TO AVOID DELAY OF BENEFITS, PLEASE COMPLETE ALL QUESTIONS.
Employer: Please complete and sign the upper section of this form. Please give the form to the employee to complete the lower section.
Employee: Please complete and sign the lower section of this form. Return the completed form with the premium due PLUS the billing
charge to the address shown on the top
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of this form. We must receive this form within 31 days of “Date Employment Terminated.”
This section to be completed by EMPLOYER
Group Policy
Group Name: _______________________________ Number: _______________________ Group ID: ____________________
Employee Information:
Employee Name: _____________________________ Birthdate: ___ / ____ / ___ Social Security #: ______ - ____ - ______
Address (Street, City, State, Zip Code): __________________________________________________________________________
Phone Number: (_______) ____________________________________
Spouse Information:
(Complete ONLY if Insured)
Spouse’s Name: _____________________________ Birthdate: _______________ Social Security #: _____ - ____ - ______
Coverage Eligible to Port Coverage Monthly Premium Initial Termination Prior Carrier
Amount Amount* Effective Date Date Effective Date
Voluntary Employee Life/AD&D 䊐 $_______________ $_______________ _____________ _____________ _____________
Voluntary Spouse Life/AD&D 䊐 $_______________ $_______________ _____________ _____________ _____________
Voluntary Dependent Life 䊐 $_______________ $_______________ _____________ _____________ _____________
Voluntary LTD 䊐 $_______________ $_______________ _____________ _____________ _____________
STD 䊐 $_______________ $_______________ _____________ _____________ _____________
Date Last Worked: ________________________________________ Date Premium Paid To: _________________
*Use current group rates to calculate Monthly Premium Amount.
Reason for Termination of Employment (Check ALL that apply)
䊐 Retirement (voluntary termination of employment initiated by employee by meeting age, length of service and/or any
other criteria for retirement from the organization)
䊐 Unable to perform each of the main duties of
any
occupation due to sickness or injury.
䊐 Resignation (voluntary termination of employment initiated by employee)
䊐 Dismissal (involuntary termination of employment initiated by employer)
䊐 Other, please explain
_______________________________________________________________________________________
Employer’s Signature ___________________________________ Printed Name ____________________________ Date _________
Company Phone Number: (______)_________________ Group Fax #: ______________________
This section to be completed by EMPLOYEE
Beneficiary Information (Life/AD&D Insurance). If naming more than one Primary or Contingent Beneficiary, please attach a
separate sheet of paper.
Employee’s Primary Beneficiary: _________________________ Employee’s Contingent Beneficiary: ______________________
Relationship: _________________________________________ Relationship: _________________________________________
Beneficiary’s Address:__________________________________ Contingent Beneficiary’s Address: _______________________
Employee’s quarterly premium: $___________________+ $5.00 Billing Fee
**
= Total Amount Enclosed: $____________________
(Monthly premium x 3)
Spouse’s quarterly premium: $___________________+ $5.00 Billing Fee
**
= Total Amount Enclosed: $____________________
(Monthly premium x 3)
Child(ren)’s quarterly premium: $___________________(No Billing Fee) = Total Amount Enclosed: $____________________
(Monthly premium x 3)
I hereby authorize The Lincoln National Life Insurance Company to begin billing directly for my: (check all applicable coverages)
䊐 Voluntary Employee Life 䊐 Voluntary Employee Life and AD&D 䊐 Voluntary Dependent Life
䊐 Voluntary Spouse Life 䊐 Voluntary Spouse Life and AD&D 䊐 Voluntary LTD
Signature of Insured Employee: _____________________________________________________ Date: ____________________
Signature of Insured Spouse: ______________________________________________________ Date: ____________________
Employee e-mail address:
APPLICATION FOR CONTINUATION OF COVERAGE For Voluntary Insurance Coverage
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MAIL THIS COMPLETED FORM WITH YOUR PREMIUM AND BILLING FEE PAYMENT TO:
Lincoln Life & Annuity Company of New York, P..O. Box 7247-0347, Philadelphia, PA 19170-0347
Lincoln Life & Annuity Company of New York
Home Office: Syracuse, NY
toll free (800) 423-2765 www.LincolnFinancial.com
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 1
GLA-03727 NY VOL 11/08
