Third-Party Investment Advisor Payment Form

The Investment Advisor Firm (“Advisor”) previously authorized by the Owners(s) of the Fidelity1 Variable Annuity Contract (the “Contract”) to make withdrawals of the Advisor’s fees (the “Fees”) from the Contract is the party to complete this form, and is subject to (i) the terms and conditions below, and (ii) the terms and conditions of the Third-Party Investment Advisor Withdrawal Authorization Form (the “Authorization Form”). For assistance in completing this form, please call 800-910-7899 from 8:30 a.m. to 7:00 p.m. Eastern time.

1 Owner(s) InfOrmatIOn

Contract/Policy Number Phone Number

Owner’s First Name Owner’s Last Name/Trust Name Owner’s Social Security Number/Tax ID Number

Joint Owner’s First Name Joint Owner’s Last Name Joint Owner’s Social Security Number

2 wIthdrawal terms and InstructIOnsTerms and Conditions • All the terms and conditions of the Third-Party Investment Advisor Withdrawal Authorization Form also apply to this form. • This form may only be used to make withdrawals of investment advisory fees. • A withdrawal will not be permitted if it would reduce the Contract value below $2,500.

Indicate how you would like to take the fee withdrawal.

Please select 1 option.

Percent of Contract Value . % (% of contract value option must be taken pro-rata)

Or

Dollar Amount Investment Option Dollar Amount

$ .

$ .

$ .

$ .

Total $ .

(Total amount to be withdrawn)

This withdrawal will be taken from the investment option(s) on a prorated basis unless you specify investment option(s) and amount(s) above.

� 010850201

3 Payment Of PrOceeds (Payments made to advisor only)Advisor Firm Information

Advisor Firm Name Tax ID Number Advisor Phone Number

Address City, State ZIP

Please select 1 option

Check paid to Advisor Firm

Deposit directly to Fidelity nonretirement account: Fidelity Nonretirement Account Number

1Fidelity refers to Fidelity Investments Life Insurance Company and in New York, Empire Fidelity Investments Life Insurance Company®.

4 tax InfOrmatIOn (This section discusses some important tax consequences for your client.)A Variable Annuity Contract or Variable Life Insurance Policy

is a tax-advantaged investment vehicle. By choosing to pay their Investment Advisor fees from this Contract, your client may be giving up

tax advantages and may suffer tax consequences as a result.

For Annuity Contracts Only:• Pursuant to an IRS Private Letter Ruling issued to Fidelity, Fees that are paid directly from a Fidelity Personal Retirement

Annuity Contract by its Owner(s) to an Advisor should not be considered taxable distributions if all the conditions set out in the Authorization Form are met. However, Fidelity has no responsibility or liability (i) to determine whether the instructions received from the Advisor are in compliance with the agreement between Owner(s) and Advisor, and (ii) to verify that the amount of Fees complies with the Authorization Form.

• Fidelity does not make any representations or warranties, by accepting instructions or otherwise, concerning the tax treatment of payment of Fees under the Internal Revenue Code, as amended, or otherwise. The Company has no responsibility or liability for any taxes, penalties, and/or interest that may be assessed by the IRS or other administrative tribunal or court arising out of this Authorization.

No federal income tax will be withheld. Tax reporting and payment of taxes are the responsibility of the taxpayer.

5 advIsOr sIgnatures (The previously authorized Advisor Representative must sign below to permit withdrawal.)

Name of Advisor’s Authorized Representative Title of Advisor’s Authorized Representative

XSIGNATURE OF ADVISOR’S AUTHORIZED REPRESENTATIVE DATE

Please mail this form to:

Fidelity Investments Life Insurance Company PO Box 770001 Cincinnati, OH 45277-0050

In New York:

Empire Fidelity Investments Life Insurance Company PO Box 770001 Cincinnati, OH 45277-0051

Overnight mail:

Fidelity Investments KC2Q 100 Crosby Parkway 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.

519039.6.0 1.807561.107 Fidelity Brokerage Services LLC, Member NYSE, SIPC� 010850202

Print: Reset: Save: Owner's First Name: Owner's Last Name/Trust Name: Joint Owner's Last Name/Trust Name: Joint Owner's First Name: Name of Advisor’s Authorized Representative: Title of Advisor’s Authorized Representative: Investment Option 2: Investment Option 3: Investment Option 4: Investment Option 1: Address: City, State ZIP: Check Box1: OffJoint Owner's SS 1: Percentage of Contract Value: Dollar Amount 1: Dollar Amount 2: Dollar Amount 3: Dollar Amount 4: Dollar Amount 5: 0Contract/Policy Nunber: Fidelity Nonretirement Account Nunber: Fee Withdrawal Option: Dollar AmountDate: Owner's SS 1: Tax ID Number 1: Advisor Firm Name: Phone1: Phone2: