Service Forms

Download the following form if you need to change your

• Address
• Name
• Beneficiary

Service Request Form (pdf)

Download the following form if you need to change your

• Ownership

Other forms:

Assignment of Policy as Collateral Security (pdf)
Loan/Withdrawal/Surrender Form (pdf)
Premium Payment Options (pdf)
Claim Form (pdf)
Claim Form (Florida) (pdf)
Claim Form (Maryland) (pdf)
Proof of Accident Form (pdf)

Please return your change requests to, Fidelity Life Association, P.O. Box 9269, Oak Brook, Illinois 60522-9269

Not all products available in all states. Fidelity Life Association is licensed in all states and the District of Columbia, except for Wyoming and New York. Our NAIC number is 63290.