Form Em91506-Dldl - Beneficiary Form - Lincoln Financial Group

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For use with:

Lincoln Director

Lincoln American Legacy Retirement

in the state of new york

Lincoln Director

Lincoln American Legacy Retirement

in the state of new york

Beneficiary form

For new participants only. Please return completed form to your employer and keep a copy for your files.

employer/plan information

Employer/

plan name_______________________________________________Plan ID______________ Contract number__________________

employee information

 Male  Married

 Female  Not Married

Employee name __________________________________________________________________________

Address ___________________________________City_____________________State_____________ Zip___________

E-mail_____________________________________________________________Phone _________-_________-_____________

Date of birth _________ /________ /______________(mm, dd, year)

Date of hire _________ /________ /______________(mm, dd, year)

Social Security number __________-___________-___________ Facility location ___________________________________________

designation of Beneficiary(ies)

The following individual(s) will be my beneficiary(ies). Please check Primary or Contingent for each individual beneficiary. If neither is checked, the

individual will be deemed to be a primary beneficiary. If any primary or contingent beneficiary dies before me, his or her interest and the interest of his

or her heirs will terminate completely, and the percentage share of any remaining beneficiary(ies) will be increased on a pro rata basis. If no primary

beneficiary(ies) survives me, the contingent beneficiary(ies) will acquire the designated share of my eligible retirement plan balance.

Note: For additional beneficiaries, please attach additional copies of this form as needed

Beneficiary’s name_____________________________________________ ______ ___________  Primary  Contingent

Address ___________________________________City_____________________State_____________ Zip___________

Social Security number __________-___________-___________ Date of birth _________ /________ /______________(mm, dd, year)

Relationship to participant  Spouse  Other

Share ________________%

Beneficiary’s name_____________________________________________ ______ ___________  Primary  Contingent

Address ___________________________________City_____________________State_____________ Zip___________

Social Security number __________-___________-___________ Date of birth _________ /________ /______________(mm, dd, year)

Relationship to participant  Spouse  Other

Share ________________%

Beneficiary’s name_____________________________________________ ______ ___________  Primary  Contingent

Address ___________________________________City_____________________State_____________ Zip___________

Social Security number __________-___________-___________ Date of birth _________ /________ /______________(mm, dd, year)

Relationship to participant  Spouse  Other

Share ________________%

Beneficiary’s name_____________________________________________ ______ ___________  Primary  Contingent

Address ___________________________________City_____________________State_____________ Zip___________

Social Security number __________-___________-___________ Date of birth _________ /________ /______________(mm, dd, year)

Relationship to participant  Spouse  Other

Share ________________%

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations.

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