Assignment Of Benefits Form printable pdf download

Assignment Of Benefits Form

Claims Department

PO Box 21008

Dept 0514

Greensboro, NC 27420-1008

Phone 800-487-1485

ASSIGNMENT OF BENEFITS

I, _ _____________________________________________________________________________ Owner/Power of Attorney for Policy

Number ________________________________________________________________________ hereby authorize Lincoln Financial

Life Insurance Company to pay Convalescent Care Benefit Payments directly to the facility:

Name of Facility: _____________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Telephone Number: ____________________________________________________________________________________________

Fax Number: _________________________________________________________________________________________________

Tax ID Number: ______________________________________________________________________________________________

________________________________________________________________

____________________________________

Signature of Owner

Date

________________________________________________________________

Name (Please Print)

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

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Assignment Of Benefits Form