Form Cl05984 - Distinctive Payee Arrangement - Lincoln Financial Group
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4Claim Dept. - 5310
Overnight Address:
P.O. Box 21008
Lincoln Financial Group
Greensboro, NC 27420-1008
Claim Dept. - 5310
Phone: 800-487-1485
100 North Greene Street
Fax: 336-691-3152
Greensboro, NC 27401
distinctive payee arrangements
insured information
Name: ______________________________________________________________________________________________________
Policy/Certificate Number(s): ____________________________________________________________________________________
SSN/TIN: ___________________________________________________________________________________________________
this form provides information on what is needed if the proceeds from this policy/certificate are to be paid to someone other than
an individual beneficiary. if one of the situations listed applies to you, please check that box and follow the instructions given.
return this section, with the completed claimant’s statement.
estate
If the proceeds of this policy/certificate are to be paid to an estate, you must submit a certified copy of the executor’s, personal representative’s
or administrator’s court appointment. The Claimant’s Statement must be fully completed and signed by the executor, personal representative
or administrator including the estate tax identification number. The decedent’s Social Security Number should not be used. If a Tax ID
Number is not provided, mandatory tax withholding will be assessed.
If an executor, personal representative or administrator is not to be appointed, please contact the Clerk of Court in the county/parish of
the insured’s residence to obtain the proper small estate procedure.
corporate
If the proceeds of this policy/certificate are to be paid to a corporation, the Claimant’s Statement must be fully completed and signed by
an officer of the corporation, including the officer’s title. Include the corporate tax identification number and a corporate resolution or
similar document signed by officers of that corporation that clearly defines who can act on behalf of the corporation.
Yes
No
Is the company incorporated?
partnership
If the proceeds of this policy/certificate are to be paid to a partnership, a Claimant’s Statement must be fully completed and signed by
the surviving partner(s). Include the partnership’s tax identification number and a partnership agreement or similar document signed by
the partners that clearly defines who can act on behalf of the partnership.
guardian
-
Includes; minors, incompetent or physically incapacitated beneficiaries
If the proceeds of this policy/certificate are to be paid to a minor, you must submit a certified copy of the court order appointing the
guardian of the minor’s Estate. The guardian must fully complete and sign the Claimant’s Statement. Include the minor’s Social Security
Number on the Claimant’s Statement. If no guardian has been appointed, the Company will hold the proceeds at interest until age of
majority. A supplementary contract will be opened after the Company has received a current address and copies of the birth certificate
and a Social Security Number for each minor.
If the proceeds of this policy/certificate are to be paid to a beneficiary who has been declared mentally incompetent, you must submit a
certified copy of the court order appointing the guardian of the beneficiary’s Estate. The guardian must complete and sign the Claimant’s
Statement and include the beneficiary’s Social Security Number.
If the proceeds of this policy/certificate are to be paid to a beneficiary who is physically incapacitated, the beneficiary can make his or
her mark on the Claimant’s Statement, witnessed by two persons, including the full addresses of both witnesses.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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CL05984
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