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Questions? Go to Fidelity.com or call 844.519.5433.

Lapse Notice Recipient—Term Life Insurance

Use this form to designate a third party (“Lapse Notice Recipient”) to receive duplicate notifications of any intent by your
insurance provider, Fidelity Investments Life Insurance Company (“FILI”), to cancel your policy due to nonpayment of premium.
Type on screen or print out and fill in using CAPITAL letters and black ink.

Helpful to Know
• The Lapse Notice Recipient named below is designated •F
 ILI will send you and your designated Lapse Notice
to receive notice of any intent by FILI to terminate the Recipient notification at least 30 days prior to the
identified life insurance policy(ies) due to nonpayment effective date of termination if the termination is due
of premium. for nonpayment of premium.
• The new Lapse Notice Recipient in Section 4 replaces
any previous recipient designated by you (the
“policyholder”).

1. Policy Owner
Policy Owner Name

Phone number will be Policy Insured Name (if different from Owner)
used if we have ques-
tions but will not be
used to update your Primary Phone
account information.

2. Policy(ies) Included
List policy(ies) that you want this form to apply to. To appoint a different Lapse Notice Recipient for other policies, use a copy of this form.
Policy Number Policy Number Policy Number

3. Remove an Existing Lapse Notice Recipient Only complete section if not designating a new recipient.

Name

4. Add a Lapse Notice Recipient Any existing Lapse Notice Recipients will be replaced by the Recipient below.

First Name Middle Name Last Name

Phone Number Email

Address

City State/Province ZIP/Postal Code Country

Form continues on next page.

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5. Policy Owner Signature and Date Policy owner must sign and date.

By signing below, you:

• Acknowledge that you have read, under-
stand, and accept all the terms described in
this form.
• Authorize Fidelity to act on all instructions
given on this form.
•C
 ertify that you are the registered owner(s)
of the policies identified in Section 2, and
that all information you provided is correct
to the best of your knowledge.
• Acknowledge
 that the Lapse Notice
Recipient will remain on your term life
insurance policy until canceled by the
owner or authorized individual.

POLICY OWNER NAME

SIGNATURE DATE MM/DD/YYYY

X X
SIGN

Did you sign the form and attach any necessary documents? Regular Mail Overnight Mail
Send the form and any necessary documents to Fidelity. Life Insurance Service Center Fidelity Investments
Questions? Go to Fidelity.com or call 844.519.5433. PO Box 770001 100 Crosby Parkway, KC2Q
Cincinnati, OH 45277-0050 Covington, KY 41015

Fidelity Investments Term Life Insurance (Policy Form Nos. FTL-96200, et al. and FTL-99200, et al.) is issued
by Fidelity Investments Life Insurance Company, 900 Salem Street, Smithfield, RI 02917, and, for New York
residents, Empire Fidelity Investments Term Life Insurance (Policy Form No. EFTL-99200, et al.) is issued
by Empire Fidelity Investments Life Insurance Company®, New York, N.Y. Fidelity Insurance Agency, Inc.
is the distributor. A contract’s financial guarantees are subject to the claims-paying ability of the issuing
insurance company.
Fidelity Brokerage Services LLC, Member NYSE, SIPC. 1022665.2.0 (10/22)

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