Form Glc-02168 - Lincoln Direct Deposit Authorization Form printable pdf download

The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609

toll free (800) 423-2765 Fax (877) 843-3950

DIRECT DEPOSIT AUTHORIZATION & AGREEMENT

CONTRACT INFORMATION

NAME: ____________________________________________ POLICYHOLDER # __________________________________

__________________________________________________

SOCIAL SECURITY # ________________________________

(Vendor # for Treasury Use Only)

BANK INFORMATION

BANK NAME AND ADDRESS:

ROUTING # ________________________________________

___________________________________________________ BANK ACCOUNT # __________________________________

___________________________________________________ TYPE OF ACCOUNT:

CHECKING

(Select One)

___________________________________________________

SAVINGS

___________________________________________________

PLEASE ATTACH A CHECK MARKED “VOID” OR BANK DOCUMENT INDICATING YOUR FULL

ACCOUNT NUMBER AND ROUTING NUMBER.

I (we) authorize and request The Lincoln National Life Insurance Company, and its subsidiaries, to make payment of any amounts

owing to me (either of us) by initiating credit entries or adjustment entries to my account indicated above in the bank named

above, hereinafter called BANK, and I (we) authorize and request BANK to accept any credit entries or adjustment entries initiated

by The Lincoln National Life Insurance Company to such account without responsibility for the correctness thereof.

It is understood that this agreement may be terminated by me (either of us) at any time by written notification to The Lincoln

National Life Insurance Company or BANK. Any such notification to The Lincoln National Life Insurance Company shall be

effective only with respect to entries initiated by The Lincoln National Life Insurance Company after receipt of such notification

and a reasonable opportunity to act on it. I understand that The Lincoln National Life Insurance Company is required to send

a notification and a reasonable opportunity to act on it. I understand that The Lincoln National Life Insurance Company is

required to send a notification to BANK before the first transaction. Any such notification to BANK shall be effective only with

respect to entries credited to my (our) account by BANK after receipt of such notification and a reasonable time to act on it.

It is also understood that this agreement shall not modify or alter the other provisions of the policy(ies) or supplementary

contract which provides for any payment due me.

ACCOUNT HOLDER SIGNATURE: ___________________________________________ DATE: __________________

FOR THE LINCOLN NATIONAL LIFE INSURANCE COMPANY USE ONLY

TO BE COMPLETED BY THE LINCOLN NATIONAL LIFE INSURANCE COMPANY REPRESENTATIVE.

REPRESENTATIVE: _________________________________________________________ DATE: __________________

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

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GLC-02168

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Form Glc-02168 - Lincoln Direct Deposit Authorization Form