Fillable BENEFICIARY DESIGNATION FORM (Servant HR)

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BENEFICIARY DESIGNATION FORM (Servant HR)

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The Lincoln National Life Insurance Company, PO Box 2649, Omaha, NE 68103-2649
toll free (800) 423-2765 Fax (800) 462-4660
www.LincolnFinancial.com
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)
Primary Beneficiary’s Name and Address
Social Security
Number
Relationship
to You
Date of
Birth
Percentage:
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.
Contingent Beneficiary’s Name and Address
Social Security
Number
Relationship
to You
Date of
Birth
Percentage:
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 afliates. Page 1 of 2
GLC-02170 8/11
SERVANTHR Servant HR, Inc.
COMPLETING YOUR BENEFICIARY DESIGNATION FORM
1. At the top of the form, fill in the information regarding your employer and yourself.
2. Next complete the information regarding who will be your primary and contingent beneficiaries. A primary beneficiary will be the
person/people that you want to receive the life insurance benefit. The contingent beneficiary or beneficiaries will only receive the life
insurance benefit if the primary beneficiary(ies) is no longer living. Indicate the percentage of the benefit amount that the beneficiary
will receive. Do not use dollar amounts. Percentages must add up to 100%.
3. If you live in a community property state, are married and naming someone other than your spouse as the primary beneficiary, you
should have your spouse sign this form to avoid any delays at claim time.
4. Sign and date the form.
Below is an example of how to complete the beneficiary designations:
PRIMARY BENEFICIARY(IES)
Primary Beneficiary’s Name and Address
Social Security
Number
Relationship
to
You
Date of
Birth
Percentage:
Must equal 100%
Name:
Jill Doe
Address: 123 Main St, Anytown, NE 00000
XXX-XX-XXXX Wife XX/XX/XX 100%
Name:
Address:
Name:
Address:
CONTINGENT BENEFICIARY(IES): Contingent beneficiaries will only receive benefit if there are no surviving primary beneficiaries.
Contingent Beneficiary’s Name and Address
Social Security
Number
Relationship
to You
Date of
Birth
Percentage:
Must equal 100%
Name:
John Doe Sr
Address: 456 Main Ln, Anytown, NE 00000
XXX-XX-XXXX Father XX/XX/XX 50%
Name: Mary Doe
Address: 789 Main Rd, Anytown, NE 00000
XXX-XX-XXXX Sister XX/XX/XX 25%
Name: Jack Doe Irrevocable Trust, Jill Doe TTEE UTA 1/04
Address: 123 Main St, Anytown, NE 00000
XXX-XX-XXXX Trust 25%
FREQUENTLY ASKED QUESTIONS
Should I name a minor child as a beneficiary?
You may name a minor child as a beneficiary, however please be aware that we cannot make payment of a claim directly to a minor. If
a claim is incurred we would need to make payment via UTMA or to the guardian of the minor’s financial estate. Or, if guardianship is
not obtained and if UTMA does not apply, the benefit will be placed On Hold - Age of Majority and payable once the minor reaches the
age of majority.
How would I name a Charitable Organization as a beneficiary?
A charitable organization that is not your employer may be named as a beneficiary. You will need to indicate the name of the charitable
organization, a contact for the organization, their tax identification number, and the percentage of the benefit that would be payable to
them.
How do I name my Estate as the beneficiary?
You may name your estate as a beneficiary. To name your estate as the beneficiary indicate “My Estate” as the beneficiary. If you
know who will be the executor or administrator of your estate you should also include that person’s name. For example: My Estate, John
Doe Executor.
How do I name a Trust as the beneficiary?
You may designate a trust as a beneficiary. To name a trust as a beneficiary, indicate Trustee (show Name and address) under Trust
Agreement Dated (show date). If the trust has a tax identification number that will need to be supplied in place of the social security
number. For example: Jack Doe Irrevocable Trust, Jill Doe TTEE UTA 1/1/04.
Page 2 of 2
GLC-02170 8/11
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Completed 16 December 2020

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