Change Of Benficiary - Lincoln Financial Group
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1The Lincoln National Life Insurance Company
Lincoln Life & Annuity Company of New York
Servicing Office - PO Box 2348
Fort Wayne IN 46801-2348
Fax Number 260-455-6310
Overnight Address: Lincoln Financial Group
Policy Change - IA
1300 S Clinton St
Fort Wayne IN 46802-3506
CHANGE OF BENEFICIARY
CONTRACT
*
INFORMATION
Contract Number ____________________________________________________________________________________________
Contract Owner’s Name _______________________________________________________________________________________
Social Security Number (Last 4 digits) ___________________________ Date of Birth ______________________________________
XXX-XX-
Telephone Number: Daytime __________________________________ Evening __________________________________________
BENEFICIARY DESIGNATION
In accordance with the provisions of the contract, I/we revoke all former beneficiary designations and elect to change the beneficiary as
indicated below. Additional beneficiaries may be designated on a separate sheet and must include a signature on each page.
Primary (you must have at least one primary beneficiary)
Name ____________________________________________________ Social Security Number _______________________________
Relationship _________________ Date of Birth _______________ Percentage ________Telephone Number ____________________
Address ____________________________________________________________________________________________________
City ____________________________________________________________________State __________ ZIP __________________
Primary
Contingent
Name ____________________________________________________ Social Security Number _______________________________
Relationship _________________ Date of Birth _______________ Percentage ________Telephone Number ____________________
Address ____________________________________________________________________________________________________
City ____________________________________________________________________State __________ ZIP __________________
Primary
Contingent
Name ____________________________________________________ Social Security Number _______________________________
Relationship _________________ Date of Birth _______________ Percentage ________Telephone Number ____________________
Address ____________________________________________________________________________________________________
City ____________________________________________________________________State __________ ZIP __________________
If designating a trust as beneficiary, complete the following:
Primary
Contingent
Name ____________________________________________________ Social Security/Tax ID Number _________________________
Trustee’s Name _____________________________________ Date of Trust _____________ Telephone Number __________________
Address ____________________________________________________________________________________________________
City ____________________________________________________________________State __________ ZIP __________________
SIGNATURES
__________________________________________________________________________
_______________________________
Contract Owner/Trustee’s Signature
Date
__________________________________________________________________________
_______________________________
Joint Owner’s Signature (if applicable)
Date
*”Contract” may be referred to as “policy” or “certificate.”
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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