2012 Enrollment Form For Group Insurance Page 3
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3BENEFICIARY INFORMATION (Complete ONLY for Life/AD&D and Accident and Critical Illness Enrollments)
Primary Beneficiary's Last Name
First
MI
Relationship of Beneficiary
Social Security Number
Street Address
City
State
Zip
Contingent Beneficiary's Last Name
First
MI
Relationship of Beneficiary
Social Security Number
Street Address
City
State
Zip
Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more
than one Primary or Contingent Beneficiary, please attach a separate sheet of paper.
Dependent and Other Insurance Information (Complete only for Accident Coverage or Critical Illness Coverage)
Last Name
First Name
Middle
Gender
Date of
Full-time
Initial
Birth
Student
SSN (Optional)
Child
Yes
No
Child
Yes
No
Child
Yes
No
Child
Yes
No
NOTE: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD
AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE
STATEMENT IS GUILTY OF INSURANCE FRAUD.
The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln
National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company.
A delayed effective date will apply if the employee is not Actively at Work, or a dependent is in a period of limited activity on the date
insurance would otherwise take effect.
Employee Full Name: ____________________________________________________
Employee Signature: ____________________________________________________
Date: _____________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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