Continuation Of Coverage Form For Group Life Insurance Form - Lincoln Financial Group
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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
CONTINUATION OF COVERAGE FORM FOR GROUP LIFE INSURANCE
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 Continue
Coverage
Monthly Premium
Initial
Termination
Prior Carrier
Amount
Amount*
Effective Date
Date
Effective Date
Basic Employee Life
$_______________
$_______________
_____________
_____________
_____________
Basic Employee AD&D
$_______________
$_______________
_____________
_____________
_____________
Dependent Life
$_______________
$_______________
_____________
_____________
_____________
Optional Employee Life
$_______________
$_______________
_____________
_____________
_____________
Optional Employee AD&D
$_______________
$_______________
_____________
_____________
_____________
Optional Dependent Life
$_______________
$_______________
_____________
_____________
_____________
Date Last Worked: __________________________________________
Date Premium Paid To: _________________
*To calculate Monthly Premium Amount, see Rate Sheet included on page 2.
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 one or more duties of his/her regular occupation or unable to perform such duties on a full-time basis 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: ( _______ ) ________________________
Group Fax #: ______________________
This section to be completed by EMPLOYEE
Beneficiary Information
. If naming more than one Primary or Contingent Beneficiary, please attach a
(Life/AD&D Insurance)
separate sheet of paper.
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(ren)’s quarterly premium: $___________________(No Billing Fee) = Total Amount Enclosed:
$____________________
(Monthly premium x 3)
I hereby authorize The Lincoln National Life Insurance Company to begin billing directly for my:
(check all applicable coverages)
Employee Life
Employee Life and AD&D
Dependent Life
Optional Employee Life
Optional Employee Life and AD&D
Optional Dependent Life
Signature of Insured Employee: _____________________________________________________ Date: ____________________
Signature of Insured Spouse: ______________________________________________________ Date: ____________________
Employee e-mail address: _________________________________________________________
If email 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.
Page 1 of 2
GLM-01362
3/09
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