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New york dealer reassignment form

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C fidelity and guaranty contracting
Agent Appointment Instructions


Fidelity & Guaranty Life Insurance Company

Baltimore, MD ADMIN 5575

Fidelity & Guaranty Life Insurance Company of New York

New York, NY Rev.05-2011

Agents must complete a compensation arrangement received will depend upon the level of committed production.

To ensure proper and timely contracting, it is important that you provide complete, accurate information.Attach all required documentation and/or fees.Make sure you read and understand the Market Conduct Guide.Keep all appointment documentation together, and submit the completed package to your recruiting General Producer:

Signed and completed Producer Information Note: Licensed Agents that sell annuities should include a copy of their current Continuing Education Certificate (both General CE & Annuity Suitability CE (if applicable)).Producer Information Form should be completed and signed for all individuals and/or agencies, corporations who are to receive payment of agent compensation directly from Fidelity & Guaranty Life.

Agents who wish to have their commissions assigned to their agency should also complete the producer information form; corporation or who are principals of an agency/corporation complete this form.

Be sure to indicate those states you wish to be appointed.Sign and complete W9.

Electronic Funds Transfer (EFT direct deposit form) - Complete and sign the Authorization Agreement for Direct Deposit form and enclose a voided check or deposit slip Anti-Money Laundering Certification (AML) All agents are required to complete the AML training, provide proof of completion.

Submit a copy of your Errors & Omissions (E&O) certificate of coverage with your signed contracting paperwork.

E&O coverage is mandatory License for Overrides Agents are required to be appointed by Fidelity & Guaranty Life Insurance Company in those states that they solicit business, both resident and non-resident license.Non-resident licensing is required for any overrides, which are paid in:

Alabama Louisiana

New Mexico South York West Virginia
States have guidelines on whether or not an agent can solicit business prior to appointment date.

We designate states that have restrictions as "Sensitive States".

These states include: Alabama


North Carolina District of Georgia

New Mexico

Utah Fidelity & Guaranty Life pays all state appointment fees and renewal fees.

General Continuing Education ess for certain states.

Fidelity & Guaranty Life will not process agent appointment in these states until the current Continuing Education Certificate has been received
new york dealer reassignment form
.In addition, Fidelity & Guaranty Life will not accept new business until the Continuing Education requirements have been received for the appointment to be processed.

These states Suitability Certifications *Fidelity & Guaranty Life will not process agent appointments or accept new business until we have received the current Annuity Suitability Certification.

training tracker on the State Regulatory Guidelines for Training matrix.


*Any business received prior to the completion of the required courses will be returned.

Agent appointment packages MUST be signed and submitted by your up-line and/or MGA (Master General Producer) Questions about these procedures should be referred to Sales Support at (800-445-6758, prompt 1).


Name of Insured
Social Security Number
Date Submitted

p 3.

Once contracted and you have been given access to SalesLink, you will be asked to sign additional Agreements via an electronic signature.ADMIN 5477 (01-2011) Fidelity & Guaranty Life Insurance Company


AUTHORIZATION FOR EMPLOYMENT PURPOSES Please be advised that a consumer report or investigative consumer report may be obtained from a consumer reporting agency for the purpose of evaluating you for employment, promotion, reassignment, or retention as an employee.

This report may contain information bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living.

Some of this information may be obtained by contacting and Please be advised that if interviews are conducted to obtain some of the above-described information, you have the right to request, in writing, within a reasonable time, that we make a complete and accurate disclosure of the nature and scope of the investigation.

You also have the right to request a written summary of your rights to obtain and dispute information By signing this form, I hereby authorize all entities having information about me, including present and former employers, personal references, criminal justice agencies, departments of motor vehicles, schools, licensing agencies, and credit reporting agencies, to release such information to Fidelity & Guaranty Life or any of its affiliates or carriers.

I acknowledge and agree that this Release and Authorization shall remain valid and in effect during the term of my employment.

Agent Name/Principal of Agency .January 2011)Department of the Treasury

Internal Revenue Service Request for Taxpayer Identification Number and CertificationGive Form to the

requester.Do not send to the IRS.Print or type See Specific Instructions on page 2.Name (as shown on your income tax return)Check appropriate box for federal tax classification (required): Individual/sole proprietor C CorporationS liability company.

Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a

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