Life Conversion Checklist Template Page 3
ADVERTISEMENT
1
2
3
4The Lincoln National Life Insurance Company, PO Box 21008, Greensboro, NC 27420-1008
(hereinafter referred to as “the Company”)
Mail to:
The Lincoln National Life Insurance Company
PO Box 0821, Carol Stream, IL 60132-0821
APPLICATION FOR CONVERSION OF GROUP LIFE INSURANCE
A. APPLICANT/PROPOSED INSURED: Please call 800-423-2765 for a Life Conversion Quote. You must complete the
Application for Conversion within 31 days from the date your group insurance terminated. Please note, eligibility will NOT be
confirmed until the completed and signed application is received by the Company.
1. a. Group Policy Name
b. Group ID
c. Group Policy Number
Proposed Insured Information:
2. Name (First, MI, Last)
3. Date of Birth (mm/dd/yy)
4. Social Security Number
5. Address (Street, City, State, ZIP)
7. h Male
6. Phone Number (include area code)
h Female
8. Has the Proposed Insured become eligible for any other Group Insurance since the date the life insurance terminated?
h Yes h No If “Yes,” for how much? _____________________________________________________________________________
Coverage Information: (As available per product. After calling for a quote, you will receive an illustration that will assist you with
completing these questions.)
9. Plan of Insurance __________________________________________________________________________________________________
10. Amount of Insurance (Specified Amount, if UL or VUL) $ ___________________
11. Have you smoked any cigarettes in the past 12 months? h Yes h No
a. h Annual
b. h Semi-Annual
c. h Quarterly
12. Premium Mode (check one)
d. h Monthly (Bank draft required for this option, please complete the attached EFT form.)
13. a. Death Benefit Option
h Level
h __________________________________ (Not available with all products, see product specifications for details)
b. Death Benefit Qualification Test (DBQT) - For IRS purposes, premiums will be tested using:
h GPT h CVAT
The DBQT cannot be changed after issue unless the terms of the policy require a change.
14. Additional Benefits and Riders (If applicable):
h Accelerated Benefit Rider
h Other Benefits and Riders (not listed above). (Please provide full details: e.g. coverage amounts/percentages/etc.):
Beneficiary Information: (If naming more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.)
15. Primary Beneficiary Name
a. Relationship
b. Social Security Number
16. Contingent Beneficiary Name
a. Relationship
b. Social Security Number
Proposed Owner Information: (Complete this Section if the Proposed Insured is not the Owner.)
17. Full Name of Owner
18. Relationship to Proposed Insured
19. Address of Owner (Street, City, State, ZIP)
20. Owner SSN or TIN
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
Page 1 of 2
LFF07384
7/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business