Notice of Changes to FG Guarantee-Platinum Series

Size: px
Start display at page:

Download "Notice of Changes to FG Guarantee-Platinum Series"

Transcription

1 Notice of Changes to FG Guarantee-Platinum Series Effective January 1, 2014 The minimum premium for qualified and non-qualified accounts is $10,000. Fidelity & Guaranty Life SM is the marketing name of Fidelity & Guaranty Life Insurance Company, issuing insurance in the United States outside of New York and, in New York only, Fidelity & Guaranty Life Insurance Company of New York. Each Fidelity & Guaranty Life company is solely responsible for its contractual commitments. ADV1450 ( )

2 FG Guarantee-Platinum A Single Premium, Fixed Deferred Annuity with tax-deferred earnings featuring a choice of a 3, 5 or 7-year rate guarantee ADV 1010 ( ) Fidelity & Guaranty Life Insurance Company Rev

3 FG Guarantee-Platinum A Single Premium, Fixed Deferred Annuity with tax-deferred earnings featuring a choice of a 3, 5 or 7-year rate guarantee FG Guarantee-Platinum is a single premium, fixed deferred annuity What is that? Single Premium: The annuity is a single premium annuity which means you make a single lump sum premium payment at issue. Deferred: The annuity is deferred which means income does not begin immediately. You pay no current income tax on interest earned. Taxes are deferred until you withdraw your earnings. Fixed: The annuity is a fixed annuity which means that Fidelity & Guaranty Life Insurance Company guarantees a fixed rate of interest. Annuity: An annuity is a vehicle to provide payments to the holder at specified intervals, usually at retirement. It is designed to be a long-term retirement tool and not be used to meet short-term financial goals. In this document are important points to think about before you buy the FG Guarantee-Platinum 3, 5 or 7 annuity from Fidelity & Guaranty Life Insurance Company. Fidelity & Guaranty Life has prepared this summary to help you understand FG Guarantee-Platinum s many options and advantages. Please confirm your understanding by signing the enclosed confirmation statement. Whether you want your annuity to become a source of guaranteed income payments, or continued tax-deferred interest accumulation, FG Guarantee-Platinum can provide the means. Choice! Select your guarantee period of three, five, or seven-years. Certainty! Know your rate for the guarantee period. Flexibility Flexibility to continue for another period or search out other opportunities. An annuity that allows you to control when you pay taxes on your interest. 1

4 FG Guarantee-Platinum 1. HOW DOES IT WORK? A. B. C. Your annuity offers competitive returns CHOICE OF A THREE, FIVE OR SEVEN-YEAR RATE GUARANTEE PERIOD You get to choose from a three, five or seven-year interest rate guarantee period, a period during which the credited rate is guaranteed. The guarantee period begins on the date of issue, and subsequent guarantee periods begin immediately following the end of each prior guarantee period. The credited interest rate, which will be applied initially to your single premium and then to your account value during the initial guarantee period, is shown in your annuity. We will never credit less than the minimum guaranteed interest rate, which will be established between 1% and 3%. with no currently taxable income TAXES ARE DEFERRED UNTIL YOU WITHDRAW YOUR EARNINGS Unlike many taxable traditional savings vehicles, you pay no current income tax on interest earned within your annuity. Taxes are deferred until you withdraw your earnings. and grants you flexibility for the future YOU HAVE THE FLEXIBILITY TO CONTINUE FOR ANOTHER THREE, FIVE OR SEVEN-YEAR PERIOD OR SEARCH OUT OTHER OPPORTUNITIES When your guarantee period expires, Fidelity & Guaranty Life will automatically renew your annuity for the same period at the thencurrent interest rate. If you renew after you attain age 91, your surrender charges will be 0% for the duration of your contract. If you would prefer to withdraw some or all of your account value at the end of any guarantee period, you will have a 30-day window to do so, free of any surrender charges. Getting Started with FG Guarantee-Platinum Minimum premium of $5,000 or $2,000 for qualified accounts. Choice of a three, five or sevenyear interest rate guarantee period. No front-end sales charges or annual maintenance fees. 100% of your premium goes to work for you right away! At the end of each guarantee period, we will provide you with a new declared interest rate for the new guarantee period. 2

5 FG Guarantee-Platinum 3 2. HOW DO I GET INCOME FROM MY ANNUITY? Partial withdrawals and options for systematic withdrawals Withdrawals up to the amount of accumulated interest may be made free of surrender charge. You may make scheduled systematic withdrawals of at least $100 with just one request and unscheduled withdrawals (up to four times per year) in an amount of at least $500. Withdrawals in excess of the accumulated interest on the annuity will be subject to surrender charges. Interest will not be credited to any amounts withdrawn. Annuity payouts From day one of your annuity, you may elect to have the account value paid to you under an annuity payment plan. Payment in the event of death If you should die before the annuity date, your beneficiary will receive the account value of your annuity. Surrender charges do not apply at death. Any gain in the annuity would be subject to income tax. If you should die after the annuity date, any benefits payable to your beneficiary would depend on the income option chosen. Surrender Charges What happens if I take some or all of the money from my annuity? Withdrawals in excess of the accumulated interest on the annuity will be subject to surrender charges. The surrender charges for FG Guarantee-Platinum will be 9% in the first year and decrease by 1% per year throughout the rate guarantee period. At the end of each guarantee period, you have 30 days in which to surrender this annuity with no surrender charge. If you do not surrender within those 30 days, this annuity will automatically renew into a new guarantee period of the same length with a new set of identical surrender charges. If you renew after you attain age 91, your surrender charges will be 0% for the duration of your contract. Years into current Guarantee Period: Surrender Charge % 8% 7% 6% 5% 4% 3% Example: Maria purchases an FG Guarantee-Platinum annuity with a five-year guaranteed rate period. Her surrender charges will begin at 9% in the 1st year, and decrease to 8% in the 2nd year, 7% in the 3rd year, 6% in the 4th year, and 5% in the 5th year. At the end of the 5th year, Maria s annuity will automatically renew into a new five-year interest guarantee period at the then current interest rate. Surrender charges will also be reset, so that in the 6th year of Maria s annuity (or the first year of the renewal period) the surrender charge will again be 9%. Surrender charges will continue to follow the same pattern throughout each renewal period. Maria s surrender charge will be 8% in the 7th year, 7% in the 8th year, 6% in the 9th year, 5% in the 10th year, 9% in the 11th year (first year of 2nd renewal period), 8% in the 12th year, etc. Is there a way to withdraw money during the surrender charge period without paying surrender charges? You will not pay a surrender charge if you withdraw up to the amount of accumulated interest. Surrender charges will not apply if you qualify for a waiver under the riders listed below.* Nursing Home Benefit Rider If you are confined to a licensed nursing home for more than 60 days, and your confinement begins at least one year after the annuity s date of issue, surrender charges will be waived on withdrawals made during the period of your confinement. Terminal Illness Benefit Rider If a licensed physician certifies that you have been diagnosed with an illness or condition that causes your life expectancy to be less than one year, and the diagnosis takes place at least one year after the annuity s date of issue, surrender charges will be waived during this period of terminal illness. Unemployment Benefit Rider If you become unemployed and remain so for at least 30 consecutive days, and your unemployment takes place after the annuity s date of issue, surrender charges will be waived during this time of unemployment as long as you are under the age of 65 at the time of your request. You will not pay surrender charges if you surrender within 30 days following the end of each guarantee period. You will not pay surrender charges if you elect an annuity payment plan. Your spouse will not pay a surrender charge if you die unless your spouse is the beneficiary and elects to continue the contract. If you renew after you attain age 91, your surrender charges will be 0% for the duration of your contract. *Please refer to your representative for availability in your state.

6 Market Value Adjustment A Market Value Adjustment (MVA) will increase or decrease your surrender value when you make a withdrawal to which a surrender charge is applied. The MVA is based on a formula that takes into account changes in yields on U.S. Treasuries between the start of the current guaranteed period and the date of the withdrawal. Generally, if interest rates have risen since you purchased your annuity (or since the start of your current interest rate guarantee period, if later), the MVA will decrease your surrender value. If interest rates have fallen, the MVA will increase your surrender value DO I PAY ANY FEES OR CHARGES? There are no initial sales charges or fees. Your single premium is available to earn interest from the date your annuity is issued. DOES THIS AFFECT MY TAXES? How will payouts and withdrawals from my annuity be taxed? The annuity is tax-deferred, which means you don t pay taxes on the interest it earns until the money is paid to you. When you take payouts or make a withdrawal, you pay ordinary income taxes on the earned interest. Withdrawals are treated as coming from earnings first and then as a return of your premium. Payments under an annuity payment plan are treated as coming partially from earnings and partially as return of premium. You may pay a federal income tax penalty on earnings you withdraw before age 59 ½. [If your state imposes a premium tax, it will be deducted from the money you receive].* You can exchange one tax-deferred annuity for another without paying taxes on the earnings when you make the exchange. Before you do, compare the benefits, features, and costs of the two annuities. You may pay a surrender charge on the annuity you are exchanging. Also, you may start a new surrender charge period in the new annuity. Does buying an annuity in a retirement plan provide extra tax benefit? Buying an annuity within an IRA, 401(k) or other taxdeferred retirement plan doesn t give you any extra tax benefit. Choose the annuity based on its other features and benefits as well as its risks and costs, not its tax benefits. Please consult your tax advisor regarding your unique situation. FG Guarantee-Platinum *Internal Revenue Code provides that if an annuity is held by a non-natural person and such person is not holding as an agent for a natural person, the contract shall not be treated as an annuity contract for income tax purposes. 4

7 FG Guarantee-Platinum 5. WHAT ELSE DO I NEED TO KNOW? Other Information We may change your annuity contract from time to time to follow federal or state laws and regulations. If we do, we ll tell you about the changes in writing. You have a set number of days (at least 10) to look at the annuity after you buy it. If you decide during that time that you don t want it, you can return the annuity and get all of your premium back, less any prior withdrawals. Read the cover page of your annuity contract as soon as you receive it to understand how many days you have to decide if you want to keep it. Your annuity values are guaranteed by Fidelity & Guaranty Life Insurance Company. As a Legal Reserve Company, Fidelity & Guaranty Life Insurance Company is required by state regulation to maintain reserves equal to or greater than guaranteed surrender values. At least once each year, we will send you a report of the current annuity values. We pay the agent, broker or firm for selling the annuity to you. Certain tax qualified annuities are subject to minimum required distributions which generally require that distributions begin no later than your attainment of age 70½ or retirement, whichever is later, and that amounts be paid to you over a period not longer than your life expectancy. 5

8 FG Guarantee-Platinum Appropriate for IRA and Pension Plan Rollovers FG Guarantee-Platinum could be an adequate vehicle for a rollover of your IRA or to serve as a rollover IRA to receive distributions from a corporate retirement plan, like a 401(k), 403(b), pension or profit sharing plan. When executed properly, these rollovers are not currently taxed. Tax-deferred compounding continues without interruption. FG Guarantee-Platinum accepts minimum amounts for qualified plans as low as $2,000. See Fidelity & Guaranty Life s IRA Disclosure Statement for more information on IRAs and rollovers. At age 70½, the IRS requires you to begin receiving minimum annual distributions from your tax-qualified retirement plans, including IRAs. Upon request, we can help you calculate your minimum required distribution from your FG Guarantee-Platinum annuity. 6. WHAT SHOULD I KNOW ABOUT FIDELITY & GUARANTY LIFE? Incorporated in 1959, Fidelity & Guaranty Life Insurance Company has a solid commitment to serving the individuals it knows best middle market consumers seeking the safety, protection, accumulation and income features of secure life insurance and annuity products. Fidelity & Guaranty Life offers its series of focused life insurance and annuity products through its network of independent marketing organizations. Insurance products are offered through Fidelity & Guaranty Life Insurance Company in every state, other than New York, as well as the District of Columbia. In New York, products are offered through a wholly owned subsidiary, Fidelity & Guaranty Life Insurance Company of New York. 6

9 Contracts issued by Fidelity & Guaranty Life Insurance Company, Des Moines, IA. Fidelity & Guaranty Life Insurance Company offers a diverse portfolio of fixed and indexed interest annuities and optional additional features. Before purchasing, consider your financial situation and alternatives available to you. Your Fidelity & Guaranty Life Insurance Company financial professional can help you determine the best alternatives for your goals and needs, or visit us at for more information. Form Numbers: FGL SPDA-MY-F (7-04); et al. Optional provisions and riders may have limitations, restrictions and additional charges. Subject to state availability. Certain restrictions may apply. This product is offered on a group or individual basis as determined by state approval. Terms and conditions are set forth in the group certificate and master contract and are subject to the laws of the state in which they were issued. Surrender charges may apply to withdrawals. Withdrawals may be taxable and may be subject to penalties prior to age 59½. Withdrawals will reduce available death benefit. This document is not a legal contract. For the exact terms and conditions, please refer to the annuity contract. Information provided regarding tax or estate planning should not be considered tax or legal advice. Consult your own tax professional or attorney regarding your unique situation. Annuities are long-term vehicles to help with retirement income needs. Interest rates subject to change at insurer s discretion and are effective annual rates. An additional bonus interest rate is paid on this contract annuity for 1 year. Annuities that offer bonus interest features may have higher fees and charges, and longer surrender charge periods than annuities that do not provide the bonus feature. A market value adjustment may apply to withdrawals and may increase or decrease the surrender value No bank guarantee. Not FDIC/NCUA/NCUSIF insured. May lose value if surrendered early.

10 Instructions for Agent FG Guarantee-Platinum 1. Review this brochure with the customer(s). 2. Have the customer(s) sign and date the Confirmation Statement. 3. In the box marked For Agent Use, verify the identity of owner(s) and annuitant(s), fill-in your name and address, and sign. 4. Detach and return the Confirmation Statement with the application to Fidelity & Guaranty Life. Confirmation Statement Please sign below to indicate your understanding. This form must be detached and returned with the application to Fidelity & Guaranty Life. By signing here, you are telling us that you have read this summary and understand the descriptions of the FG Guarantee-Platinum deferred fixed annuity features. You also understand that subject to the guarantee values in the annuity, the cash surrender values in the annuity may increase or decrease based on an MVA adjustment prior to the date or dates specified in the annuity. You are also telling us that neither Fidelity & Guaranty Life nor your agent has made any guarantees or promises regarding interest rates under the annuity. The actual rate in your annuity will be based on current data as of the date the annuity is issued. You understand that the Company offers deferred annuity products with different features and benefits and that you can also apply for those products by contacting the Company or one of its agents. You have received a copy of the Buyer s Guide (and the Supplement-to-Buyer s Guide for VT only) and understand its disclosures. Signature of Owner Signature of Joint Owner, if any Date Date For Agent Use: The agent has carefully read and has complied with the FG Guarantee-Platinum Product Training. Agent Agency Address Signature of Agent City, State, Zip ADV 1090 ( )

11 Annuity Application Product: FG Guarantee-Platinum m SPDA m FPDA Owner(s) Name: SSN/TIN: Fidelity & Guaranty Life Insurance Company Home Office: Des Moines, IA Administrative Office: P.O. Box 81497; Lincoln, NE Joint Owner (if any): SSN/TIN: m Male m Female Date of Birth: m Male m Female Date of Birth: Address: Phone No.: Address: Employer Name & Address: Relationship to Annuitant: Identification #: State: Type of Identification: Address: Phone No.: Address: Employer Name & Address: Relationship to Owner: Identification #: State: Type of Identification: m State Issued m Immigration m State Issued m Immigration m Military m Passport m Military m Passport m Other Annuitant(s) (if other than Owner, complete this section) Name: SSN/TIN: m Other Joint/Contingent (if any): SSN/TIN: m Male m Female Date of Birth: m Male m Female Date of Birth: Address: Address: Identification #: State: Identification #: State: Type of Identification: Type of Identification: m State Issued m Immigration m State Issued m Immigration m Military m Passport m Military m Passport m Other m Other Beneficiary Note: If more than one beneficiary is named, indicate the class and percentage for each. Each class must total 100%. Primary Contingent m m Name: SSN/TIN: % Relationship to Owner: Date of Birth: m m Name: SSN/TIN: % Relationship to Owner: Date of Birth: m m Name: SSN/TIN: % Relationship to Owner: Date of Birth: m m Name: SSN/TIN: % Relationship to Owner: Purpose of Annuity (Choose ONE plan and if applicable, transfer/exchange form) m Qualified m Non-qualified m Traditional IRA m Roth IRA m SEP IRA m 403(b) TSA m Other (specify plan type): Date of Birth: OMAD 6227 (10-12) Page 1 of 3 Rev

12 Annuity Application Product: FG Guarantee-Platinum m SPDA m FPDA Premium Initial/Single Premium Paid: (premium paid with application) $ Make check payable to Fidelity and Guaranty Life Insurance Company. m Rollover m Contribution for Tax Year Interest Rate Guaranteed Rate % Annuity Year 1 % or Period Year(s) Remainder of Rate Period (if applicable) Replacement Do you have an existing life insurance or annuity policy? m Yes m No (If yes, please list insurance Company name, Policy type, Policy # and Year issued.) Will the annuity applied for replace or change an existing life insurance or annuity policy? m Yes If a 1035 exchange or transfer, attach applicable forms. Exchange/Transfer Amount: $ Policy/Certificate No.: Company: Special Instructions m No Fraud Warning Notices (Please review the notice that applies in your state. If your state is not listed, please review the first notice listed.) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may be subject to criminal and civil penalties. AR/LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or representative of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a contract holder or claimant for the purpose of defrauding or attempting to defraud the contract holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department regulatory agencies. DC: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. KY/OH: I understand that any person who, with intent to defraud, or knowingly that he or she is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement is guilty of insurance fraud. (Owner s Initials) FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. (Owner s Initials) ME/TN/WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefit. MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NJ: Any person who includes any false or misleading information on an application for an insurance contract is subject to criminal and civil penalties. NM/PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. OK: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OR/VT: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. OMAD 6227 (10-12) Page 2 of 3 Rev

13 Annuity Application Product: FG Guarantee-Platinum m SPDA m FPDA Authorizations I/(We) have read the statements made in this application. To the best of my (our) knowledge and belief, the statements made are complete, true, and correctly recorded. I/(We) understand that: a copy of this application will form a part of any annuity issued; the annuity will not take effect until delivered to the Owner; no agent has the authority to modify any annuity issued; and there are terms, conditions, charges, and fees for any optional rider selected. I/(We) understand that I/(we) have applied for an annuity. I/(We) have received a copy of the Company s disclosure material for this annuity. If the annuity is issued with a market value adjustment rider, the cash surrender values may increase or decrease based on a market value adjustment prior to the date or dates specified in the annuity; the market value adjustment applies when the surrender charge applies. Signature(s) I/(We) certify, under penalties of perjury, that I am a/(we are) U.S. Citizen(s) or resident(s) of the U.S. (includes U.S. resident aliens) and that the taxpayer identification number(s) is (are) correct. I/(We) understand that federal law requires all financial institutions to obtain identity information in order to verify my (our) indentity(ies) and I (we) authorize its use for this purpose. This information includes, but is not limited to, the name(s), residential address(es), date(s) of birth, Social Security or taxpayer identification number(s), and any other information necessary to sufficiently verify indentity(ies). I/(We) understand that failure to provide this information could result in the application being rejected. Third party sources may be used to verify the information provided. Signed at: Date: Signature of Owner: Signature of Joint Owner: Signature of Annuitant: Signature of Joint Annuitant: Agent Does the applicant have an existing life or annuity policy? m Yes m No To the best of your knowledge, does this application replace or change existing life insurance or annuities? m Yes m No I attest that I have witnessed all signatures. I certify that the Company s disclosure material has been presented to the applicant and a copy was provided to the applicant. I have not made any statements which differ from this material nor have I made any guarantees or promises about the expected future values of the annuity. I have received a copy of, have carefully read and complied with the applied for fixed annuity s training manual. I have verified the identity of the Owner, Joint Owner, Annuitant and/or Joint Annuitant through an examination of a state or federal government photo identification card provided by the Owner, Joint Owner, Annuitant and/or Joint Annuitant such as a driver s license or passport. I have truly and accurately recorded on this application the information provided by the applicant. Signature(s) Agent s Signature: Date: Print Agent s Name: Fidelity & Guaranty Life Agent #: Agent s License No. (required only in FL): Agent s Phone No: Agent s Fax No: Agent s Address: For Split Commissions second Agent complete the below section Agent s Signature: Date: Print Agent s Name: Fidelity & Guaranty Life Agent #: Agent s License No. (required only in FL): Agent s Phone No: Agent s Fax No: Agent s Address: OMAD 6227 (10-12) Page 3 of 3 Rev

FG Guarantee-Platinum. A Single Premium, Fixed Deferred Annuity featuring a choice of a 3, 5 or 7-year rate guarantee

FG Guarantee-Platinum. A Single Premium, Fixed Deferred Annuity featuring a choice of a 3, 5 or 7-year rate guarantee FG Guarantee-Platinum A Single Premium, Fixed Deferred Annuity featuring a choice of a 3, 5 or 7-year rate guarantee ADV 1010 (01-2011) Fidelity & Guaranty Life Insurance Company Rev. 04-2016 16-214 FG

More information

FG Guarantee-Platinum 7. A Single Premium, Fixed Deferred Annuity featuring a 7-year rate guarantee

FG Guarantee-Platinum 7. A Single Premium, Fixed Deferred Annuity featuring a 7-year rate guarantee FG Guarantee-Platinum 7 A Single Premium, Fixed Deferred Annuity featuring a 7-year rate guarantee ADV 1882 (04-2017) Fidelity & Guaranty Life Insurance Company Rev. 04-2017 17-0495 A Single Premium, Fixed

More information

FG Index-Choice 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

FG Index-Choice 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning FG Index-Choice 10 Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 1281 (05-2012) Fidelity & Guaranty Life Insurance Company Rev. 03-2015 14-280 FG Index-Choice

More information

FG AccumulatorPlus 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

FG AccumulatorPlus 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning FG AccumulatorPlus 10 Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 1206 (11-2011) Fidelity & Guaranty Life Insurance Company Rev 03-2015 14-277 FG AccumulatorPlus

More information

Prosperity Elite 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

Prosperity Elite 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning Prosperity Elite 0 Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 4 (04-0) Fidelity & Guaranty Life Insurance Company Rev. 0-0 -559 Prosperity Elite 0 Flexible

More information

FG Guarantee-Platinum 5. A Single Premium, Fixed Deferred Annuity featuring a 5-year rate guarantee

FG Guarantee-Platinum 5. A Single Premium, Fixed Deferred Annuity featuring a 5-year rate guarantee FG Guarantee-Platinum 5 A Single Premium, Fixed Deferred Annuity featuring a 5-year rate guarantee ADV 1010 (01-2011) Fidelity & Guaranty Life Insurance Company Rev. 08-2017 17-0915 FG Guarantee-Platinum

More information

Individual Annuity Application

Individual Annuity Application Individual Annuity Application Single Premium Fixed Annuity Fidelity & Guaranty Life Insurance Company - Home Office: Des Moines, Iowa Administrative Office: P.O. Box 81497; Lincoln, NE 68501-81497 FG

More information

FG AccumulatorPlus 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

FG AccumulatorPlus 10. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning FG AccumulatorPlus 0 Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 06 (-0) Fidelity & Guaranty Life Insurance Company Rev. 0-0 -56 FG AccumulatorPlus 0 Flexible

More information

Notice of Changes to FG Guarantee-Platinum Series

Notice of Changes to FG Guarantee-Platinum Series Notice of Changes to FG Guarantee-Platinum Series Effective January 1, 2014 The minimum premium for qualified and non-qualified accounts is $10,000. Fidelity & Guaranty Life SM is the marketing name of

More information

Prosperity Elite 7. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

Prosperity Elite 7. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning Prosperity Elite 7 Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 6 (03-0) Fidelity & Guaranty Life Insurance Company Rev. 0-0 -558 Prosperity Elite 7 Flexible

More information

FG Guarantee- Platinum 5 YOU. Tax-deferred growth at a fixed interest rate certainty in an uncertain market.

FG Guarantee- Platinum 5 YOU. Tax-deferred growth at a fixed interest rate certainty in an uncertain market. Fixed ANNUITY FG Guarantee- Platinum 5 YOU Tax-deferred growth at a fixed interest rate certainty in an uncertain market. ADV 2011 (02-2019) Fidelity & Guaranty Life Insurance Company 19-0060 FG Guarantee-Platinum

More information

Immediate Annuity Application

Immediate Annuity Application Standard Insurance Company Individual Annuities 800.247.6888 Tel 800.378.4570 Fax 1100 SW Sixth Avenue Portland OR 97204-1093 www.standard.com 1 Purchase Immediate Annuity Application Tailored Income Annuity

More information

CLAIMANT OPTION REQUEST Nonqualified Annuity Non-Spouse Beneficiary

CLAIMANT OPTION REQUEST Nonqualified Annuity Non-Spouse Beneficiary Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135 Mailing : Symetra Life Insurance Company PO Box 3882 Seattle, WA 98124-3882 Phone 1-800-796-3872 TTY/TDD 1-800-833-6388

More information

Prosperity Elite 7. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

Prosperity Elite 7. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning Prosperity Elite 7 Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 1391 (04-2013) Fidelity & Guaranty Life Insurance Company Rev. 08-2017 17-0872 Prosperity Elite

More information

Performance Pro. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

Performance Pro. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning Performance Pro Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 1572 (12-2014) Fidelity & Guaranty Life Insurance Company Rev. 03-2015 14-987 Performance Pro Flexible

More information

Prosperity Elite 7. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

Prosperity Elite 7. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning Prosperity Elite 7 Flexible Premium Fixed Deferred ed Annuity Options for your retirement planning ADV 9 (0-0) Fidelity & Guaranty Life Insurance Company Rev. 08-07 7-087 Prosperity Elite 7 Flexible Premium

More information

6/11/ :23 AM EST. Document Name Description Expiration Date

6/11/ :23 AM EST. Document Name Description Expiration Date Documents Package Prepared for: Prepared Date: Consolidated Marketing Group, Inc. 6/11/2010 11:23 AM EST Document Name Description Expiration Date AGLC100560-2003_031... Annuity Application for HorizonChoice

More information

Forethought Indexed Annuities SM

Forethought Indexed Annuities SM Forethought Indexed Annuities SM FA3509-04 Forethought Future Income Solutions Indexed Annuities SM Single Premium Deferred Annuity Application (Please Print) One Forethought Center P.O. Box 246 Batesville,

More information

ANNUITY APPLICATION. All references to "the Company" shall mean EquiTrust Life Insurance Company of West Des Moines, Iowa,

ANNUITY APPLICATION. All references to the Company shall mean EquiTrust Life Insurance Company of West Des Moines, Iowa, ANNUITY APPLICATION EquiTrust Life Insurance Company 5400 University Ave Attn: Box 14500 West Des Moines IA 50266 Product Contract # (Home Office Use Only) Print Legibly Producer Name Full Office Address

More information

FIRST MIDDLE LAST PLEASE INCLUDE AN ORIGINAL CERTIFIED DEATH CERTIFICATE WITH THIS CLAIM FORM. Individual Beneficiary Name: FIRST MIDDLE LAST

FIRST MIDDLE LAST PLEASE INCLUDE AN ORIGINAL CERTIFIED DEATH CERTIFICATE WITH THIS CLAIM FORM. Individual Beneficiary Name: FIRST MIDDLE LAST ANNUITY DEATH CLAIM We want to ensure you receive your benefit payment promptly, so please complete the applicable sections and be sure to enclose the documentation requested. Each named beneficiary will

More information

GREEK CATHOLIC UNION OF THE USA (Herein called GCU)

GREEK CATHOLIC UNION OF THE USA (Herein called GCU) GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 TUSCARAWAS ROAD, BEAVER, PENNSYLVANIA 15009-9513 1-800-722-4428 DEFERRED ANNUITY APPLICATION (Please print) Is the Proposed Annuitant a member of

More information

Great American Life Insurance Company Loyal American Life Insurance Company Administrative Address: P.O. Box 5420, Cincinnati, Ohio

Great American Life Insurance Company Loyal American Life Insurance Company Administrative Address: P.O. Box 5420, Cincinnati, Ohio Great American Life Insurance Company Loyal American Life Insurance Company Administrative : P.O. Box 5420, Cincinnati, Ohio 45201-5420 1. Owner Primary Owner Member Companies Order Ticket for Fixed Annuity

More information

Life and Annuity Division Protective Life Insurance Company 1

Life and Annuity Division Protective Life Insurance Company 1 Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 VARIABLE Protective Life and Annuity Insurance Company Annuity Claimant's Statement Post Office Box 1928

More information

Application for FIXED DEFERRED ANNUITY

Application for FIXED DEFERRED ANNUITY Application for FIXED DEFERRED ANNUITY Protective Life Insurance Company Home Office Nashville, Tennessee Administrative Office 1707 N. Randall Road, Elgin, Illinois 60123-9409 For Arizona Applicants:

More information

Performance Pro. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning

Performance Pro. Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning Performance Pro Flexible Premium Fixed Deferred Indexed Annuity Options for your retirement planning ADV 1572 (12-2014) Fidelity & Guaranty Life Insurance Company Rev. 04-2018 18-0493 Performance Pro Flexible

More information

FG Immediate-Income. Single Premium Immediate Annuity. ADV 1011 ( ) Fidelity & Guaranty Life Insurance Company Rev.

FG Immediate-Income. Single Premium Immediate Annuity. ADV 1011 ( ) Fidelity & Guaranty Life Insurance Company Rev. Single Premium Immediate Annuity ADV 1011 (01-2011) Fidelity & Guaranty Life Insurance Company Rev. 04-2017 17-0472 Single Premium Immediate Annuity FG Immediate-Income is a Single Premium, Immediate Annuity

More information

Application for FIXED DEFERRED ANNUITY

Application for FIXED DEFERRED ANNUITY Application for FIXED DEFERRED ANNUITY Protective Life Insurance Company Overnight U. S. Postal Mail Nashville, Tennessee 2801 Hwy 280 South P. O. Box 10648 Birmingham, Alabama 35223 Birmingham, Alabama

More information

Policy #(s) Relationship to Deceased Social Security Number/EIN

Policy #(s) Relationship to Deceased Social Security Number/EIN Member Life Insurance and Annuities Companies: Annuity Investors Life Insurance Company Great American Life Insurance Company Manhattan National Life Insurance Company Administration for Life Insurance

More information

Life and Annuity Division Protective Life Insurance Company 1

Life and Annuity Division Protective Life Insurance Company 1 Life and Annuity Division Protective Life Insurance Company 1 West Coast Life Insurance Company 1 Protective Life and Annuity Insurance Company Annuity Claimant's Statement Post Office Box 1928 / Birmingham,

More information

Notice of Changes to Prosperity Elite 7, 10 and 14

Notice of Changes to Prosperity Elite 7, 10 and 14 Notice of s to Prosperity Elite 7, 0 and 4 Effective 9/30/5 The following applies to Prosperity Elite 7, 0 and 4 contracts issued 9/30/5 or later: The simple interest rate is 5% for the Guaranteed Minimum

More information

Application for FIXED DEFERRED ANNUITY

Application for FIXED DEFERRED ANNUITY Application for FIXED DEFERRED ANNUITY Protective Life Insurance Company Overnight U. S. Postal Mail Nashville, Tennessee 2801 Hwy 280 South P. O. Box 10648 Birmingham, Alabama 35223 Birmingham, Alabama

More information

GREEK CATHOLIC UNION OF THE USA (Herein called GCU)

GREEK CATHOLIC UNION OF THE USA (Herein called GCU) GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 TUSCARAWAS ROAD, BEAVER, PENNSYLVANIA 15009-9513 1-800-722-4428 DEFERRED ANNUITY APPLICATION (Please print) Is the Proposed Annuitant a member of

More information

Product Highlights FG Index-Series

Product Highlights FG Index-Series FG AccumulatorPlus 10 & 14 FG Index-Choice 10 Product Highlights FG Index-Series Fixed Deferred Indexed Annuities ADV 1013 (01-2011) FOR PRODUCER USE ONLY. NOT FOR USE WITH THE GENERAL PUBLIC. Rev. 03-2015

More information

New York Life Insurance Company

New York Life Insurance Company The Company You Keep New York Life Insurance Company Group Membership Association Claims PO Box 30782 Tampa FL 33630-3782 (800) 792-9686 Dear Beneficiary: Please accept our condolences on your recent loss.

More information

First Name MI Last Name Social Security Number/TIN. Gender: Male Female U.S. Citizen: Yes No First Name MI Last Name Social Security Number/TIN

First Name MI Last Name Social Security Number/TIN. Gender: Male Female U.S. Citizen: Yes No First Name MI Last Name Social Security Number/TIN Annuitant Gender: Male Female US Citizen: Yes No Fixed Annuity Application Mail to: PO Box 79905, Des Moines, IA 50325-0905 Overnight to: 4350 Westown Pkwy, West Des Moines, IA 50266 Street Address (PO

More information

FG Retirement Pro. Modified Single Premium Deferred Annuity Options for your retirement planning

FG Retirement Pro. Modified Single Premium Deferred Annuity Options for your retirement planning FG Retirement Pro Modified Single Premium Deferred Annuity Options for your retirement planning ADV 1591 (07-2015) Fidelity & Guaranty Life Insurance Company Rev. 06-2016 16-279 Why Buy This Product? Income

More information

ANNUITY CLAIMANT STATEMENT

ANNUITY CLAIMANT STATEMENT ANNUITY CLAIMANT STATEMENT Section 1. GENERAL INSTRUCTIONS Please sign and return the completed form along with an original Certified Death Certificate for the deceased and the original contract or certificate

More information

LIFE CLAIMANT STATEMENT Lumico Life Insurance Company

LIFE CLAIMANT STATEMENT Lumico Life Insurance Company Mailing Address PO Box 83303 Lincoln, NE 68501-3303 LIFE CLAIMANT STATEMENT Lumico Life Insurance Company INSTRUCTIONS The following items are required for all claims: O An original certified death certificate

More information

PRUDENTIAL IMMEDIATE INCOME ANNUITY APPLICATION FOR USE IN NEVADA ONLY

PRUDENTIAL IMMEDIATE INCOME ANNUITY APPLICATION FOR USE IN NEVADA ONLY PRUDENTIAL IMMEDIATE INCOME ANNUITY APPLICATION FOR USE IN NEVADA ONLY Annuities are issued by The Prudential Insurance Company of America Key Elements For A Good Order Application: We know how important

More information

Claim Form for Structured Settlements

Claim Form for Structured Settlements Claim Form for Structured Settlements New York Life Insurance Company New York Life Insurance and Annuity Corp. A Delaware Corp. The Company You Keep Important Information for Completing Your Claim Form

More information

Instructions for Completing Proof of Death Claimant s Statement

Instructions for Completing Proof of Death Claimant s Statement Instructions for Completing Proof of Death Claimant s Statement We have prepared this claim kit to assist you in filing a claim for annuity death benefits. It is important that we receive all of the information

More information

Life Insurance Benefits Application Instructions

Life Insurance Benefits Application Instructions Application Instructions Please Read Carefully The application for life insurance benefits consists of the forms included in this packet, as well as the additional information noted under item 1 below.

More information

Pension/Profit Sharing/401(k) Annuity Surrender Request for Qualified Plans With MetLife Tax Reporting Fax:

Pension/Profit Sharing/401(k) Annuity Surrender Request for Qualified Plans With MetLife Tax Reporting Fax: Return this form to: MetLife PO Box 9146 Des Moines, IA 50306-9146 POLICY SERVICE OFFICE MetLife Insurance Company of Connecticut Pension/Profit Sharing/401(k) Annuity Surrender Request for Qualified Plans

More information

GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM

GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM PLEASE SUBMIT THE FOLLOWING: 1. THE CLAIM FORM (PAGE 2) FULLY COMPLETED BY THE EMPLOYER

More information

Life Insurance Benefits Application Instructions

Life Insurance Benefits Application Instructions Application Instructions Please Read Carefully The application for life insurance benefits consists of the forms included in this packet, as well as the additional information noted under item 1 below.

More information

Application for Fixed Deferred Annuity

Application for Fixed Deferred Annuity Great American Life Insurance Company Administrative : P.O. Box 5420, Cincinnati, Ohio 45201-5420 Overnight Packages: 301 E. Fourth St., 8th Floor, Cincinnati, OH 45202 Fax Number: 855-306-7113 1. Owner

More information

PRUDENTIAL IMMEDIATE INCOME ANNUITY APPLICATION FOR USE IN KENTUCKY AND NEW JERSEY ONLY

PRUDENTIAL IMMEDIATE INCOME ANNUITY APPLICATION FOR USE IN KENTUCKY AND NEW JERSEY ONLY PRUDENTIAL IMMEDIATE INCOME ANNUITY APPLICATION FOR USE IN KENTUCKY AND NEW JERSEY ONLY Annuities are issued by The Prudential Insurance Company of America Key Elements For A Good Order Application: We

More information

Is the beneficiary the spouse of the deceased annuity contract owner? Yes No. City State/Province ZIP/Postal Code Country

Is the beneficiary the spouse of the deceased annuity contract owner? Yes No. City State/Province ZIP/Postal Code Country Questions on your annuity? Call 800-544-4374. Claimant Statement Form Deferred Annuity Use this form to complete the settlement of your inherited deferred annuity contract. If you need more room for information

More information

SENIOR SAFEGUARD DEATH CLAIM

SENIOR SAFEGUARD DEATH CLAIM SENIOR SAFEGUARD DEATH CLAIM We want to ensure you receive your benefit payment promptly, so please complete the applicable sections and be sure to enclose the documentation requested. Each named beneficiary

More information

Mailing Address (if this is a PO Box, a street address is required) City State Zip Code

Mailing Address (if this is a PO Box, a street address is required) City State Zip Code Beneficiary Statement Tax Information Under the Federal Income Tax law, we are required to request that you (as the payee) provide Standard Insurance Company (as payor) with your correct Social Security

More information

PRUDENTIAL SM PREMIER VARIABLE ANNUITY SERIES APPLICATION FORM Annuities are issued by Pruco Life Insurance Company

PRUDENTIAL SM PREMIER VARIABLE ANNUITY SERIES APPLICATION FORM Annuities are issued by Pruco Life Insurance Company PRUDENTIAL SM PREMIER VARIABLE ANNUITY SERIES APPLICATION FORM Annuities are issued by Pruco Life Insurance Company For Broker/Dealer Use Only Networking No. Annuity No. (If established) Not for use in

More information

THIS SPACE INTENTIONALLY LEFT BLANK

THIS SPACE INTENTIONALLY LEFT BLANK INSTRUCTIONS: 1. Please make certain that all pertinent questions are answered and the proper supporting documents are included before forwarding claim to avoid unnecessary delay in processing the claim.

More information

Life Insurance Claimant s Statement

Life Insurance Claimant s Statement Life Insurance Claimant s Statement Policy Policy number(s) Information Name of Deceased Other names by which the deceased may have been known 55 No. 300 West, Suite 375 Salt Lake City, Utah 84101 (801)

More information

Fixed/Indexed Annuity Application

Fixed/Indexed Annuity Application Fixed/Indexed Annuity Application The Lincoln National Life Insurance Company (Company) Fort Wayne, Indiana Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE INITIALED AND

More information

Additional documentation and instructions may be required when the beneficiary is a(n):

Additional documentation and instructions may be required when the beneficiary is a(n): Claim Dept. - 5310 Overnight Address: P.O. Box 21008 Lincoln Financial Group Greensboro, NC 27420-1008 Claim Dept. - 5310 Phone: 800-487-1485 100 North Greene Street Greensboro, NC 27401 Policy Number:

More information

CLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( )

CLAIM FORM. DATE OF BIRTH: 3. PATIENT'S NAME & ADDRESS- IF ADDRESS IS NEW, PLEASE CHECK BOX r PHONE: ( ) PRIMERICA LIFE INSURANCE COMPANY as Administered by Senior Health Ins. Co. of Pennsylvania Home Office: Boston, MA P.O. Box 64913 St. Paul, MN 55164 Telephone: 1-877-451-5824 CLAIM FORM The patient or

More information

FG Life-Elite. Fixed Indexed Universal Life Insurance Consumer Brochure

FG Life-Elite. Fixed Indexed Universal Life Insurance Consumer Brochure FG Life-Elite Fixed Indexed Universal Life Insurance Consumer Brochure ADV 1311 (09-2012) Fidelity & Guaranty Life Insurance Company Rev. 06-2016 16-355 FG Life-Elite Fixed Indexed Universal Life Insurance

More information

LIFE INSURANCE DEATH CLAIM

LIFE INSURANCE DEATH CLAIM LIFE INSURANCE DEATH CLAIM We want to ensure you receive your benefit payment promptly, so please complete the applicable sections and be sure to enclose the documentation requested. Each named beneficiary

More information

Sun Life Assurance Company of Canada Group Enrollment form

Sun Life Assurance Company of Canada Group Enrollment form Sun Life Assurance Company of Canada Group Enrollment form Complete all sections of the Group Enrollment Form. Make sure you complete and sign the form during the enrollment period or within 31 days of

More information

Product Highlights FG Index-Series

Product Highlights FG Index-Series FG AccumulatorPlus 0 & 4 FG Index-Choice 0 FG Index-Series Fixed Deferred Indexed Annuities ADV 03 (0-20) Rev. -203 3-649 FG Index-Series - Fixed Deferred Indexed Annuities NO BONUS B O N U S UP-FRONT

More information

ANNUITY CLAIMANT STATEMENT

ANNUITY CLAIMANT STATEMENT ANNUITY CLAIMANT STATEMENT Group Annuities and Supplemental Contracts Section 1. GENERAL INSTRUCTIONS Please sign and return the completed form along with a copy of the Certified Death Certificate for

More information

Accident Medical Claim Form

Accident Medical Claim Form 137 Main Street Dubuque, IA Accident Medical Claim Form Please read and follow these instructions should there be a need to file a claim for a covered accident. Your policy says you must notify us of your

More information

2. Certified Death Certificate - Attach a certified death certificate showing cause of death for the insured.

2. Certified Death Certificate - Attach a certified death certificate showing cause of death for the insured. SBLI USA Life Insurance Company, Inc. S.USA Life Insurance Company, Inc. Shenandoah Life Insurance Company (Each the Company ) Members of the Prosperity Life Group CLAIMANT S STATEMENT INSTRUCTIONS FOR

More information

GREEK CATHOLIC UNION OF THE USA (Herein called GCU)

GREEK CATHOLIC UNION OF THE USA (Herein called GCU) GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 TUSCARAWAS ROAD, BEAVER, PENNSYLVANIA 15009-9513 1-800-722-4428 IMMEDIATE ANNUITY APPLICATION (Please print) Is the Proposed Annuitant a member

More information

AIG Benefit Solutions

AIG Benefit Solutions PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF THIS CLAIM. POLICYHOLDER S STATEMENT Policy Number: 3803Z1 Name of Insured (Policyholder) Address (Street, City, State, Zip

More information

Your life insurance claim kit

Your life insurance claim kit U.S. Life Insurance Claims Metropolitan Life Insurance Company Your life insurance claim kit On behalf of MetLife, please accept our sincere condolences during this difficult time. Helping you submit your

More information

Claimant s Statement for Life Insurance Benefits

Claimant s Statement for Life Insurance Benefits Headquarters: 6200 S. Gilmore Road, Fairfield, OH 45014-5141 Mailing address: P.O. Box 145496, Cincinnati, OH 45250-5496 cinfin.com 513-870-2000 Claimant s Statement for Life Insurance Benefits If you

More information

Application for Deferred Annuity with Multiple Interest Crediting Strategies

Application for Deferred Annuity with Multiple Interest Crediting Strategies Annuity Investors Life Insurance Company Administrative : P.O. Box 5420, Cincinnati, Ohio 45201-5420 Overnight Packages: 301 E. Fourth St., 8th Floor, Cincinnati, OH 45202 Fax Number: 877-731-3920 www.gaigannuities.com

More information

Dear Beneficiary: We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created

Dear Beneficiary: We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created Dear Beneficiary: We at MetLife are sorry for your loss. To help you through what can be a very difficult, emotional, and confusing time, we created a settlement option, the Total Control Account Money

More information

How to Apply for Long Term Disability Conversion Insurance

How to Apply for Long Term Disability Conversion Insurance How to Apply for Long Term Disability Conversion Insurance Please follow these steps to apply for Conversion: 1. Complete the LTD Conversion Application provided in this package. Please answer each question

More information

Allstate ChoiceRate Annuity

Allstate ChoiceRate Annuity Allstate ChoiceRate Annuity Allstate Life Insurance Company P.O. Box 660191 Dallas, TX 75266-0191 Telephone Number: 1-800-203-0068 Fax Number: 1-866-628-1006 Prospectus dated October 2, 2017 Allstate Life

More information

Peace of Mind...With Zurich American Life Insurance Company

Peace of Mind...With Zurich American Life Insurance Company Peace of Mind...With Zurich American Life Insurance Company It s never easy to make a major financial decision, even in the best of times. We understand the difficulty of making financial decisions right

More information

Application Trade Credit Insurance Multi Buyer

Application Trade Credit Insurance Multi Buyer Chubb Global Markets Political Risk & Credit 1133 Avenue of the Americas New York, NY 10036 (212) 835-3138 (NY) (312) 612-8827 (Chicago) (213) 612-5512 (Los Angeles) Application Trade Credit Insurance

More information

Group Policy G SOCIAL SECURITY NO. WEIGHT LBS. BILLING ADDRESS / / CITY STATE ZIP CODE HOME PHONE

Group Policy G SOCIAL SECURITY NO. WEIGHT LBS. BILLING ADDRESS / / CITY STATE ZIP CODE HOME PHONE Group Term Life Insurance Application Please complete and return this form to: Worldwide Assurance for Employees of Public Agencies (WAEPA) 433 Park Ave., Falls Church, VA 22046 (800)368-3484 www.waepa.org

More information

Arlington Public Schools 403(b) Retirement Plan

Arlington Public Schools 403(b) Retirement Plan Arlington Public Schools 403(b) Retirement Plan For use with: program Request for a Rollover Section I Plan Information PLEASE PRINT CLEARLY Carefully read the rollover notice you received from your distributing

More information

PROTECT YOUR LOVED ONES AND YOUR INCOME

PROTECT YOUR LOVED ONES AND YOUR INCOME X HELP PROTECT YOUR LOVED ONES AND YOUR INCOME Management Consulting & Research, LLC All Full Time Employees Optional Term Life Insurance with Matching OAD&D Optional Dependent Life Insurance with Matching

More information

Claim Form. What to Know About Filing Your Claim

Claim Form. What to Know About Filing Your Claim Corporate Office: Omaha, NE Administrative Services: PO Box 10464 Des Moines, IA 50306 137 Main Street Dubuque, IA 52001 Toll Free 855.637.6930 Claim Form What to Know About Filing Your Claim You can avoid

More information

Instructions for Completing this Application GENERAL INFORMATION. 1. Name of Applicant: 2. Business Address:

Instructions for Completing this Application GENERAL INFORMATION. 1. Name of Applicant: 2. Business Address: This completed document should be submitted to: ALTRU, LLC 3975 Erie Avenue Cincinnati, OH 45208 T: 800-529-8850 www.altru.com OLD REPUBLIC INSURANCE COMPANY MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION

More information

a An original certified death certificate showing the cause of death. Photocopies are not acceptable.

a An original certified death certificate showing the cause of death. Photocopies are not acceptable. CLAIMANT STATEMENT COMMONWEALTH ANNUITY AN LIFE INSURANCE COMPANY Mailing Address COMMONWEALTH ANNUITY AN LIFE INSURANCE COMPANY PO BOX 83047 LINCOLN, NE 68501-3047 INSTRUCTIONS Proof of Loss Part I The

More information

Employer Instructions for Filing Group Life Insurance Claims

Employer Instructions for Filing Group Life Insurance Claims Metropolitan Life Insurance Company Group Life Claims Employer Instructions for Filing Group Life Insurance Claims 1. Detach this page and complete the Employer s Statement on the following page. 2. Give

More information

GREEK CATHOLIC UNION OF THE USA (Herein called GCU)

GREEK CATHOLIC UNION OF THE USA (Herein called GCU) GREEK CATHOLIC UNION OF THE USA (Herein called GCU) 5400 TUSCARAWAS ROAD, BEAVER, PENNSYLVANIA 15009-9513 1-800-722-4428 DEFERRED ANNUITY APPLICATION (Please print) Is the Proposed Annuitant a member of

More information

Health Screening Benefit Claim Form

Health Screening Benefit Claim Form Part 1 Health Screening Benefit Claim Form Things to know before you begin Complete Part 1 of the claim form (pages 1-5). In addition to Part 1, you will also need to submit Proof Requirements. There are

More information

Must be completed. If there are multiple Beneficiaries, please have each Beneficiary complete a separate claim form. Male

Must be completed. If there are multiple Beneficiaries, please have each Beneficiary complete a separate claim form. Male Beneficiary Claim Form Mail to: Nationwide Life Insurance Company and Nationwide Life and Annuity Insurance Company Individual Annuities, P.O. Box 182021, Columbus, Ohio, 43218-2021, 1-800-848-6331, Fax

More information

INSTRUCTIONS FOR FILING A CLAIM LIMITED BENEFIT CANCER EXPENSE POLICY

INSTRUCTIONS FOR FILING A CLAIM LIMITED BENEFIT CANCER EXPENSE POLICY INSTRUCTIONS FOR FILING A CLAIM LIMITED BENEFIT CANCER EXPENSE POLICY The forms must be completed by the claimant. All questions on the forms must be answered in full. Incomplete or illegible answers may

More information

key* E V11.0

key* E V11.0 key* 00434441 0004 E V11.0 The Guardian Life Insurance Company of America The Guardian Life Insurance company of America underwrites group term life, accidental death and dismemberment, Short term disability,

More information

LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS

LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM On behalf of Boston Mutual Life Insurance Company, please accept our sincere condolences

More information

Hospital Indemnity Insurance Claim Form

Hospital Indemnity Insurance Claim Form Hospital Indemnity Insurance Claim Form Things to know before you begin If you are submitting a claim for a Hospitalization which you have not yet reported to us, please complete this claim form. Once

More information

Cancer Claim Filing Instructions

Cancer Claim Filing Instructions Cancer Claim Filing Instructions Page one Insured s Statement of Claim Complete policy and insured information and answer all questions. Page two Authorization Claimant or Authorized Representative must

More information

Evanston Insurance Company Markel American Insurance Company Markel Insurance Company

Evanston Insurance Company Markel American Insurance Company Markel Insurance Company Evanston Insurance Company Markel American Insurance Company Markel Insurance Company FOR PROFIT MANAGEMENT LIABILITY RENEWAL APPLICATION BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE

More information

Thank you. Should you have any questions, please call us at (800)

Thank you. Should you have any questions, please call us at (800) Dear Policyholder: Please complete and sign the attached claim form. Additionally, the following items are needed in order to process your Medical/Dental claim in the most efficient and expedient way possible.

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. Aetna Life Insurance Company PO Box 14418 Des Moines, IA 50306-3418 Phone: 1-800-882-8395 Fax: 1-515-330-3296 Continue your Aetna life insurance coverage with these options. Thank you for your interest

More information

FG Life-Elite SM. Fixed Indexed Universal Life Insurance Consumer Brochure

FG Life-Elite SM. Fixed Indexed Universal Life Insurance Consumer Brochure FG Life-Elite SM Fixed Indexed Universal Life Insurance Consumer Brochure ADV 1019 (01-2011) Fidelity & Guaranty Life Insurance Company 11-048 Rev. 03-2011 FG Life-Elite SM Fixed Indexed Universal Life

More information

ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application

ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application NOTICE The Policy for which you are applying is written on a claims made and reported basis. Only claims first made

More information

Life Claim Statement Employee/Claimant

Life Claim Statement Employee/Claimant Life Claim Statement Employee/Claimant If you live in the state of Arizona, the following statement applies to you: For your protection Arizona Law requires the following statement to appear on this form.

More information

FG Life-Choice. Fixed Indexed Universal Life Insurance Consumer Brochure

FG Life-Choice. Fixed Indexed Universal Life Insurance Consumer Brochure FG Life-Choice Fixed Indexed Universal Life Insurance Consumer Brochure ADV 1309 (09-2012) Fidelity & Guaranty Life Insurance Company Rev. 06-2013 13-129 FG Life-Choice Fixed Indexed Universal Life Insurance

More information

PLEASE READ THE POLICY CAREFULLY

PLEASE READ THE POLICY CAREFULLY CRIME INSURANCE APPLICATION - MASSACHUSETTS PLEASE READ THE POLICY CAREFULLY Please fully answer all questions and submit all requested information. Terms

More information

On behalf of MetLife, please accept our sincere condolences during this difficult time.

On behalf of MetLife, please accept our sincere condolences during this difficult time. U.S. Life Insurance Claims Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company General American Life Insurance Company On behalf of MetLife, please accept our sincere condolences

More information

Attached is the material you have requested about MetLife s Accelerated Benefits Option ( ABO ) for your Group Insurance plan.

Attached is the material you have requested about MetLife s Accelerated Benefits Option ( ABO ) for your Group Insurance plan. American Airlines Metropolitan Life Insurance Group Life Claims Telephone Number: 1-800-638-6420 Dear Claimant: Attached is the material you have requested about MetLife s Accelerated Benefits Option (

More information

Distribution in the form of a Lincoln Group Deferred Annuity i4life Advantage rider

Distribution in the form of a Lincoln Group Deferred Annuity i4life Advantage rider Lincoln American Legacy Retirement SM Distribution in the form of a Lincoln Group Deferred Annuity i4life Advantage rider Instructions To apply for i4life Advantage, you must be under age 86 for single

More information

FG Life-Choice. Fixed Indexed Universal Life Insurance Consumer Brochure

FG Life-Choice. Fixed Indexed Universal Life Insurance Consumer Brochure FG Life-Choice Fixed Indexed Universal Life Insurance Consumer Brochure ADV 1309 (09-2012) Fidelity & Guaranty Life Insurance Company Rev. 06-2018 18-0774 FG Life-Choice Fixed Indexed Universal Life Insurance

More information