Form Cl05984 - Distinctive Payee Arrangement - Lincoln Financial Group Page 3

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policy/certificate number(s) ___________________________________________________________________________________

 split-dollar

The beneficiary and the employer must come to an agreement based on the split dollar document provisions. A Claimant’s Statement must

be fully completed and signed by each party for their share of the proceeds, stating also the other’s interest based on their mutual agreement.

Employer’s Share: $ ___________________________________________________________________________________________

Employer’s Signature: ___________________________________________ Title: _____________________ Date: _______________

Employer Address: ____________________________________________________________________________________________

City: ________________________________________ State: _______ Zip: ___________ Tax ID Number: ____________________

Beneficiary’s Signature: ____________________________________________________________________ Date: _______________

 assignment

- If the policy/certificate has been collaterally assigned, you must complete this section.

Policy/certificate number(s) _____________________________________ Pay this amount to assignee $ ______________________

By signing below, you agree that all claims paid under the policy(ies)/certificate(s) named may be settled by paying the indicated amount

to the assignee. The balance, if any, will be paid to the beneficiary of the policy(ies)/certificate(s).

Assignee’s Signature: ____________________________________________ Title: ____________________ Date: _______________

Assignee’s Company Name: ____________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City: _______________________________________ State: _______ Zip: ___________ Tax ID Number: _____________________

Beneficiary’s Signature: ___________________________________________________________________ Date: ________________

Under the terms of the assignment, the assignee may have the right to collect the entire proceeds. The assignee should fully complete

and sign the Claimant’s Statement. If the assignee is not claiming any of the proceeds, a formal release should be furnished along with

the beneficiary’s fully completed Claimant’s Statement.

 Family policy/certificate, Family rider or spouse/child rider -

To be completed only if primary insured has deceased.

If the claim is being made under a family policy/certficiate, family rider or a child/spouse rider, list the full names and dates of birth of all living children

born of the marriage, step-children or legally adopted children. If additional space is needed, attach a separate sheet with the requested information.

Name: ____________________________________________

SSN: _____________________

Date of Birth: _______________

Name: ____________________________________________

SSN: _____________________

Date of Birth: _______________

Name: ____________________________________________

SSN: _____________________

Date of Birth: _______________

Name: ____________________________________________

SSN: _____________________

Date of Birth: _______________