Life Client Solutions Contact Information
The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York First Penn-Pacific Life Insurance Company (as in your contract and herein “the Company”)
Mail: PO Box 21008, Greensboro, NC 27420-1008 Phone: 800-487-1485 Fax: 800-819-1987 Email:
[email protected] www.LincolnFinancial.com
Contract Change Request Form General Information (Please type or print clearly.) This section must be completed. Policy/Certificate No.:____________________________________________________________________________________ Issued by (the Company):_________________________________________________________________________________
Insured Information Full Legal Name (First, Middle, Last): ________________________________________________________________________ Insured’s Mailing Address: ________________________________________________________________________________ City:_________________________________________________ State:____________ Zip:_________________________ Social Security Number:_________________________________ Date of Birth:____________________________________ Daytime Telephone Number: _____________________________________________________ Check here if new address Email Address:__________________________________________________________________________________________
Owner Information (If different from Insured) Full Legal Name (First, Middle, Last): ________________________________________________________________________ Owner’s Mailing Address: _________________________________________________________________________________ City:_________________________________________________ State:____________ Zip:_________________________ Social Security Number:_________________________________ Date of Birth/Trust**:______________________________ Daytime Telephone Number: _____________________________________________________ Check here if new address Email Address:__________________________________________________________________________________________ *Employer Identification Number for Trusts or Entities. **The date the trust was established
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. CS07390
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Amount of Insurance Reduce the face amount to $__________________________ effective __________________________________________ (Note: If the amount or number of units of any Additional Benefit, other than Waiver of Premium, must be reduced due to the reduction in face amount, the following section requesting the reduction in the Additional Benefit must be completed.)
Additional Benefits An Additional Benefit can be terminated or reduced only on a premium due date. When a Term Insurance Agreement is to be terminated or reduced, always show the name of the specified term agreement.
Terminate Accidental Death Benefit $___________________________________ Guaranteed Insurability Agreement $___________________________ Waiver of Premium Disability Reduce amount or number of units shown: Term Insurance Agreement units of____________________________ Units of Family Security Agreement____________________________ Units of Children’s Insurance Rider____________________________ Paid Up Insurance In accordance with the Paid Up Insurance non-forfeiture provision, I elect Paid Up Insurance in the amount of $______________________________________________ effective___________________________________________
payable at the same time and on the same conditions described in the policy except any amount so payable shall be paid in one sum. If the policy contains any additional benefits, such benefits are terminated with the Paid Up Insurance.
Automatic Premium Loan Provision I request the Automatic Premium Loan provision to be operative in the event a premium remains unpaid at the end of its grace period. I revoke the previous request for the Automatic Premium Loan provision.
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Authorizations and Signatures I certify that the information provided on this form is complete and correct. _______________________________________________________________________ ____________________________ Owner’s Signature**
Date
_______________________________________________________________________ ____________________________ Name (print or type)
Title*
_______________________________________________________________________ ____________________________ Other’s Signature (Irrevocable Beneficiary’s if applicable)
Date
_______________________________________________________________________ ____________________________ Name (print or type)
Title*
* Required for a corporation, partnership, or trust.
Signature Requirements Owner - Signature(s) Required - Digital/Electronic signatures will not be accepted. Individual(s)* - Policyowner(s) Corporation, Bank or Financial Institution - Signature of one officer with title, and a corporate resolution which names all officers authorized to sign on the behalf of the corporation; or two officer’s signatures, with title, without corporate resolution. Conservator or POA - Signature of Conservator or POA with title. We require Letter of Conservatorship along with court order designating conservator/guardian or copy of the POA document to be on file. If POA is dated more than 3 years, we require an affidavit to accompany the request. Signature Example: John Doe, POA for Jane Doe. Trust - Signature of all trustee(s) with title along with the completed Certification of Trustee Powers form AN07086. Partnership or LLC - We require one general/managing partner signature with title and a copy of the Partnership agreement for Partnerships OR one managing member’s signature with title and a copy of the operating agreement for LLCs. Custodian/Minor - We require court order “Letter of Guardianship” or UGMA or UTMA paperwork. (If the custodian designation was completed on page 3, additional paperwork is not required.) Signed by an “X” - If signor is unable to sign and must sign with an “X,” we require signature be notarized. Stamped signatures - We will not knowingly accept a stamped signature. All other insterested parties - Contact customer service to verify signature(s) needed. *If you are signing the form in any capacity other than an individual an appropriate title is required. **A witness signature of a disinterested party is required in the state of Massachusetts.
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