Use this form to begin annuity payments.
Annuity Loan Application & Agreement
Use this form to establish a loan on your account.
CARES Act Annuity Request Form
The CARES Act was signed into law on March 27, 2020 to help provide economic relief to individuals impacted by the COVID-19 outbreak.
Change Investment Allocation
Use this form to modify your existing and/or future investment allocations. This includes a one time re-balance and/or a transfer of Contract Value between investment options.
Domestic Violence Confidential Communication
Form for victims of domestic violence in New York to submit a valid order of protection and request a confidential alternative means of communication. Use this form to provide an alternative address, telephone number or other method of contact.
Use this form to activate electronic services such as telephone authorization. This authorization allows you to submit a one time re-balance, an exchange between funds, change your future allocation and make address changes via the telephone.
Electronic Bank Info
Use this form to activate or update electronic bank deposits/withdrawals.
Incoming Funds Transfer Rollover
Use this form to transfer funds from your current carrier to First Security Benefit Life Insurance and Annuity Company of New York.
For replacing an existing life insurance policy or annuity contract with a First Security Benefit Life Insurance product.
Non-Financial Change (Change to name, address, beneficiary, etc.)
Use this form to modify or change information regarding the roles on your account: Owner, Joint Owner, Annuitant and/or Beneficiary name and/or address change.
One-Time Withdrawal Form
To make a one-time withdrawal from your account, please contact your Financial Representative or our Service Center (800.888.2461) to request a form.
Proof of Death
This form is to be completed in order to claim proceeds payable upon death. A separate Proof of Death form should be completed and signed by each beneficiary.
Required Minimum Distribution
To add or change Required Minimum Distribution options, contact your Financial Representative or our Service Center (800.888.2461) to request a form.
Salary Reduction Agreement
Use this form to set up contributions to your 457 or Tax Sheltered account from your paycheck. Please check with your employer to verify that this agreement meets your employer's requirements.
Scheduled Systematic Withdrawals
To add or change Scheduled Systematic Withdrawal options, contact your Financial Representative or our Service Center (800.888.2461) to request a form.
Surrender Charge Waiver
This form must accompany each withdrawal requested under the Surrender Charge Waiver option. Certify your reason for waiver and have your physician complete and sign the Physician's Signature Section.