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Most Requested Forms


Select links to download forms (PDFs).


Loan Application, Agreement and Promissory Note: Use this form to establish a loan on your retirement account for group retirement products.


Loan Application, Agreement and Promissory Note (Group Retirement Products Only)


Loan Application, Agreement and Promissory Note (Fixed Annuities, Fixed Indexed Annuities, Variable Annuities)


Non-Financial Change: Modify or change information regarding: Owner, Joint Owner, Annuitant, Beneficiary and/or address change.


Non-Financial Change (Group Retirement Products Only)


Non-Financial Change (Fixed Annuities, Fixed Indexed Annuities, Variable Annuities)



Companion Life


Issued by Companion Life Insurance Company, Hauppauge, NY, administered by First Security Benefit Life Insurance and Annuity Company of New York, NY, and underwritten by Mutual of Omaha Investor Services, Inc.


For help on filling out the forms, please view the instructions.


Form Description
Annuitization Election of Option For annuitizing your contract, designating Annuity Life and Non-Life options and Secondary Payee information. Select your investment basis, method and frequency of the payout, and tax withholding information.
Asset Reallocation/Dollar Cost Averaging

Asset Reallocation - Allows you to automatically transfer funds quarterly, semi-annually, or annually to maintain a specific percent allocation among your investment options.

Dollar Cost Averaging - Allows you to periodically exchange contract value from one investment option to one or more other options. You may select the option by which you would like funds transferred as well as select the transfer to occur monthly, quarterly, semi-annually or annually.

Authorization for Automatic Deposits For establishing the privilege to have payments made from your Companion Life Contract directly to your bank account. This form works similar to the Electronic Funds Transfer form, it enables you to transfer funds electronically.
Automatic Bank Draft For making electronic investments directly from your bank account to First Security Benefit Life Insurance and Annuity Company of New York (FSBL). Within the form, you may select the amount you would like automatically invested and the frequency of the investments.
Change of Ownership For transferring the current ownership of a life insurance policy to a new owner. Do not use this form when assigning a policy for a loan.
Electronic Exchange Authorization For establishing the privilege to make changes to your contract via telephone. With this option you can submit a one time asset rebalance, an exchange between funds, change your future allocations and make address changes.
Incoming Funds Transfer For transferring assets from your Current Carrier to a Companion Life Annuity Contract.
Information Authorization For replacing an existing life insurance policy or annuity contract with a Companion Life Insurance product.
One-Time Withdrawal To make a one-time withdrawal from your account, please contact your Advisor or our Service Center (800.888.2461) to request a form.
Proof of Death For selecting how to handle proceeds, applying to receive payments electronically via Electronic Funds Transfer (EFT), and selecting Federal income tax options. Note: Every beneficiary is required to complete his or her own form in the case of a death benefit.
Registration Change For changing the name and/or address of the existing Annuitant/Participant, Beneficiary(ies), Owner, or Joint Owner of the Contract.
Release of Information Authorization Use this form to allow other individuals to obtain account values, policy information and to request fund transfers on your annuity contract or life policy.
Request for Scheduled Systematic Payments To add or change Scheduled Systematic Withdrawal options, contact your Advisor or our Service Center (800.888.2461) to request a form.
Request for Transfer of Assets For transferring funds from one account to another, completing a one-time Asset Re-balance, changing the allocation of future payments (Change of Future Allocation), or applying for Telephone Exchange Authorization, which allows you to exchange fund shares over the phone.
Systematic Transfer Enrollment Program Use this form to establish a Systematic Transfer Enrollment Program (STEP). Funds invested in the STEP account will be transferred monthly to allocations you select.
Withdrawal Charge Waiver For establishing privileges to withdraw funds from your contract without incurring a surrender penalty. Must meet requirements outlined on the form. This form must accompany any withdrawal form requested under the Hospital/Nursing Home, Disability or Terminal Illness Waiver Options.

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