Ultra Variable Life Flexible Premium Service Forms
For help on filling out the forms, please view the instructions.

General Forms

Use this form to begin annuity payments.

Annuity Loan Application and Agreement

Use this form to establish a loan on your account.

Collateral Assignment

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

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.

Electronic Authorization

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

Electronic Bank Info

Use this form to activate or update electronic bank deposits/withdrawals.

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.

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.

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.

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 Systematic Withdrawal

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

Stretch Systematic Withdrawal

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

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.

Form Completion Instructions
Please review these instructions prior to completing any of the forms online. The majority of our forms are designed in a fillable format so you may enter the required information online. If you experience problems and need assistance, please call our Service Center at 800.888.2461.

  • Select the form you wish to complete.
  • Enter the information into the fillable fields.
  • Save the form in a desired location on your computer.
  • Print a copy of the form.
  • Make sure you obtain all applicable signatures.
  • Return the form to First Security Benefit Life for processing. You may mail or fax the form.

First Security Benefit Life Administrative Office
P.O. Box 750497
Topeka, KS 66675-0497
Fax to: 785.368.1772

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