Guaranty Life Beneficiary Form – Fill Out and Use This PDF

Request for Service

INSURER: FIDELITY & GUARANTY LIFE INSURANCE COMPANY

I N S U R E D

1.Change Beneficiary

It is hereby requested that the beneficiary designation, including any optional settlement agreement or mode of settlement, is hereby rescinded and the following substituted therefore: (Please print, providing full address and relationship to the Insured/Annuitant.)

	Name	Social Security No.	Date of Birth	Relationship to Insured/Annuitant
Primary
Beneficiary(ies)	Mailing Address		City		State	Zip
	Name	Social Security No.	Date of Birth	Relationship to Insured/Annuitant
Contingent
Beneficiary(ies)	Mailing Address		City		State	Zip

It is understood and agreed that, unless otherwise directed, proceeds will be paid in equal shares to any primary beneficiaries who survive the insured, but if none survives, proceeds will be paid in equal shares to any contingent beneficiaries who survive the insured.

2.Change Name

Do not use this form when transferring ownership rights (use ADMIN 0177). Use this form only if owner remains the same, but the name changes.

Please change the name of the:	From (Former Name – Please Print)		Social Security Number
Insured/Annuitant
Payor	To (New Name – Please Print)		Date of Birth
Owner
Address		City		State	Zip

Reason for Change. (If other than correction, attach copy of legal evidence. Corporate name change requires proof filed with state in which corporation is domiciled.)

3.	Change of Mailing Address
	Please change the address of the:	Insured/Annuitant	Payor	Owner
	To (New Address)		City		State	Zip

4.Change Mode of Payment of Premium

Change to:

Annual

Semi-Annual

Quarterly

COM (Attach COM Authorization Card)

Change Universal Life Planned Premium to:

5.Change Maturity Date

CONTINUED ON REVERSE

ADMIN 0840 (02-2004)

Fidelity & Guaranty Life Insurance Company Baltimore, MD

REV 01-2011

Request for Service

INSURER: FIDELITY & GUARANTY LIFE INSURANCE COMPANY

6.Change Designation of Payee

The Payee is the person who will receive periodic annuity payments.

New Payee (Name)	Social Security No.	Date of Birth

7.Request for Change of Dividend Option / Surrender of Dividends

a.Change Dividend Option to:

Cash

Paid-Up Additions

Reduction of Premium (not applicable to special monthly modes)

Accumulate at Interest

One Yr. Term (evidence of insurability required)

b.Surrender Dividend Value of:

Paid-up dividend additions

Dividends held on deposit to accumulate at interest. If partial surrender, indicate amount:

$

on Policy No.

on the life of

.

If said cash surrender value is to be applied to any other Fidelity and Guaranty Life Insurance policy, give details here; otherwise value will be paid to Owner:

Social Security / Tax Identification Number (Required):

Under penalties of perjury, I certify that the Tax ID information provided above is correct and true.

Acknowledged and accepted by Fidelity and Guaranty Life Insurance Company

Date:By:

BENEFICIARY – SPECIAL INSTRUCTIONS AND SPECIMEN DESIGNATIONS

Signature Requirements. Reverse side of this form must be signed by person(s) having the right to change the Beneficiary.

1.If a policy owned by a corporation—by each of TWO individual officers authorized by the corporation to effect the requested change on behalf of said corporation. Officers should indicate their corporate job title.

2.If policy owned by a partnership—signatures of all partners required.

3.If policy owned by Trustee of Pension or Profit-sharing Trust, by the Trustee empowered under the Trust to make such change. Specimen Designations:

Insured’s Estate - “Executors or Administrators of the Insured’s Estate.”

One Primary and One Contingent – “Mary J. Doe, Insured’s wife, if living at Insured’s death, otherwise equally to such lawful children of Insured (Or substitute—to such children of Insured by said wife), as may then be living.”

Delayed Payment (Common Disaster) Clause – “Mary J. Doe, Insured’s wife, if living on the 30th day after the death of the Insured; otherwise . . .

“

Corporation – “The Brown Paper Company, Inc., a Maryland Corporation, its successors and assigns.”

Partnership – “John Doe and Sons, a partnership consisting of John Doe, James Doe, and Robert Doe, its successors or assigns.”

Corporate Trustees – “First National Bank, Baltimore, MD, Trustee, or its successors in trust, under Trust Agreement dated February 15, 1989.” Individual Trustee – “John J. Jones Insurance Trust naming Mary Smith as Trustee under Trust Agreement dated February 15, 1989.” Multi-Beneficiaries – If proceeds are not to be distributed in equal shares, indicate the proper distributing by using percentages.

ADMIN 0840 (02-2004)

Fidelity & Guaranty Life Insurance Company Baltimore, MD

REV 01-2011