Authorize or Change Automatic Premium Bank Information

Authorize electronic drafts easily with this form.

Instructions

Complete Financial Institution Section

Complete the financial institution section of this form with the following

  • Name of institution
  • Type of account
  • Routing number
  • Account number
  • Policy number

Signatures

Complete the signature section with account holder and policy owner printed name, signature and date.

Submit form

Return the completed forms with any required documentation via U.S. mail, overnight mail or fax to Fidelity & Guaranty Life Insurance Company Service Center.

Postal Mail

Fidelity & Guaranty Life Insurance Company Service Center
P.O. Box 81497
Lincoln, NE 68501-1497

Overnight Mail

Fidelity & Guaranty Life Insurance Company Service Center
777 Research Drive
Lincoln, NE 68521

Fax

800-281-5777

Allow 3-5 days to process

Fidelity & Guaranty Life Insurance Company will process the request within 3-5 business days of receipt if in good order.

Confirmation

A confirmation letter that the request was processed will be mailed to the owner's address of record.

Admin 5615

Pre-Authorized Check Authorization Form admin 5617

BACK
18-0111

Still have questions?

Reach out to our customer service.