Service Forms: Companion Life

These service forms are applicable to annuities and life insurance policies that were issued by Companion Life Insurance Company, that are now administered by First Security Benefit Life Insurance and Annuity Company of New York.

Use this form to begin annuity payments.

Annuity Loan Application and Agreement
Use this form to establish a loan on your account.

Collateral Assignment
Use this form to assign a Non-Qualified Contract/Policy (the "Contract") as collateral.

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.

Electronic Authorization
Use this form to activate electronic services such as telephone authorization.

Electronic Bank Info
Use this form to activate or update electronic bank deposits/withdrawals.

Information Authorization
For replacing an existing life insurance policy or annuity contract with a First Security Benefit Life product.

Internal Exchange Statement and Agreement
Use this form to transfer funds internally from one account to another.

Investment Advisor Authorization
Use this form to establish authority of your investment advisor.

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
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 from should be completed and signed by each beneficiary.

Required Minimum Distribution
To add or change Required Minimum Distribution options, contact your Advisor 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.

Schedule Systematic Withdrawal
To add or change Scheduled Systematic Withdrawal options, contact your Advisor 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.

FS-10000-85 | 2021/12/31