Form Gla-03727 - Application For Portability
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1**MAIL THIS COMPLETED FORM WITH YOUR PREMIUM AND BILLING CHARGE PAYMENT TO:
The Lincoln National Life Insurance Company, P.O. Box 0821, Carol Stream, IL 60132-0821
APPLICATION FOR PORTABILITY
TO AVOID DELAY OF BENEFITS, PLEASE COMPLETE ALL QUESTIONS.
Employer: Please complete and sign the upper section of this form. Please give the form to the employee to complete the lower section.
Employee: Please complete and sign the lower section of this form. Return the completed form with the premium due PLUS the billing
charge to the address shown on the top
**
of this form. We must receive this form & payment within 31 days of “Date Employment Terminated.”
This section to be completed by EMPLOYER
Group Policy
Group Name: _______________________________ Number: _______________________ Group ID: _______________________
Employee Information:
Employee Name:________________________________Birthdate:_____/_____/_______Social Security #:_______-______-_________
Address
:_______________________________________________________________________________
(Street, City, State, Zip Code)
Phone Number: ( _______ ) ______________________________
Gender: Male Female
Spouse Information:
(Complete ONLY if Insured)
Spouse’s Name:_________________________________Birthdate:_____/_____/_______Social Security #:_______-______-_________
Coverage Eligible to Port
Coverage
Monthly Premium
Initial
Termination
Prior Carrier
Amount/Plan
Amount*
Effective Date
Date
Effective Date
Voluntary Employee Life/AD&D $_______________ $_______________ _____________ _____________ _______________
$_______________ $_______________ _____________ _____________ _______________
Voluntary Spouse Life/AD&D
$_______________ $_______________ _____________ _____________ _______________
Voluntary Dependent Life
$_______________ $_______________ _____________ _____________ _______________
Voluntary LTD
Yes No
Voluntary Accident
$_______________ _____________ _____________ _______________
$_______________ $_______________ _____________ _____________ _______________
Long Term Disability
$_______________ $_______________ _____________ _____________ _______________
Short Term Disability
Date Last Worked: ________________________________________
Date Premium Paid To: __________________________
*Use current group rates to calculate Monthly Premium Amount.
Reason for Termination of Employment
(Check ALL that apply)
Retirement
(voluntary termination of employment initiated by employee by meeting age, length of service and/or any other criteria for
retirement from the organization)
Unable to perform each of the main duties of any occupation due to sickness or injury.
Resignation
(voluntary termination of employment initiated by employee)
Dismissal
(involuntary termination of employment initiated by employer)
Other, please explain________________________________________________________________________________________
Employer’s Signature ___________________________________ Printed Name ____________________________ Date__________
Company Phone Number: (______)____________________________Employer’s Email Address: ___________________________
This section to be completed by EMPLOYEE
Beneficiary Information
. If naming more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.
(Life/AD&D Insurance)
Employee’s Primary Beneficiary: __________________________ Employee’s Contingent Beneficiary: _________________________
Relationship: __________________________________________ Relationship: ___________________________________________
Beneficiary’s Address: __________________________________ Contingent Beneficiary’s Address: ___________________________
Employee’s quarterly premium: $___________________+ $5.00 Billing Fee
= Total Amount Enclosed: $______________________
**
(Monthly premium x 3)
Spouse’s quarterly premium:
$___________________+ $5.00 Billing Fee
**
= Total Amount Enclosed: $______________________
(Monthly premium x 3)
Child
’s quarterly premium: $___________________(No Billing Fee) = Total Amount Enclosed:
$______________________
(ren)
(Monthly premium x 3)
I hereby authorize The Lincoln National Life Insurance Company to begin billing directly for my:
(check all applicable coverages)
Voluntary Employee Life
Voluntary Employee Life and AD&D
Voluntary Dependent Life
Voluntary Accident
Voluntary Spouse Life
Voluntary Spouse Life and AD&D
Voluntary LTD
LTD
STD
Signature of Insured Employee: ______________________________________________________ Date: _____________________
Signature of Insured Spouse: ________________________________________________________ Date: _____________________
Employee e-mail address: __________________________________________________________
If e-mail address supplied, we will contact you through email. Did you remember to include your payment?
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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