Contract Change Request - 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
Policy Change - IA
1300 S Clinton St., Fort Wayne, IN 46802-3506
CONTRACT CHANGE REQUEST
IMPORTANT INFORMATION
This form is used for name, address, Social Security number** and date of birth changes.
THE USA PATRIOT Act requires financial institutions to obtain, verify, and maintain information that identifies each person who opens
a new account or is added to an existing account with the Company. To meet this Federal obligation the Company will ask individuals for
their name, address, date of birth, including a driver’s license or other governmental issued identification that will allow us to verify their
identity. For certain entities, such as trusts, estates, corporations, partnerships, or other organizations, identifying documentation is also
required. For both individuals and legal entities, the Company may include the use of third party sources to verify the information provided.
Personal Information Changes
Date of change ______________________________________ Contract number _________________________________________
Changes apply to: Contract owner
Annuitant
Changes made to: Name*
Permanent address
Temporary address Social Security number** Date of birth***
Previous name _______________________________________________________________________________________________
Current name ________________________________________________________________________________________________
Address ____________________________________________________________________________________________________
City ______________________________________________________________State _________ Zip ________________________
Corrected Social Security number** _____________________________________________________________________________
Corrected date of birth ________________________________________________________________________________________
*If making a name change due to divorce, marriage, etc., please indicate previous name, current name, and attach a copy of a marriage
certificate, court order, driver’s license, Social Security card, military identification, or divorce decree.
**If making a Social Security number correction, IRS form W-9 MUST be attached.
***If making a change to the year of birth you must provide proof (Government issued ID, etc).
AUTHORIZATION AND SIGNATURES
________________________________________________________________________
______________________________
Contract owner’s previous signature
Date
________________________________________________________________________
______________________________
Contract owner’s current signature
Date
________________________________________________________________________
______________________________
Agent’s signature
Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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