The Lincoln National Life Insurance Company
Lincoln Life & Annuity Company of New York
First Penn - Pacific Life Insurance Co. (collectively “Lincoln”)
Mail: Claim Dept. - 5310, P.O. Box 21008, Greensboro, NC 27420-1008
Overnight Address: Lincoln Financial Group
Claim Dept. - 5310
100 N. Greene St., Greensboro, NC 27401
Phone: 800-487-1485
Policy Number:____________________________________ Claim Number:_____________________________________
Claimant’s Statement
INSTRUCTIONS – Important Information – please read carefully and completely
Required documentation for a death claim:
•
Certified death certificate showing the manner of death (non-returnable)
•
A separate Claimant’s Statement must be completed and signed by each beneficiary.
Additional documentation and instructions may be required when the beneficiary is a(n):
•
Estate
•
Trust
•
Guardian (minors and incompetent beneficiaries)
•
Corporation
•
Partnership
•
Assignment to third parties
Please refer to the Distinctive Payee Arrangements form (number CL05984) for full instructions.
Power of Attorney: If an attorney-in-fact under a Power of Attorney is completing the Claimant’s Statement on behalf of the
claimant, a copy of the Power of Attorney document must be provided. If the Power of Attorney document was executed more
than three years ago, additional information from the attorney-in-fact may be required. The Social Security number of the person
who granted the Power of Attorney must be included. The attorney-in-fact’s Social Security number may not be used.
Other Possible Requirements (please note that failure to include this information where applicable may cause delay in
processing the claim.):
• Deceased Beneficiary – if any named beneficiary of the contract is deceased, a copy of the death certificate of such
deceased beneficiary must accompany this form.
• Foreign Death – if death of the insured occurred outside of the United States, we will require a Report of the Death of an American
Citizen Abroad and a Foreign Death Questionnaire. A translated Certified Copy of the Death Certificate may also be required.
• Consent to transfer or a state tax waiver – A form for consent or notice is required in some states. When consent is
required, the state must give approval before the death benefit can be paid. If this form is required, it will be provided to the
beneficiary by us.
Lincoln does not require that the policy(ies) be returned to Lincoln for filing of a claim. However, Lincoln does ask that
the relevant policy(ies) be destroyed once payment is received.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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CL05983NY1/16
Policy Number:____________________________________
Deceased’s Information
If the deceased was known by any other names, such as maiden name, hyphenated name, nickname, derivative form of the first
and/or middle name, please include them below:
Name:________________________________________________________________________________________________
Address:______________________________________________________________________________________________
City, State, Zip:_________________________________________________________________________________________
Date of Birth:_______________________________________ Date of Death:______________________________________
Social Security Number:__________________________________________________________________________________
Citizenship: Was deceased a U.S. Citizen?
hYes hNo
If “No”, please list country of citizenship:______________________________________________________________________
Cause of Death:_________________________________________________________________________________________
If the policy(ies) contains an Accidental Death Benefit, are you claiming it?
h Yes h No
Note: Furnish all detailed newspaper clippings, policy reports and coroner’s report. Lincoln may require additional information,
depending on the circumstances of the death.
Claimant Information:
Name:________________________________________________________________________________________________
Address:______________________________________________________________________________________________
City, State, Zip:_________________________________________________________________________________________
Social Security or Tax ID Number:_______________________ Date of Birth:_______________________________________
Daytime Telephone No:_______________________________ Evening Telephone No:_______________________________
Email Address (optional):__________________________________________________________________________________
Claimant’s relationship to Decedent: I am filing this claim as:
h An individual who is a named beneficiary under the policy
h A Trustee of a Trust which is a named beneficiary under the policy
h An Executor of an Estate which is a named beneficiary under the policy
h Other:_________________________________________________________________________________________
Citizenship: Are you a U.S. Citizen?
hYes hNo
If No, please indicate country of Residence:_______________ and Citizenship:_____________________________________
If you are a resident of a foreign country, a W-8BEN or a W-9 must be completed.
This form can be found at: http://www.irs.gov/pub/irs-pdf/fw9.pdf or http://www.irs.gov/pub/irs-pdf/fw8ben.pdf
If you would like us to mail your proceeds to an address other than the above, please specify:
Name:________________________________________________________________________________________________
Address:______________________________________________________________________________________________
City, State, Zip:_________________________________________________________________________________________
You can help expedite the payment of your claim by completing all of the information on this page.
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Policy Number:____________________________________
For your convenience and assistance when your claim is approved, pages 3 and 4 offer you the ability to receive your
death benefits or place your funds into one of the other settlement options. Please read your options carefully and know
that Lincoln is available to address any questions that you may have. The options are numbered for your convenience.
PAYMENT OPTIONS:
Select one of the following two numbered options.
Please Note: If the owner of the policy has previously designated a payment option, Lincoln is required to disburse funds
pursuant to that designation.
1.
h Lump Sum – Three options are provided
If you select this option, you may choose a single check, Electronic Funds Transfer (EFT) or Wire Deposit. If you
do not select a payment option, the default method of payment will be a single check.
h One Single Check
h Electronic Funds Transfer
Distributions through EFT will be deposited directly into your account at your financial institution.
h Wire Deposit (A fee of $25 will be assessed, except for Custodial Accounts. Fees are subject to change.)
Complete the following for EFT and Wire Deposits:
Financial Institution’s Name:___________________________________________________________________________
Telephone Number:_________________________________________________________________________________
Address:__________________________________________________________________________________________
City, State, Zip:_____________________________________________________________________________________
Type of Account: h Checking (must attach a “voided” check or wire instructions on bank letterhead.)
h Savings (must attach Savings account statement with routing number, account number and accountholder name)
ABA/Transit Routing Number (Contact your Financial Institution):______________________________________________
Account Number:___________________________________________________________________________________
Your signature on page 4 of this form serves as authorization to deposit payments and initiate corrections, if necessary, to the
financial institution named above. The institution must be a member of the National Automated Clearing House Association (NACHA).
You also agree to hold Lincoln harmless for the date funds are credited by the institution to your account. This authorization will
remain in effect until your funds are depleted or you notify Lincoln of a change in sufficient time to act.
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CL05983NY1/16
Policy Number:____________________________________
2. h Settlement Option
If you would like additional information regarding settlement options, please call Lincoln at 1-800-487-1485, option 4.
After you have carefully reviewed the options, please indicate your selection below.
The interest rate will be the greater of the rate stated in the policy or Lincoln’s declared rate.
Explanation of Settlement Options
h Life Only – Proceeds plus interest are paid in installments as long as you are living. Payments cease at your death.
h Life With Ten Years Guaranteed – Proceeds plus interest are paid in installments as long as you are living. If you die
within ten years after payments start, we will continue payments to your beneficiary for the balance of the ten year period.
h Refund Annuity – Proceeds plus interest are paid in installments as long as you are living. If you die before receiving
payments equaling the original amount of the contract, we will continue payments to your beneficiary until the total
payments to you and your beneficiary equals the original amount of the contract.
h Period Certain – Proceeds plus interest are paid in equal installments for any number of years you select from one to thirty.
h Amount Certain – Payments are made in equal installments of an amount you select until the proceeds plus interest are exhausted.
1. The frequency of payments: hMonthly h Quarterly h Semi-Annual h Annual
2. The method of payment:
hCheck
h Electronic Fund Transfer (EFT)
CONSENT: I authorize any doctor, hospital or other medical or medically related facility, insurance company, consumer reporting
agency, employer, the Social Security Administration, the Internal Revenue Service or any other organization or person having
any knowledge of the deceased (named below) and his/her earnings or health to give Lincoln Financial Group®, its subsidiaries
or authorized representative any information needed to determine policy claim benefits. This may include (but is not limited to)
information regarding: medical treatment/history, prescriptions, HIV antibody testing, Acquired Immune Deficiency Syndrome or
related complexes, driving records, earnings information, tax returns, mental illness and use of alcohol or drugs. A photocopy of
this form is as valid as the original and I may request one. This form will be in force for one year from the date shown below. I
may revoke it at any time for information not then obtained by writing to Lincoln Financial Group® at the address indicated above.
________________________________________________________________
Name of Deceased
SIGNATURE:
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
You understand that by furnishing a claim form, Lincoln does not waive any defense or acknowledge that there is any insurance
in force or that you are the designated beneficiary. If necessary, Lincoln may ask for more information to confirm this claim.
By signing below, I certify that the information provided is complete and accurate as shown.
Fraud Warning for New York Residents:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
I acknowledge that I have read the FRAUD WARNING.
________________________________________________________________
Claimant’s Full Legal Name (Please Type or Print)
________________________________________________________________ Claimant’s Signature
________________________________
Date
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CL05983NY1/16
Lincoln Financial Group® Privacy Practices Notice
The Lincoln Financial Group companies* are committed to protecting your privacy. To provide the products and services you
expect from a financial services leader, we must collect personal information about you. We do not sell your personal information
to third parties. This Notice describes our current privacy practices. While your relationship with us continues, we will update and
send our Privacy Practices Notice as required by law. Even after that relationship ends, we will continue to protect your personal
information. You do not need to take any action because of this Notice, but you do have certain rights as described below.
Information We May Collect And Use
We collect personal information about you to help us identify you as our customer or our former customer; to process your
requests and transactions; to offer investment or insurance services to you; to pay your claim; to analyze in order to enhance
our products and services; or to tell you about our products or services we believe you may want and use; and as otherwise
permitted by law. The type of personal information we collect depends on the products or services you request and may include
the following:
•
Information from you: When you submit your application or other forms, you give us information such as your
name, address, Social Security number; and your financial, health, and employment history.
•
Information about your transactions: We maintain information about your transactions with us, such as the
products you buy from us; the amount you paid for those products; your account balances; and your payment and
claims history.
•
Information from outside our family of companies: If you are purchasing insurance products, we may
collect information from consumer reporting agencies such as your credit history; credit scores; and driving and
employment records. With your authorization, we may also collect information, such as medical information from
other individuals or businesses.
•
Information from your employer: If your employer purchases group products from us, we may obtain information
about you from your employer in order to enroll you in the plan.
How We Use Your Personal Information
We may share your personal information within our companies and with certain service providers. They use this information to
process transactions you have requested; provide customer service; to analyze in order to enhance our products and services;
and inform you of products or services we offer that you may find useful. Our service providers may or may not be affiliated with us.
They include financial service providers (for example, third party administrators; broker-dealers; insurance agents and brokers,
registered representatives; reinsurers and other financial services companies with whom we have joint marketing agreements).
Our service providers also include non-financial companies and individuals (for example, consultants; vendors; and companies
that perform marketing services on our behalf). Information we obtain from a report prepared by a service provider may be
kept by the service provider and shared with other persons; however, we require our service providers to protect your personal
information and to use or disclose it only for the work they are performing for us, or as permitted by law.
When you apply for one of our products, we may share information about your application with credit bureaus. We also may
provide information to group policy owners, regulatory authorities and law enforcement officials, and to other non-affiliated or
affiliated parties as permitted by law. In the event of a sale of all or part of our businesses, we may share customer information
as part of the sale. We do not sell or share your information with outside marketers who may want to offer you their own
products and services; nor do we share information we receive about you from a consumer reporting agency. You do
not need to take any action for this benefit.
Lincoln
Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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Security of Information
We have an important responsibility to keep your information safe. We use safeguards to protect your information from unauthorized disclosure. Our employees are authorized to access your information only when they need it to provide you with products,
services, or to maintain your accounts. Employees who have access to your personal information are required to keep it confidential. Employees are trained on the importance of data privacy. Your Rights Regarding Your Personal Information
Access: We want to make sure we have accurate information about you. Upon written request we will tell you, within 30 business
days, what personal information we have about you. You may see a copy of your personal information in person or receive a
copy by mail, whichever you prefer. We will share with you who provided the information. In some cases we may provide your
medical information to your personal physician. We will not provide you with information we have collected in connection with,
or in anticipation of, a claim or legal proceeding. If you request a copy of the information, we may charge you a fee for copying
and mailing costs. In very limited circumstances, your request may be denied. You may then request that the denial be reviewed.
Accuracy of Information: If you feel the personal information we have about you is inaccurate or incomplete, you may ask us
to amend the information. Your request must be in writing and must include the reason you are requesting the change. We will
respond within 30 business days. If we make changes to your records as a result of your request, we will notify you in writing and
we will send the updated information, at your request, to any person who may have received the information within the prior two
years. We will also send the updated information to any insurance support organization that gave us the information, and any
service provider that received the information within the prior 7 years. If your requested change is denied, we will provide you
with reasons for the denial. You may write to request the denial be reviewed. A copy of your request will be kept on file with your
personal information so anyone reviewing your information in the future will be aware of your request.
Accounting of Disclosures: If applicable, you may request an accounting of disclosures made of your medical information,
except for disclosures:
• For purposes of payment activities or company operations;
• To the individual who is the subject of the personal information or to that individual’s personal representative;
• To persons involved in your health care;
• For notification for disaster relief purposes;
• For national security or intelligence purposes;
• To law enforcement officials or correctional institutions; or
• For which an authorization is required.
You may request an accounting of disclosures for a time period of less than two years from the date of your request.
You may ask in writing for the specific reasons for an adverse underwriting decision. An adverse underwriting decision is where
we decline your application for insurance, offer to insure you at a higher than standard rate, or terminate your coverage.
Your state may provide for additional privacy protections under applicable laws. We will protect your information in accordance
with these additional protections.
Questions about your personal information should be directed to:
Lincoln Financial Group
Attn: Enterprise Compliance and Ethics
Corporate Privacy Office, 7C-01
1300 S. Clinton St.
Fort Wayne, IN 46802
Please include all policy/contract/account numbers with your correspondence.
*This information applies to the following Lincoln Financial Group companies:
First Penn-Pacific Life Insurance Company
Lincoln Financial Group Trust Company, Inc.
Lincoln Investment Advisors Corporation
Lincoln Financial Distributors, Inc.
Lincoln Life & Annuity Company of New York
Lincoln Retirement Services Company, LLC
Lincoln Variable Insurance Products Trust
The Lincoln National Life Insurance Company
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