Service Forms: SecureDesigns® Variable Annuity

Use this form to begin annuity payments.

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

Asset Reallocation
Use this form to automatically transfer contract values to maintain a specific percentage allocation among your current and future investment options.

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.

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

Dollar Cost Averaging
Use this form to request periodic exchanges from one investment option to one or more 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.

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

Electric 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.

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
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 System Systematic Withdrawal
To add or change Scheduled Systematic Withdrawal options, contact your Advisor or our Service Center (800.888.2461) to request a form.

Suitability and Best Interest Certification
Use this form to show that there is a reasonable basis for believing that the purchase suits your current investment goals and financial situation, and that you have been reasonably informed of the terms and features of a variable annuity and would benefit from certain features of a variable annuity.

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.

Annuities are long term investments suitable for retirement investing. 

Annuities are not insured by the FDIC or otherwise insured or guaranteed by the Federal government or any of its agencies. They are not obligations of or guaranteed by, any bank, savings and loan or credit union.

The investment return and principal value of an investment in variable annuities will fluctuate and you may have a gain or loss at redemption.

You should carefully consider the investment objectives, risks, charges, and expenses of the investment options available under the variable annuities offered. You may obtain a prospectus and/or summary prospectus that contains this and other information about the investment options or variable annuity by calling our Service Center at 800.888.2461. You should read the prospectus and/or summary prospectus carefully before investing. Investing in variable annuities involves risk and there is no guarantee of investment results.

Annuities are issued by First Security Benefit Life Insurance and Annuity Company of New York (FSBL), Albany, NY. Variable annuities are distributed by Security Distributors, an affiliate of FSBL. The SecureDesigns® Variable Annuity (form FSB236 (10-10)) is a flexible premium deferred variable annuity issued by FSBL.

Neither FSBL nor Security Distributors is a fiduciary and the information provided is not intended to be investment advice. This information is general in nature and intended for use with the general public. For additional information, including any specific advice or recommendations, please visit with your financial professional.

FS-10001-16 | 2021/12/31