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Most Requested Forms

 

Select links to download forms (PDFs).

 

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

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

Form Description: Use this form to establish a loan on your retirement account.

 

Non-Financial Change (Group Retirement Products Only)

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

Non-Financial Change (New York products Only)

Form Description: Modify or change information regarding: Owner, Joint Owner, Annuitant, Beneficiary and/or address change.

 

Required Minimum Distribution (Group Retirement Products Only)

Required Minimum Distribution (Fixed Annuities, Fixed Indexed Annuities, Variable Annuities)

Required Minimum Distribution (New York Products Only)

Form Description: Use this form to request a Required Minimum Distribution.

 

Scheduled Systematic Withdrawal (Group Retirement Products Only)

Scheduled Systematic Withdrawal (Fixed Annuities, Fixed Indexed Annuities, Variable Annuities)

Scheduled Systematic Withdrawal (New York Products Only)

Form Description: Use this form to establish or change a Scheduled Systematic Withdrawal (SSW).

Forms:

Domestic Violence Confidential Communication (New York)

 

New York Confidentiality Program for Domestic Violence Victims and Endangered Individuals

 

New York Insurance Law Section 2612 concerns all insurers regulated under the New York State Insurance Law, and provides in relevant part that if any person covered by an insurance policy delivers to the insurer a valid order of protection against the policyholder or other person covered by the policy, then the insurer is prohibited for the duration of the order from disclosing to the policyholder or other person the address and telephone number of the insured, or of any person or entity providing covered services to the insured. If a child is a covered person, then the right established by this law may be asserted by the child's parent or guardian.

 

The New York State Department of Financial Services has promulgated 11 NYCRR 244 (Insurance Regulation 168) which requires New York insurers, such as First Security Benefit Life Insurance and Annuity Company of New York (FSBL), to develop and implement confidentiality protocols for victims of domestic violence who submit a valid order of protection and request a confidential alternative means of communication.

 

Download the Domestic Violence Confidential Communication Request Form (PDF).

 

For further information on domestic violence services, you can contact the New York State Domestic and Sexual Violence Hotline by dialing 800.942.6906 or by accessing the New York State Office for Prevention of Domestic Violence website.

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