Contrato Fidelity

lnstructions

Step 1. Complete, Sign and Date this Form. lf you are a corporate principal, complete a separate form for the corporation. Forward the form(s) to your appointing agency.

Step 2. Appointing General Agencies, please complete the portian of the form authorizing the hierarchy set up and compensation.

Step 3. Once contracted and you have been given access to Saleslink, you will be asked to sign additional Agreements via an electronic signature.

To be completed by the Appointing Agency

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Producer/Agency lnformation

lf the answer to any question from 1-11 below is yes, please attach an explanation. Additional information such as supporting documents may be required.

Direct Deposit lnformation - REQUIRED

This authorization is to remain in force until Fidelity & Guaranty has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the Company and/or the Bank a reasonable opportunity to act on it. This authorization is governed by Maryland law, including Maryland Uniform Commercial Code.

I (we) hereby authorize FIDELITY & GUARANTY LIFE INSURANCE COMPANY or FIDELITY & GUARANTY LIFE INSURANCE COMPANY OF NEW YORK (“FIDELITY & GUARANTY”) to deposit my (our) commission payment with the financial institution identified below (“Bank”) and the Bank to credit the same to my (our) account as described below. In the event that Fidelity & Guaranty notifies the Bank that funds to which I (we) am not entitled have been deposited to my (our) account by it in error, I (we) hereby authorize the Bank to return said funds to Fidelity & Guaranty upon demand and agree to hold Fidelity & Guaranty harmless from any and all liability in connection therewith. Fidelity & Guaranty will process chargeback of commissions within its commission system, and only net commission due will be eligible for deposit to my (our) account.

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DISCLOSURE AND AUTHORIZATION

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Request for Taxpayer Identification Number and Certification

NOTE: Check the appropiate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropiate box for the tax classification of its owner.

4. Exemptions (codes apply only to certain entities, not only individuals;see instructions on
page 3)

(Applies to accounts maintained outside the U.S.)

Taxpayer Identification Number (TIN)

 

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

or

I understand that General Information Services/GBRS is requesting this information on behalf of

and give my full consent for periodic criminal history background checks to be performed for the duration of my employment with this company.

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