Beneficiary Designation Form - Lincoln Financial Group
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2The Lincoln National Life Insurance Company, PO Box 2616, Omaha, NE 68103-2616
toll free (800) 423-2765 Fax (877) 573-6177
BENEFICIARY DESIGNATION FORM
Policyholder/Employer
Policy Number(s)
Employee Name
Employee Social Security or Certificate Number
Employee Address (Street, City, State)
Employee Telephone Number
WHO ARE YOUR BENEFICIARIES?
It is very important to clearly indicate your primary beneficiary(ies) and contingent beneficiary(ies). Proceeds are paid to contingent
beneficiary(ies) only if there is no surviving primary beneficiary(ies). If multiple primary beneficiaries or contingent beneficiaries are
named and no percentage distribution is noted, then any proceeds payable to such beneficiaries will be split equally. If more space is needed
to list your beneficiaries please attach a sheet to this form. The beneficiary(ies) named on this form will be valid for all basic, optional,
and/or voluntary group term life and AD&D coverages unless otherwise indicated by you. The beneficiary designation may not go
into effect until this form is signed and dated by you. Page 2 of this form includes examples of how to complete this form.
PRIMARY BENEFICIARY(IES)
Social Security
Relationship
Date of
Percentage:
Primary Beneficiary’s Name and Address
Number
to You
Birth
Must equal 100%
Name:
Address:
Name:
Address:
Name:
Address:
CONTINGENT BENEFICIARY(IES):
Contingent beneficiaries will only receive benefit if there are no surviving primary beneficiaries.
Social Security
Relationship
Date of
Percentage:
Contingent Beneficiary’s Name and Address
Number
to You
Birth
Must equal 100%
Name:
Address:
Name:
Address:
Name:
Address:
Community Property State Consent for residents of Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas,
Washington, or Wisconsin. If you are married, live in a community property state, and name someone other than your spouse as
beneficiary, you may have your spouse sign below to waive his or her rights to any community property interest in the benefit.
As the Insured’s spouse, I do hereby consent to the beneficiary designation(s) indicated on this form and waive any rights that I may
have to the proceeds of such insurance under applicable community property laws.
_________________________________________________________________________
______________________________
Signature of Spouse
Date
__________________________________________________________________________
_______________________________
Signature of Employee
Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
Page 1 of 2
GLC-02170
10/08
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