Life Conversion Checklist Template (Page 2 of 4) in pdf

The Lincoln National Life Insurance Company, PO Box 21008, Greensboro, NC 27420-1008

(hereinafter referred to as “the Company”)

Please call 800-423-2765 for a quote or

email this form to .

Mail this completed form and premium payment to:

The Lincoln National Life Insurance Company

PO Box 0821, Carol Stream, IL 60132-0821

REQUEST FOR QUOTE - LINCOLN GROUP CONVERSION

A. EMPLOYER/GROUP ADMINISTRATOR: Please note, the Employee must complete the Request for Quote/Application

for Conversion within 31 days from the date their Loss of Coverage.

1. Group Policy Name

Group ID

Policy Number

Covered Employee / Member Information:

2. Name (First, MI, Last)

3. Date of Birth (mm/dd/yy)

4. Date of Hire or Enrollment

5. Date Employee Insurance Terminated

6. Date Employment Terminated

7. Amount of Lost Coverage:

8. Date Employee Last Worked:

Amount $ ________________________

9. Reason for Loss

h Retirement h Disabled h Employment Terminated h Policy Termination h Age Reduction

of Coverage:

h Other, please explain: _ ___________________________________________________________________

Covered Spouse Information:

10. Amount of Lost Coverage for Spouse $ _________________________

Covered Dependent Information:

11. Amount of Lost Coverage for Dependent $ _________________________

I, the Administrator of the Group Policy, declare that the information provided above is complete and true to the best of my knowledge.

Administrator Name (Please Print)

Administrator Phone Number (include area code)

Administrator Email Address

Signature of Employer / Group Administrator

Date

B. EMPLOYEE/MEMBER: Please note, you must complete the Application for Conversion within 31 days from the date

your Employment/Membership terminated or you had a loss of coverage. No policy will be issued and no benefit will be

payable until all information, including premium is received. Please call 800-423-2765 for a Life Conversion quote (have

this form available when calling) or email us at . If you are interested in the proposed Life

Conversion Quote, you will be sent a proposal document and Application for Conversion form to proceed with the Life

Conversion Application Process.

Proposed Insured Information:

Employee Name

Employee SSN

Employee Cigarette Use

h Yes h No

Employee Address

First Name

M.I.

Last Name

SSN

Gender

Birth Date Cigarette Use

SPOUSE:

h M h F

h Yes h No

CHILDREN:

h M h F

h Yes h No

h M h F

h Yes h No

h M h F

h Yes h No

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

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Life Conversion Checklist Template Page 2

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