HTML Preview Insurance Application Form page number 1.
Fidelity Investments
Account Application/Enrollment Form
and Beneficiary Designation
1. general instructions
Opening a new account: Please complete this form and sign it on the back. Once your account is established, you can submit a
Workplace Savings Plan Contribution Form (Salary Reduction Agreement) to your employer who can then forward contributions to your
account. Please contact Fidelity, your employer, or your tax advisor to determine your maximum allowable contribution.
Moving assets from an existing plan: To consolidate/move money to your employer-sponsored retirement savings account, please complete
the enclosed Transfer/Rollover/Exchange form. If a form was not included within your enrollment kit, please call to request a form.
Fees: Your account may be subject to an annual maintenance and/or recordkeeping fee.
Mailing instructions: Return this form in the enclosed postage-paid envelope or to
Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277-0090
If you wish to send your form via overnight service, please send it to
Fidelity Investments, Mailzone KC1E, 100 Crosby Parkway, Covington, KY 41015
Questions? Call Fidelity Investments at 1-800-343-0860, Monday through Friday, from 8:00
a.m. to midnight ET, excluding
holidays that the New York Stock Exchange is closed, or visit us at www.fidelity.com/atwork.
2. selecting Your investment options
In whole percentages please indicate how you wish to have your contributions allocated to the investment options available for
investment under your plan. Please ensure that your allocations total 100%, for example, 50% for your first, 30% for your second, and
20% for your third fund choice. If your percentages do not add up to 100% or you select an unavailable investment option, your contri-
bution will be invested in an investment option according to your plan rules.
If you would like to select more than four investment options, please write the fund code, fund name, and allocation percentage on a
separate sheet of paper and attach it to your account application. The fund code can be found in your investment options brochure.
3. designating Your beneficiarY(ies)
You are not limited to two primary and two contingent beneficiaries. The beneficiaries designated on this form will apply
to all the plans named in Section 1. To assign additional beneficiaries, or to designate a more complex beneficiary designation, please
attach, sign, and date a separate piece of paper. You may revoke the beneficiary designation and designate a different beneficiary by
submitting a new Beneficiary Designation Form to Fidelity or your Human Resources department.
When designating primary and contingent beneficiaries, please use whole percentages and be sure that the percentages
for each group of beneficiaries total 100%. Your primary beneficiary cannot be your contingent beneficiary. If you designate a trust as a
beneficiary, please include the date the trust was created, and the trustee’s name.
If more than one person is named and no percentages are indicated, payment will be made in equal shares to your primary beneficia-
ries who survive you. If a percentage is indicated and a primary beneficiary does not survive you, the percentage of that beneficiary’s
designated share shall be divided among the surviving primary beneficiaries in proportion to the percentage selected for them.
4. spousal consent
Spousal Consent: If you are married, your plan requires you to designate that your spouse receives 50% or more of your vested
account balance in the form of a preretirement survivor annuity. If you are married and you do not designate your spouse as your
primary beneficiary for a portion of your account balances as described above, your spouse must sign the Spousal Consent portion
of this form in the presence of a notary public or a representative of the plan.
Age 35 Requirement: Your spouse must be the primary beneficiary of your account as described above unless your spouse con-
sents to a different primary beneficiary. If this designation occurs prior to the first day of the plan year in which you attain age 35,
this designation is void on the earlier of (a) the first day of the plan year in which you attain age 35, or (b) the date of separation from
service. When this designation is voided, your spouse will become the beneficiary for the amount described above. If you wish to
designate a different primary beneficiary at that time you will need to complete a new Beneficiary Designation form.
5. authorization
Please provide your signature.
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Fidelity Investments Institutional Operations Company, Inc.
022320001