Advisor Authorization Form - Fidelity Investments

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Advisor Authorization Form

Use this form to designate an Advisor Firm Limited Durable Power of Attorney for your insurance policy or annuity contract. If you have questions when completing this form, please call 800-910-7899, Monday through Friday, from 8:30 a.m. to 7 p.m. Eastern time.

1 Contract Owner/Policy Holder's Information

Owner's First Name Joint Owner's First Name

Owner's Last Name/Trust Name Joint Owner's Last Name/Trust Name

Owner's Social Security or Tax ID Number Joint Owner's Social Security or Tax ID Number

Phone Number

2 Brokerage Account Information (if available)

If you have a Fidelity Brokerage Services LLC account and would like us to link your annuity to it for reporting and statement purposes, please include the number here.

Fidelity Brokerage Account

If you have a National Financial Services LLC account and would like us to link your annuity to it for reporting and statement purposes, please include the number here.

National Financial Account

3 Owner Hereby Grants a Limited Durable Power of Attorney ("POA")

Each undersigned Annuity Contract or Insurance Policy Owner ("Owner") hereby grants a Limited Durable Power of Attorney ("POA") over the applicable contract(s)/policy(ies) to the Authorized Investment Advisory Firm ("Advisor") named on the following page. The POA shall remain in full force and effect with respect to any Owner until terminated in writing by such Owner, and shall survive any Owner's incapacity or disability.

Fidelity Insurance Agency, Inc., Fidelity Investments Life Insurance Company, and Empire Fidelity Investments Life Insurance Company (collectively, the "Companies") may rely on this POA until duly notified in writing of either (1) written revocation of this POA or (2) death of the Owner or Joint Owner. This POA revokes all earlier Powers of Attorney granted with respect to such annuity contracts and/or life insurance policies. The Companies shall not be liable for any actions taken on behalf of an Owner before actual notice of the revocation of this POA by such Owner or the death of such Owner.

This POA applies only to an annuity contract and/or life insurance policy (check all boxes that apply):

That is being applied for at the same time as submitting this form That has already been issued by Fidelity Investments Life Insurance Company or Empire Fidelity Investments Life Insurance Company

Contract or Policy Number

Contract or Policy Number

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010990601

4 Advisor Firm Information (This section is to be completed by the Advisor Firm.)

Advisor Firm Name

Tax ID Number

Street Address City

Phone Number

State

ZIP

Primary Advisor Contact(s)

Advisor ID Number

The individual signing below represents that he or she has the authority to sign on behalf of the Advisor. By his or her signature below, the Advisor hereby agrees that any information provided to the Companies in connection with the authorizations provided above by each signing Owner will be subject to verification by the Companies. The Advisor hereby authorizes the Companies to obtain a credit report or other financial responsibility reports concerning the Advisor. Upon written request, Fidelity will provide the name and address of the credit reporting agency used.

PRINTED NAME OF ADVISOR'S AUTHORIZED PRINCIPAL

x

SIGNATURE OF ADVISOR'S AUTHORIZED PRINCIPAL

DATE

5 AUTHORIZED Actions of Advisor

Check one of the two boxes below. Each box is followed by a list of activities authorized by checking that box.

For Advisor Asset Managed Annuity Contract or Insurance Policy: A. Receive duplicate statements and confirmations. B. Identify individuals associated with the firm to exercise the powers granted herein. C. Provide the Owner's personal information for prefilling applications and related paperwork required for

issuance of insurance policy and annuity contracts. D. Transfer values and make asset allocation decisions among the investment options of any life insurance

policy or variable annuity contract. E. Receive, without limitation, any nonpublic personal financial information about any owner.

For Advisor Non-Asset Managed Annuity Contract or Insurance Policy: A. Receive duplicate statements and confirmations. B. Receive, without limitation, any nonpublic personal information about any Owner.

6 To Be Completed by the Advisor

For Advisors who are clients of Fidelity Institutional Wealth Services (IWS), please associate all annuity contracts and insurance policies referenced on this form to the following G numbers.

G

G

G

G

Do you use DST FAN Mail to receive client information?

G

G

Yes

No

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7 Owners' Acknowledgments and Signatures

Each Owner hereby authorizes the Companies and their affiliates to share with each other any and all nonpublic personal financial information about the Owner in their possession. Owner authorizes Companies and their affiliates to provide such information to the Advisor and any third-party vendor who provides the Advisor with administrative support. The Advisor must designate in writing the name of the third-party vendor and provide such written designation to the Companies. Each Owner hereby directs and authorizes each of the Companies to deliver to the Advisor for the benefit of each Owner copies of all prospectuses, reports, supplements to prospectuses, proxies, confirmations, statements, and other materials that the Companies would send directly to Owners of the applicable contract(s)/policy(ies), absent this authorization.

Each Owner acknowledges and represents as follows:

I understand that my Advisor is not an agent of Fidelity Investments or its affiliates and is not authorized to make representations on behalf of Fidelity Investments. I may consider the purchase of one or more life insurance or annuity contracts offered for sale by Fidelity Insurance Agency, Inc. I understand that Fidelity Insurance Agency, Inc., offers life insurance and annuity contracts issued by both affiliated and nonaffiliated insurance companies. I understand that any recommendation and/or information provided by the Advisor or any person associated with the Advisor about any specific annuity or life insurance product is done so in the Advisor's capacity as a registered investment advisor, not as an insurance licensed representative of Fidelity Investments Life Insurance Company, Empire Fidelity Investments Life Insurance Company, and/or Fidelity Insurance Agency, Inc.

The Advisor hereby represents that it will deliver or cause to be delivered to each Owner at or prior to the purchase of any product for which there exists a prospectus, a copy of the then-current prospectus, unless such prospectus has already been delivered to each Owner.

Each Owner signing below hereby acknowledges that he or she has read, understood, and agrees to the terms set forth above, including the appointment of the Advisor as Owner's attorney-in-fact.

x

SIGNATURE OF OWNER

DATE

x

SIGNATURE OF JOINT OWNER

DATE

Please mail this form to: Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0050 In New York: Empire Fidelity Investments Life Insurance Company, P.O. Box 770001, Cincinnati, OH 45277-0051 Overnight Mail: Fidelity Investments, 100 Crosby Parkway, KC2Q, Covington, KY 41015

Fidelity insurance products are issued by Fidelity Investments Life Insurance Company (FILI), and in New York, by Empire Fidelity Investments Life Insurance Company,? New York, N.Y. FILI is licensed in all states except New York. Other insurance products available at Fidelity are issued by third-party insurance companies, which are not affiliated with any Fidelity Investments company. A contract's financial guarantees are subject to the claims-paying ability of the issuing insurance company.

Fidelity Brokerage Services LLC, Member NYSE, SIPC

319.779440911.147.1.016

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010990603

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