitoring my investment decisions or other activity in connection with the BrokerageLink account. The Participant and I are responsible for determining whether any investment, security, or strategy is appropriate or suitable for the Participant, based on the Participant s investment objectives and financial situation, and Fidelity will not give me or the Participant any tax, legal, or investment advice or recommendations. I agree that Fidelity may, but is not obligated to, perform a background check on me or otherwise verify any information I provide, and I authorize Fidelity to obtain a credit report or other financial responsibility report about me at any time. Upon written request, Fidelity will provide the name and address of the reporting agency used. I agree that Fidelity has the right to reject me as Authorized Agent as a result of such a credit report or for any other reason at any time, and that Fidelity may notify the Participant of any such rejection.

5 My Role as Agent I am solely responsible to the Participant for all my trading and other activities in connection with the BrokerageLink account. I agree to act in connection with the BrokerageLink account only as specifically authorized by the Participant, and to comply with all applicable laws and regulations in connection with the BrokerageLink account. I agree to cease all trading or other activity in connection with the BrokerageLink account, and to notify Fidelity in writing, immediately upon the Participant s disability, incapacity, or death, or upon the occurrence of any other revocation of my authority. Release and Indemnification I agree to indemnify and to hold Indemnified Persons ( Indemnified Persons means Fidelity, its control persons, officers, directors, agents, and employees, the Plan, the Plan Sponsor, and the Plan Fiduciaries [including but not limited to the plan administrator, the plan administrative committee, and investment committee]) harmless from, and to pay the Indemnified Persons promptly upon demand for, any and all losses, liabilities, claims, and costs (including reasonable attorney s fees) that may be brought against Indemnified Persons that arise from my acts or omissions with respect to the BrokerageLink account. This Fidelity BrokerageLink Limited Third-Party Trading Authorization and Indemnification Form is in addition to and in no way restricts any rights that may exist at law or under any other agreement(s) between Fidelity and me or between Fidelity and the Participant. Governing Law This Authorization and Indemnification shall be construed, administered, and enforced according to the laws of the Commonwealth of Massachusetts. Successors and Assigns This Limited Third-Party Trading Authorization and Indemnification shall inure to the benefit of Fidelity and of any successor firm or firms, and to the benefit of the affiliates and assigns of Fidelity or any successor firm. This Limited Third-Party Trading Authorization and Indemnification will be binding upon my successors, heirs, executors, and administrators. I agree not to assign this Limited Third-Party Trading Authorization and Indemnification without the written consent of Fidelity and the Participant. Predispute Arbitration Agreement This agreement contains a predispute arbitration clause. By signing an arbitration agreement, the parties agree as follows: (a) All parties to this agreement are giving up the right to sue each other in court, including the right to a trial by jury, except as provided by the rules of the arbitration forum in which a claim is filed. (b) Arbitration awards are generally final and binding; a party s ability to have a court reverse or modify an arbitration award is very limited. (c) The ability of the parties to obtain documents, witness statements, and other discovery is generally more limited in arbitration than in court proceedings. (d) The arbitrators do not have to explain the reason(s) for their award, unless, in an eligible case, a joint request for an explained decision has been submitted by all parties to the panel at least 20 days prior to the first scheduled hearing date. (e) The panel of arbitrators may include a minority of arbitrators who were or are affiliated with the securities industry. (f) The rules of some arbitration forums may impose time limits for bringing a claim in arbitration. In some cases, a claim that is ineligible for arbitration may be brought in court. (g) The rules of the arbitration forum in which the claim is filed, and any amendments thereto, shall be incorporated into this agreement. All controversies that may arise between us concerning any subject matter, issue, or circumstance whatsoever (including, but not limited to, controversies concerning any account, order or transaction, or the continuation, performance, interpretation, or breach of this or any other agreement between us, whether entered into or arising before, on, or after the date this Account is opened) shall be determined by arbitration in accordance with the rules then prevailing of the Financial Industry Regulatory Authority (FINRA) or any U.S. securities self-regulatory organization or U.S. securities exchange of which the person, entity, or entities against whom the claim is made is a member. If I designate the rules of a U.S. self-regulatory organization or U.S. securities exchange and those rules fail to be applied for any reason, then I shall designate the prevailing rules of any other U.S. securities self-regulatory organization or U.S. securities exchange of which the person, entity, or entities against whom the claim is made is a member. If I do not notify you in writing of my designation within five (5) days after I receive from you a written demand for arbitration, then I authorize you to make such designation on my behalf. The commencement of arbitration through a particular self-regulatory organization or securities exchange is not integral to the underlying agreement to arbitrate. I understand that judgment upon any arbitration award may be entered in any court of competent jurisdiction. No person shall bring a putative or certified class action to arbitration, nor seek to enforce any predispute arbitration agreement against any person who has initiated in court a putative class action, or who is a member of a putative class action who has not opted out of the class with respect to any claims encompassed by the putative class action until: (i) the class certification is denied; or (ii) the class is decertified; or (iii) the customer is excluded from the class by the court. Such forbearance to enforce an agreement to arbitrate shall not constitute a waiver of any rights under this agreement except to the extent stated herein.

6 Fidelity Brokerage Services LLC, Member NYSE, SIPC P.O. Box , Cincinnati, OH FMR LLC. All rights reserved.