Customer Account Forms

Service Request Form

You can use the Service Request Form to make updates to your primary policy information including:

  • Changes in the policy owner's name, address or beneficiary

  • Changes in the policy owner's or insured's address of record, primary address and/or secondary address

  • Changes in the policy owner's or insured’s marital or parental status of record (such as marriage, divorce, court order or adoption)

  • Changes in the primary and/or contingent beneficiary designation(s)

You can download the Service Request Form here.

Ownership Change Request Form

If you need to make a change in the designated policy owner for your policy, you can download the Ownership Change Request Form here.

Other Forms

Assignment of Policy as Collateral Security Form

If you need to request that your life insurance policy be used as a form of collateral to secure a loan with a bank, other business entity or individual, you simply need to access and review the Assignment of Policy as Collateral Security Form here. To help you better understand the process, you may want to talk to a lender representative and/or your life insurance agent for more details.

Many businesses accept this form of loan security given the guarantee of funds if the borrower were to die or be in default. To do this, you will need to transfer some beneficiary or ownership rights in the policy contract from one party to another.

If you have questions for our Fidelity Life Customer Service team, please call them for assistance at 800.369.3990, Monday thru Friday from 8 am - 5 pm CT.

Loan/Withdrawal/Surrender Form

You can use the Loan/Withdrawal/Surrender Form if you need to:

  • Set up a loan with Fidelity Life Association using a portion of your policy value. *Note: A loan option is only available on certain products; you may refer to your policy specifications to determine if a loan option is available.

  • Voluntarily terminate your policy by requesting to surrender it.

  • Request a disbursement from your policy value in the form of a partial withdrawal. *Note: A partial withdrawal is only available on certain products; refer to your policy specifications to determine if a partial withdrawal option is available.

  • Set up tax withholding on your policy payments.

  • Change your dividend payout option for your policy.

You can download the Loan/Withdrawal Surrender Form here. Once you have completed the document, simply submit it to us for processing. The policy packet should be returned with a surrender request or the policy owner must destroy the policy. If you’re the policyholder and reside in a community property state (AZ, CA, ID, LA, NV, NM, TX, WA or WI) your spouse’s signature is required.

If you have any questions, please call our Fidelity Life Customer Service team at 800.369.3990, Monday thru Friday from 8 am - 5 pm CT.

* NOTE: Fidelity Life Association will not accept emails or phone calls to surrender, cancel or request a free-look period on a policy since we would not be able to verify the identification of the sender or the caller.

Premium Payment Option Form

This form is used to change any of your payments options on your policy. You can download the form, complete the appropriate section with the financial account information update you need, and submit it to us to make the change. The Premium Payment Option Form allows you to easily change:

  • The frequency of recurring policy premium payments (monthly, quarterly, semiannual and annually)

  • The payment source including your credit card, debit card, electronic funds transfer (EFT) or direct bill set up

You can download the Premium Payment Option Form here. If you have any questions, please call our Fidelity Life Customer Service team at 800.369.3990, Monday thru Friday from 8 am - 5 pm CT.

**Recurring payment options: If you have an existing credit card on file for recurring payments and want to change to a different one, or if you have a recurring electronic funds transfer set up with one bank account number (but want to use a different bank account number), you should be able to make some of those updates yourself online. Visit our Customer Account Log In page, and select the link to our registration website. Once registered, you should be able to make some of those updates.

Claims Form

A beneficiary, or someone acting on behalf of the beneficiary, can access the appropriate state Claim Form here and submit a completed form, with a certified death certificate, to our Customer Service team.

While we have a general death benefits claim form covering beneficiaries in most states, several states are required to have one specific to their residents. Simply find the one that is designated for the state in which you live.

If you have any questions about locating the appropriate form or completing some of the necessary information, please call our Fidelity Life Customer Service team for assistance Monday thru Friday at 800.369.3990 from 8 am to 5 pm CT.

What are you waiting for? Let's get started

Sitemap