Fidelity Life Ownership Change Request Form

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Ownership Change Request Form
Innovation is Our Policy
Fidelity Life Association
P.O. Box 5030
Des Plaines, IL 60017
Tel (800) 369-3990
Fax (866) 947-8738
Policy Number: ___________________________________
Owner: __________________________________________
Owner’s Social Security Number: __________________________________
Insured: _________________________________________
Owner’s Phone Number: _________________________________________
(including area code)
Ownership Change:
Check:
Owner
If new owner is an individual, is owner a United States citizen?
Yes
No
If NO, please provide:
Country of Origin: ________________________
Passport number and country of issuance: __________________________________________
Alien identification number of other number of government issued identification: _______________________ Country of Issuance: ___________
___________________________________________________________________________
Name of New Owner
__________________________________________________
____________________________
__________
_______________
Street Address
City
State
Zip
__________________________________________________
____________________________
____________________________
Daytime Phone Number of New Owner
Social Security/Tax I.D. Number
Date of Birth
of New Owner
Assuming this form is in good order, the new ownership designation cancels all previous designations.
The new address will replace the existing address on record for the owner only.
Both of the existing owner(s) and the new owner(s) must sign in the Signatures section below.
Ownership change to a trust – include the name and date of the trust, the trustee’s name, and taxpayer ID number of the trust. The trustee
must then also sign below in the Signatures section as the New Owner. Also the first page and the signature page of the trust agreement must be
attached to this form.
Ownership change to a partnership – all partners must sign including their title.
A change of ownership may have tax consequences. The Company suggests you consult an attorney, accountant, or tax advisor for more
information.
Secondary Address (if needed to receive duplicate copies of billing correspondence)
___________________________________________________________
_______________________________________________________
Secondary Addressee Name (please print)
Daytime Phone #
___________________________________________________________
_______________________________________________________
Secondary Addressee Address
City
State
Zip
OC 04/13
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