Form Cs06893 - Life Beneficiary And Name Change Form Page 2
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3Benefi ciary Designation (continued)
If the benefi ciary is a Trust, complete the following:
Primary
Contingent
Second Contingent
Trust Name __________________________________________________________________________________________
Tax ID Number _______________________________________________Date of Trust _____________________________
Trustee Name(s) ______________________________________________________________________________________
Trustee Name(s) ______________________________________________________________________________________
Address _____________________________________________________________________________________________
The potential for adverse tax consequences may exist when the insured, the benefi ciary and the owner are all different. You may wish
to consult with your tax advisor, attorney, or a representative of the Internal Revenue Service for specifi c information.
AUTHORIZATION AND SIGNATURES FOR BENEFICIARY CHANGES
One offi cer’s signature with title and corporate resolution papers are required for corporate-owned policies/certifi cates.
If owner is a trust, title pages (which indicates the full name, the trust with the date of trust along with the trustee names) and
signatory pages of trust is required.
*Title required for a corporation, partnership or trust.
_______________________________________________________________________
_______________________________
Owner’s Signature
Date
_______________________________________________________________________
_______________________________
Name (print or type)
*Title
_______________________________________________________________________
_______________________________
Owner’s Signature
Date
_______________________________________________________________________
_______________________________
Name (print or type)
*Title
_______________________________________________________________________
_______________________________
Other Required Signature (if applicable)
Date
_______________________________________________________________________
_______________________________
Name (print or type)
*Title
_______________________________________________________________________
_______________________________
Witness Signature (Massachusetts only)
Date
NAME CHANGE
This change applies to:
Insured
Owner
Assignee
Other
You are changing your name (please print Full Name)
From ____________________________________________________________________________________________________
To ______________________________________________________________________________________________________
Reason for name change:
Marriage (attach a copy of certifi cate)
Divorce (attach a copy of decree)
Corporate Name Change (attach certifi ed copy of Corporate Resolution authorizing the change)
Other (please specify and attach a copy of court order)
New Address (if applicable) _______________________________________________________________________________
City, State, ZIP ____________________________________________________________________________________________
Signature for Name Change _______________________________________________________ Date ______________________
(Signature required by Policy Owner or party whose name is changing)
Title _____________________________________________________________________________________________________
HOME OFFICE ACKNOWLEDGEMENT
By _____________________________________________________________________________ Recorded Date _________________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affi liates.
Page 2 of 3
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