Life customer service contact information lfg (305.84 KB)

File Name: CS07390

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Summary

Contract Change Request Form
Life Customer Service Contact Information
Mail: PO Box 21008, Greensboro, NC 27420-1008
Phone: 800-487-1485 Fax: 800-819-1987
Email: [email protected]
LincolnFinancial.com
The Lincoln National Life Insurance Company (Lincoln)
Lincoln Life & Annuity Company of New York (Lincoln)
General Information (Type or print clearly.) — Required
Complete and return by email, fax, or mail using the information above

Policy* Number:
Owner Information (If Business Entity or Trust, list full legal name; submit additional pages as necessary) — Required
h Individual Owner: / / /
(First) (M.I.) (Last) (Suffix)
h Trust/Entity Owner:
Trustee/Officer: / / /
(First) (M.I.) (Last) (Suffix)
Trustee/Officer Title:
Mailing Address (Street): (Apt. or Suite):
(City/State/ZIP): / /
Date of Birth/Trust Date** (mm/dd/yyyy): / / SSN/TIN***:
Home Phone Number: - - Cell Phone Number: - -
Email Address:
Insured Information (If different from Owner) — Required
Full Legal Name: / / /
(First) (Middle) (Last) (Suffix)
Mailing Address (Street): (Apt. or Suite):
(City/State/ZIP): / /
Date of Birth (mm/dd/yyyy): / / SSN:
Home Phone Number: - - Cell Phone Number: - -
Email Address:
*Policy may be referred to as Certificate
**The date the trust was established
***The submission of a completed IRS Form W-9 may be required. Tax Identification Number for Trusts or Entities
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 4
CS07390 6/21
Amount of Insurance
 Reduce the face amount to $ _______________________
Premium will not automatically change. If you would like to change the premium complete Change Premium below

 Change to a Level Death Benefit Option (Not applicable for Term or Whole Life policies)
 Change Premium to $ _______________________  Annually  Semi-annually  Quarterly  Monthly
(Not applicable for Term or Whole Life policies)
Any time a policy change is made, it would be to your benefit to obtain a policy illustration by contacting a Customer
Contact Representative at 800-487-1485 between the hours 8:00a.m. – 6:00 p.m. (Eastern Time), Monday through Friday

Additional Benefits
An Additional Benefit termination or change will be effective the next policy monthly anniversary date after the request is received
in good order

 Terminate Disability Waiver of Premium
 Terminate  Reduce Child Term Rider $_______________________________
 Terminate  Reduce Spouse Term Rider $ ____________________________
 Terminate  Reduce Family Security Benefit $ _________________________
 Terminate  Reduce Accidental Death Benefit $ ________________________
 Terminate  Reduce Guaranteed Insurability Option $ ___________________
 Terminate  Reduce Other _________________________________________ $ ___________________________
When a Term Insurance Rider or Benefit is to be terminated or reduced, the name of the
specified Term Rider or Benefit is required

Paid Up Insurance – See policy provisions for availability. Not applicable for Term or Whole Life policies

 In accordance with the Paid Up Insurance provision, I elect Paid Up Insurance. Amount will be calculated as of the next policy
monthly anniversary date after the request is received in good order

Benefits payable at the same time and on the same conditions described in the policy, except any amount payable shall be paid
in one sum. If the policy contains any additional benefits, such benefits are terminated with the Paid Up Insurance

Elect Non-Forfeiture Option – Applicable for whole life policies

 To PLACE the policy on the following non-forfeiture option checked below
OR
 To ELECT option checked below in the event of default in premium payment
 Reduced Paid-Up Insurance
The Undersigned hereby apply to have the above policy continued in force as paid-up insurance for the reduced amount
to which we are entitled according to its terms. It is understood that any indebtedness to Lincoln secured by said policy will
be deducted from the cash value of the policy used to calculate the reduced paid-up value

 Extended Term Insurance
The Undersigned hereby apply to have the above policy continued in force as paid-up extended term insurance for the
period to which we are entitled according to its terms. It is understood that any indebtedness to Lincoln secured by said
policy will be deducted from the amount of the extended term insurance

 Automatic Premium Loan Provision
Also choose Reduced Paid-Up or Extended Term Insurance as a secondary option
I request the Automatic Premium Loan provision to be added 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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Income Tax Withholding Election
Required for whole life non-forfeiture option election with loan payoff
The withholding tax applies only to the taxable portion of the requested change, if applicable. If you want to know the taxable
amount prior to making this election, please contact a Customer Care Representative at 800-487-1485 between the hours 8:00
a.m. – 6:00 p.m. (Eastern Time), Monday through Friday

Withholding Information
Under federal and state laws, you may choose to not have taxes withheld from certain life insurance payments, or withheld at
a certain percentage or amount from such payments. For either option, you are still responsible for any income tax due on the
taxable portion of the payment. You may be subject to tax penalties under the Estimated Tax Payment Rules if your payment
of estimated tax and withholding, if any, are not sufficient. For Non-Resident Aliens, federal income tax will be withheld at the
applicable rate unless you provide a compliant form W-8BEN or W-8BEN-E and any supporting documentation required

Taxpayer Identification Number and Certification
Under penalties of perjury, the Owner(s) certifies that:
1. The Social Security Number(s) or Federal Tax Identification Number(s) provided for the Owner(s) is the correct number
(or the Owner(s) is waiting for a number to be issued)
2. The Owner(s) is not subject to backup withholding either because (a) the Owner(s) is exempt from backup withholding,
or (b) the Owner(s) has not been notified by the Internal Revenue Service (IRS) that the Owner(s) is subject to backup
withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified the Owner(s) that he or she
is no longer subject to backup withholding;
3. The Owner(s) is a U.S. citizen or other U.S. person; and
4. The FATCA code(s) entered on this form (if any) indicating that the Owner(s) is exempt from FATCA reporting is correct

Exemption from FATCA reporting code (if any) ________________
Certification instructions - You must cross out item 2 above if you have been notified by the IRS that you are currently subject to
backup withholding because you have failed to report all interest and dividends on your tax return

Make your Tax Election below by checking the appropriate box:
We recommend that you contact your tax advisor before making any tax withholding elections to answer any questions that you
may have regarding your state’s withholding laws

If you do not make an election, or if you do not furnish us with your Social Security number or Tax Identification number, we
will withhold 10% for Federal Income Tax and any appropriate State Income Tax from the taxable portion of your payment. If a
withholding election is made that is contrary to IRS or State requirements, then the IRS or State requirements will be applied

Choose to Withhold
 I want to have Federal Income Tax withheld at  __________% or  $__________________
 I want to have Federal Income Tax and State Income Tax (if state mandated) withheld

 I want to have State Income Tax withheld, but not at the mandated rate; withhold  ________ % or  $
Choose Not to Withhold
 I do NOT want to have Federal Income Tax or State Income Tax withheld

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CS07390 6/21
Authorizations and Signatures
To ensure that this document has been signed properly, please refer to the Signature Requirements table

I certify that the information provided on this form is complete and correct. (Submit additional pages as necessary.)
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding

/ /
Signature of Owner/Trustee/Officer* Date (MM/DD/YYYY)*
Printed or Typed Name of Owner/Trustee/Officer Title* (Provide Title if owned by a Trust or Corporation)
/ /
Signature of Owner/Trustee/Officer* Date (MM/DD/YYYY)*
Printed or Typed Name of Owner/Trustee/Officer Title* (Provide Title if owned by a Trust or Corporation)
/ /
Signature of Assignee/Irrevocable Beneficiary* Date (MM/DD/YYYY)*
Printed or Typed Name of Assignee/Irrevocable Beneficiary Title* (Provide Title if assigned to a Trust or Corporation)
/ /
Signature of Assignee/Irrevocable Beneficiary* Date (MM/DD/YYYY)*
Printed or Typed Name of Assignee/Irrevocable Beneficiary Title* (Provide Title if assigned to a Trust or Corporation)
*Required, if applicable
Signature Requirements
Owner Signature(s) Required
Individual(s) Signature of the Policyowner(s)
Signature of Attorney-in-fact with title. We require a copy of the POA document to be on file with
Power of Attorney (POA) Lincoln. If the POA is more than 3 years old, we require an affidavit that the POA is still current to
accompany the request. Signature Example: John Doe, Attorney-in-Fact for Jane Doe

Signature of Conservator or Guardian with title. We require Letter(s) of Conservatorship or
Conservator or Guardian
Letter(s) of Guardianship of the Estate to be on file with Lincoln

Signature of Custodian with title. We require a court order, or other documentation evidencing an
Custodian of Minor appointment as Custodian under a state Uniform Transfers [Gifts] to Minors Act, to be on file with
the Lincoln

Corporation, Bank or Signature of one officer with title, and a Corporate Resolution which names all officers authorized to
Financial Institution sign on behalf of the corporation; or two officer’s signatures, with title, without Corporate Resolution

Signature of the Pension Plan Administrator and a copy of Plan documents naming the
Pension Plan
Administrator

Trust Signature of all Trustee(s) with title along with the completed Certification of Trustee Powers form

Signature of one general/managing partner with title and a copy of the Partnership Agreement
Partnership or LLC for Partnerships OR one managing member’s signature with title and a copy of the Operating
Agreement for LLCs

Signed by an “X” Signature notarized, if the signor is unable to sign and must sign with an “X”

Stamped signatures We will not knowingly accept a stamped signature

All other interested parties Contact Customer Service to verify signature(s) needed

Titles If you are signing the form in any capacity other than as an individual an appropriate title is required

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CS07390 6/21

Life Customer Service Contact Information. Mail: PO Box 21008, Greensboro, NC 27420-1008. Phone: 800-487-1485. Fax: 800-819-1987. Email: [email protected]. …