Fillable Group Life Insurance Claim Form

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Group Life Insurance Claim Form

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Lincoln Financial Group is the marketing name for Lincoln National Corporation and its aliates. Page 1 of 8
GLC-01253 CLMFRM 6/20
Group Life Insurance Claim Form
Employer or Plan Administrator Statement
To avoid delays or denial of benets, please complete all questions.
Group Name: __________________________________________________________________________________________
Address: ________________________________ City: ________________________ State: _______ Zip: _______________
Group Policy Number: ____________ - ____________________________ - ____________
Billing Location: ______________________________________________________________
Employee Name: _____________________________________________________________
Employee Name or Member Name
The Deceased is insured as:
Employee Spouse Child Member
1. Name of Deceased: _____________________________________________________ State of Residence: __________
2. Date of Death: ____________________________ Date of Birth: _____________________________ Age: __________
Gender:
Male Female
3. Social Security Number: ______________________________________ _____________________________________
Employee’s SSN Date of Birth Dependent SSN Date of Birth
Insurance Class (Refer to policy schedule of insurance): _____________________________
4. AmountofLifeBenet:
Basic: $ ______________________ Optional Life: $ _____________________ Voluntary Life: $ ________________
Dependent Life: $ ______________ OtherLifeBenetClaimed: ____________ Amount: $ _____________________
IfdeathisduetoanAccident,amountofAccidentalDeath(AD)Benet:
AD Basic: $ ___________________ Optional AD: $ ______________________ Voluntary AD: $ ________________
Dependent AD: $ _______________ OtherADBenetClaimed: ____________ Amount: $ _____________________
5. Date of Hire: Full Time __________________________ Part Time _______________________
Annual Salary (if salary based): $ ___________________ Date Of Last Salary Increase: __________________________
Date Premium Last Paid: __________________________
6. EectiveDateofInsurancewithLincolnFinancialGroup: ____________________________________________________
7. DateonwhichtheEmployeewaslastpresentatWork? _____________________________________________________
8. REASONFORCEASINGWORK
Illness(includingdisabilityleaveofabsence) LeaveofAbsence(otherthandisability) Accident
Quit Dismissed Vacation TemporaryLayo Retired Deceased
9. EmployeeWas: Full-time Union Hourly Exempt Commissioned
(CheckAllThatApply) Part-time Non-Union Salaried Non-Exempt
Other (Explain) _________________________________________________________________
10. AverageHoursWorkedPerWeek:___________Occupation: ________________________________________________
Completed by: ______________________________________________ Date: ____________________________________
Title: ______________________________________________________ Phone Number:____________________________
E-mail Address: _____________________________________________ Fax Number: ______________________________
The Lincoln National Life Insurance Company, PO Box 2649, Omaha, NE 68103-2649
Toll Free (800) 423-2765 Fax (800) 462-4660
LincolnFinancial.com
LifeClaims@lfg.com - For claims submission
Claims@lfg.com - For direct claim status inquiries and questions on existing claims
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its aliates. Page 2 of 8
GLC-01253 CLMFRM 6/20
Beneciary’s Statement
Please type or print legibly—name and address as stated will appear on checks
Name: ___________________________________________________________________ Gender:
Male Female
First Middle Initial Last
Beneciary’sSocialSecurityNumberor
TaxpayerIdenticationNumber: ____________________________________________
Date of Birth (MM/DD/YY): ______________ Home Phone: _________________ Daytime Phone: __________________
Address: _____________________________________________________________________________________________
City: ____________________________________________________ State: ____________ Zip: ____________________
E-mail Address: ________________________________________________________________________________________
Name of Deceased: _____________________________________________ Relationship to Deceased: __________________
Ifthebeneciaryisoneofthefollowing:
Minor Estate Incompetent Organization Trust
Pleaseprovidecontactnameandphonenumberofthepersonalorlegalrepresentativeofthatbeneciary:
_____________________________________________________________________________________________________
PAYMENT OPTIONS: Please select one of the following three options (One Single Check, Direct Deposit, or SecureLine
Interest-Bearing Checking Account) and please also make sure to sign and date on page 3.
One Single Check - This is the default payment option if no option is selected.
Direct Deposit - Complete the following information to allow the benet amount to be directed deposited to your account.
BankName: ________________________________________________________________________________________
Address: ___________________________________________________________________________________________
Routing #: ____________________________________ BankAccount#: ______________________________________
Type of Account (Select One):
Checking Savings
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LincolnFinancialGroup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noticationtoTheLincolnNationalLife
InsuranceCompanyorBANK.AnysuchnoticationtoTheLincolnNationalLifeInsuranceCompanyshallbeeectiveonlywith
respecttoentriesinitiatedbyTheLincolnNationalLifeInsuranceCompanyafterreceiptofsuchnoticationandareasonable
opportunitytoactonit.IunderstandthatTheLincolnNationalLifeInsuranceCompanyisrequiredtosendanoticationand
a reasonable opportunity to act on it. I understand that The Lincoln National Life Insurance Company is required to send a
noticationtoBANKbeforethersttransaction.AnysuchnoticationtoBANKshallbeeectiveonlywithrespecttoentries
creditedtomy(our)accountbyBANKafterreceiptofsuchnotication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.
SecureLine Interest-Bearing Checking Account (Not available in New York).
SecureLineisaserviceoeredtohelpyoumanageinsuranceproceeds.WithSecureLine,anaccountisestablishedfromthe
proceeds payable on a policy administered by a Lincoln Financial Group
®
company (Lincoln). Lincoln’s contractual obligation
topaythoseproceedsissatisedbydepositingtheproceedsintoyouraccount.TheNorthernTrustBank(NorthernTrust)
administersyouraccountonLincoln’sbehalfandthefundssupportingyouraccountareheldwithinLincoln’sgeneralaccount.
Once your SecureLine account is opened, you will receive a personalized checkbook. If you decide you want the entire
proceedsimmediately,youjustneedtowriteonecheckfortheentirebalance.Otherwiseyoucanusethisaccountforpaying
expensesastheyoccur–whileearninginterestonyourmoney.Youcanwriteasmanychecksasyouwish.Eachcheckmust
beforatleast$250andthetotalofallcheckswrittenmaynotexceedyourbalance.
The Lincoln National Life Insurance Company, PO Box 2649, Omaha, NE 68103-2649
Toll Free (800) 423-2765 Fax (800) 462-4660
LincolnFinancial.com
LifeClaims@lfg.com - For claims submission
Claims@lfg.com - For direct claim status inquiries and questions on existing claims
*IftheInsuredPersonpreviouslydesignatedapaymentoptionavailableunderthepolicy,wearerequiredtodisbursefundspursuanttothatdesignation.
Please sign at the bottom of page 3
Page 3 of 8
GLC-01253 CLMFRM 6/20
• Interest Rates – Your SecureLine account starts earning interest the day the account is opened. Interest is compounded
dailyandcreditedtoyouraccountonthelastdayofeachmonth.Theminimumratecreditedisequaltothenationalaverage
forinterestbearingcheckingaccountsaspublisheddailybyBloomberg,plus1%.TheCompanymayupdatethatminimum
rateatourdiscretion.Theinterestwillbeupdatedmonthly.Youcanndthecurrentinterestratethatwillbecreditedtoyour
accountatwww.lfg.combyclickingontheQuickLink“FileaClaim”.Youbegintoearninterestthedaytheaccountisopened
andcontinuetoearninterestuntilallthefundsarewithdrawn.TheinterestratecreditedtoyourSecureLineaccountmaybe
more or less than the rate earned on funds held in Lincoln’s general account. Consider comparing this interest rate to your
bankaccountinterestrateorconsultyournancialprofessionaltocompareinterestratesoncomparablebankormutualfund
accounts.Interestearnedonyouraccountbalancemaybetaxable;IRSform1099-INTwillbesentinJanuaryofeachyear
toreporttaxableincome.Youshouldconsultyourtaxadvisorformoreinformation.
• Protection Of Deposits – Your money in your SecureLine account is protected because it is held in Lincoln’s general account
and is guaranteed by the full faith and credit of the Lincoln Financial Group
®
company that established your account. Because
yourfundsarenotheldinafederally-regulatedbank,yourfundsarenotprotectedbytheFederalDepositInsuranceCorporate
(FDIC).However,intheunlikelycaseofinsolvencyofLincoln,yourfundsareprotectedbyyourstate’sinsuranceguaranty
system. Contact the National Organization of Life and Health Guaranty Associations (http://nolhga.com; 703-481-5206) to
learnmoreaboutwhatlimitsmightexistrelatedtostateinsuranceguarantyprotection.
• MonthlyStatements–Eachmonthyouwillreceiveastatementshowingyourcurrentbalance,withdrawals,interestcredited
andanyotheractivity.Cancelledchecksarenotreturnedwithyourstatement.
• FeesorAdministrativeCharges–Therearenospecialfeesforchecksandnofeesformonthlycheckingaccountservice.You
willbechargedafeeof$15ifyoustopapaymentand$10ifyoupresentacheckforpaymentwithoutsucientfunds.Additional
checksmaybeorderedatnocost.JustcontactaCustomerServiceRepresentativeatNorthernTrustat1-800-343-2551.
• MinimumBalance–YourSecureLineaccountwillremainopenuntilyourbalancedropsbelow$1000,atwhichtimeyour
accountwillbeautomaticallyclosedandacheckfortheremainingfundsplusinterestwillbemailedtoyou.
• SettlementOptions-TheLincolnpolicymayprovideyouwithotherbenetsettlementoptions.Youmaychoosetowithdraw
the balance of your account and place it in another payment option oered by Lincoln. Contact a Customer Service
Representativeat800-423-2765formoreinformation.
• Louisiana Department of Insurance, PO Box 94214, Baton Rouge, LA 70804, (225) 342-1226.
• Funds in your SecureLine
®
accountmaybereportedtoyourStateasunclaimedpropertyiftheaccounthashadnoactivity
for a prolonged period (2-4 years, depending on your State’s unclaimed property act.)
FOR FURTHER INFORMATION , PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE.
If you are electing a SecureLine Interest-Bearing Account, please complete the Beneciary Designation section below. If there
is a SecureLine Interest-Bearing Account balance remaining at the time of your death, it will be paid to the beneciary(ies) you
designate below.
PRIMARY BENEFICIARY(IES)
Primary Beneciary’s Name and Address Social Security
Number
Relationship to You Date of Birth Percentage:
MustEqual100%
Name: ______________________________
Address: ____________________________
Name: ______________________________
Address: ____________________________
IunderstandthatTheLincolnNationalLifeInsuranceCompanyfurnishesthisformwithoutwaivinganydefensetheCompany
mayhaveoradmittingthatanyinsuranceisinforce.
IhavecompletedandattachedtheAuthorizationforReleaseofInformation.Aphotocopyofthisauthorizationshallbeasvalid
as the original.
Icertify,underpenaltyofperjury,thattheSocialSecurityNumberorotherTaxpayerIdenticationNumberinformationlistedabove
iscorrect.IunderstandthatmysignaturemaybeusedforsignaturevericationformySecureLineAccountandotherpurposes.
Signature: _____________________________________________________________Date: ______________________________
(Signasyouwouldacheckassignaturemaybeusedforcheckverication)
Page 4 of 8
GLC-01253 CLMFRM 6/20
Authorization for Release of Information
1. I (the undersigned) authorizeanyphysician,medicalprofessional,pharmacistorotherproviderofhealthcareservices,hospital,
clinic,othermedicalormedicallyrelatedfacility;coroner’soce;insuranceorreinsurancecompany;governmentagency;
departmentoflabor;lawenforcementorpublicsafetydepartment;grouppolicyholder;employer;orpolicyorbenetplan
administrator to release information from the records of:
Claimant/Insured Name: __________________________________________________________________________
Last First Middle
Date of Birth: _______________________________ Social Security Number: ______________________________
2. Claimant/Insured Information to be released:
• data or records regarding medical history, treatment, prescriptions, consultations, autopsy [including medical and psychological
reports,records,charts,notes(excludingpsychotherapynotes),x-rays,lmsorcorrespondence,andanymedicalcondition(s)];
• anyinformationregardinginsurancecoverage;and
• accidentreportoranyocialinvestigativereports(suchaspolice,re,FAA,OSHA,ortoxicologyreport).
3. Information to be released to: The Lincoln National Life Insurance Company
PO Box 2649
Omaha, NE 68103-2649
4. IunderstandtheinformationobtainedbyuseofthisAuthorizationwillbeusedbyTheLincolnNationalLifeInsuranceCompany
(“Company”)toevaluatemyclaimfordeathbenets.TheCompanywillonlyreleasesuchinformation:
• toitsreinsurer,orotherpersonsororganizationsperformingbusinessorlegalservicesinconnectionwithmyclaim(s);or
• asotherwisemayberequiredbylaworasImayfurtherauthorize.
IfurtherunderstandthatrefusaltosignthisAuthorizationmayresultinthedenialofbenets.
5.
Iunderstandtheinformationusedordisclosedmaybesubjecttore-disclosurebytherecipientandmaynolongerbeprotectedby
federallaw.For Colorado claims, the disclosed information may notberedisclosedorreusedbytherecipientunderColoradolaw.
6. IunderstandthatImayrevokethisAuthorizationinwritingatanytime,excepttotheextent:
1) theCompanyhastakenactioninrelianceonthisAuthorization;or
2) theCompanyisusingthisAuthorizationinconnectionwithacontestableclaim.
Ifwrittenrevocationisnotreceived,thisAuthorizationwillbeconsideredvalidforaperiodoftimenottoexceed24monthsfrom
thedateofmysignaturebelow.ToinitiaterevocationofthisAuthorization,directallcorrespondencetotheCompanyattheabove
address.
7. AphotocopyofthisAuthorizationistobeconsideredasvalidastheoriginal.
8. IunderstandIamentitledtoreceiveacopyofthisAuthorization.
SIGNATURE: _______________________________________ DATE: _____________________________________
Claimant/legalRepresentative(Nearestrelative,legalguardian,orappointedrepresentativetosignonlyifclaimant/insuredisa
minor,legallyincompetent,ordeceased.)Powerofattorneyorguardianshipmustbeattached.
PRINT NAME: _______________________________________
RelationshiptoClaimant/Insuredofpersonal/legalrepresentativesigningforClaimant/Insured: __________________________
ADDRESS: ________________________________________________ PHONE NO: __________________________
Street
________________________________________________
City State Zip Code
Death Claim
Page 5 of 8
GLC-01253 CLMFRM 6/20
Accidental Death Benet Information
A beneciaryorthepersonal/legal representative ofthedeceased will onlycompletethis page whenapplyingforAccidental
DeathBenets.
1. Group Name: ________________________________________________________________________________________
2. Name of Insured: _____________________________________________________________________________________
3.NameofDeceased(Ifdierentfromabove): ____________________ Relationship to Insured: _____________________
4.OnwhatdatedidtheAccidentoccur?(MM/DD/YY): ______________
WheredidtheAccidentOccur?(Address,City,State): ________________________________________________________
DescribeindetailhowtheAccidentoccurred: ______________________________________________________________
______________________________________________________________
______________________________________________________________
5.DidtheDeceasedhaveanydiseaseorphysicaldefect?
Yes No
If Yes, please describe in detail: ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6.Wasapoliceorotherinvestigativereportcompleted?
Yes No
IfYes,pleaseprovideacopyoftheocialinvestigativereport(i.e.police,accident,OSHA,etc)and/orprovidecontactinformation:
__________________________________________________________________________________________________
7.Listname/address/phonenumberofallphysicianswhotreatedthedeceasedinconnectionwiththeaccident:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
8.Listname/address/phonenumberofallhospitalswhotreatedthedeceasedinconnectionwiththeaccident:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
9.WasanAutopsyperformed?
Yes No
IfYes,pleasesubmitcopyoftheAutopsyreportand/orprovidecontactinformation:
__________________________________________________________________________________________________
Person completing form: __________________________________________ Phone: ______________________________
Address: _____________________________________________________________________________________________
City: ____________________________________________________ State: ____________ Zip: ____________________
Relationship to Deceased: ______________________
Signature of Person Completing this form: _______________________________________ Date: _____________________
Page 6 of 8
GLC-01253 CLMFRM 6/20
Important Claim Process Information
Inordertoexpeditetheclaimprocess,pleaseseethefollowingimportantclaimprocessinformationwhensubmittingaclaim:
Proof of Loss:
AllLifeClaimsmustbeaccompaniedbyaCertiedDeathCerticate.
AccidentalDeathBenets:
IfdeathresultedfromanythingotherthanNaturalCauses(i.e.accident,homicide),acopyoftheocialinvestigativereport
(i.e.police,accident,re,FAA,OSHA)mustaccompanyorfollowtheclaim.AD&Dbenetscannotbepaidonanyclaimwithout
aninvestigativereportregardingtheInsuredPerson’s/Dependent’sdeath.IfyourGroupContractcontainsanAlcohol/Drug
Exclusion,aToxicologyReportwillberequired.PleasecompletetheAccidentalDeathBenetInformationportionoftheclaim
formtoprovidebackgroundinformationregardingaccident.
PaymentVerication:
Groupsshouldincludetheenrollmentform,copiesofanybeneciarychanges,absoluteassignmentsorfuneralassignments
whensubmittingaclaim.
BeneciaryisDeceased:
IfthePrimaryBeneciaryisnolongerliving-aCertiedDeathCerticatemustaccompanytheclaimbeforepaymentcanbe
madetotheContingent(secondary)Beneciary.IftheContingent(secondary)Beneciaryisalsodeceased,aCertiedDeath
CerticatewillalsoberequiredinordertopaycertainrelativesortheEstate,accordingtothecontract.
BeneciaryisanEstate:
CourtdocumentsofappointmentmustbeforwardedtoThe Lincoln National Life Insurance Company before payment can
bemadetoanEstate.ThedocumentsofappointmentmustnamethePersonalRepresentativeoftheEstate(alsocalledthe
Executor,Executrix,Administratororothersimilartitle)towhombenetscanbepaid.
BeneciaryisaTrust:
IfpaymentistobemadetoaTrust,acopyoftheTrustDocumentmustbeprovidedwiththeclaim.Suchdocumentsmust
designatetheTrusteetowhomproceedswillbepaid.
BeneciaryisaMinor:
Accordingtostatelaw,aminorlackscapacitytosignabindingreleaseofaninsurancecontract.
Forthisreason,lifeinsurancebenetsarenotdirectlypayabletoaminorbeneciary.Thefollowingareoptionsavailablewhen
thebeneciaryisaminor:
1. UTMA(UniformTransfertoMinorsAct)–UTMApaymentcanbeutilizedprovidingthatthebenetamountincluding
interestisundertheamountallowedfortheminorbeneciary’sstateofresidence.
2. Guardianship papers – The minor’s custodian may obtain formal guardianship papers for the minor’s estate. These
legalguardianshipdocumentsmustbeobtainedpriortothereleaseofthebenet.Ifguardianshippapersarenot
obtainedandifUTMAdoesnotapply,thebenetwillbepaidoncetheminorreachestheageofmajority.
Page 7 of 8
GLC-01253 CLMFRM 6/20
FRAUD NOTICES. For your protection, certain states require that the following notices appear on this form.
Alabama.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenet
orwhoknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybe
subjecttorestitutionnesorconnementinprison,oranycombinationthereof.
Alaska.Apersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveaninsurancecompanylesa
claimcontainingfalse,incompleteormisleadinginformationmaybeprosecutedunderstatelaw.
Arizona. For your protectionArizona law requires the following statement to appear on this form.Any
personwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossissubjecttocriminaland
civilpenalties.
Arkansas, Louisiana, Rhode Island and West Virginia.Anypersonwhoknowinglypresentsafalseor
fraudulentclaimforpaymentofalossorbenetorknowinglypresentsfalseinformationinanapplicationfor
insuranceisguiltyofacrimeandmaybesubjecttonesandconnementinprison.
California.ForyourprotectionCalifornialawrequiresthefollowingtoappearonthisform:Anypersonwho
knowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybe
subjecttonesandconnementinstateprison.
Colorado.It is unlawfultoknowinglyprovidefalse, incomplete,ormisleadingfactsor information toan
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
includeimprisonment,nes,denialofinsuranceandcivildamages.Anyinsurancecompanyoragentof
aninsurancecompanywhoknowinglyprovidesfalse,incomplete,ormisleadingfactsorinformationtoa
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
withregardtoasettlementorawardpayablefrominsuranceproceedsshallbereportedtotheColorado
DivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
Delaware.Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia.Itisacrimetoprovidefalseormisleadinginformationtoaninsurerforthepurpose
ofdefraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/ornes.Inaddition,an
insurermaydenyinsurancebenetsiffalseinformationmateriallyrelatedtoaclaimwasprovidedbythe
applicant.
Florida.Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerlesastatementof
claim or application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
Idaho.Anypersonwhoknowingly,andwithintenttodefraudordeceiveanyinsurancecompany,lesa
statement or claim containing any false, incomplete or misleading information is guilty of a felony.
Indiana.Apersonwhoknowinglyandwithintenttodefraudaninsurerlesastatementofclaimcontaining
any false, incomplete, or misleading information commits a felony.
Kentucky.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonles
a statement of claim containing any materially false information or conceals, for the purpose of misleading,
informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrime.
Maine.Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompany
forthepurposeofdefraudingthecompany.Penaltiesmayincludeimprisonment,nesoradenialofinsurance
benets.
Maryland.Anypersonwhoknowinglyorwillfullypresentsafalseorfraudulentclaimforpaymentofaloss
orbenetorwhoknowinglyorwillfullypresentsfalseinformationinanapplicationforinsuranceisguiltyof
acrimeandmaybesubjecttonesandconnementinprison.
Page 8 of 8
GLC-01253 CLMFRM 6/20
Minnesota.Apersonwholesaclaimwithintenttodefraudorhelpscommitafraudagainstaninsureris
guilty of a crime.
New Hampshire.Anypersonwho,withapurposetoinjure,defraudordeceiveanyinsurancecompany,les
astatementofclaimcontaininganyfalse,incompleteormisleadinginformationissubjecttoprosecution
andpunishmentforinsurancefraud,asprovidedinRSA638:20.
New Jersey.Any person who knowingly les a statement of claim containing any false or misleading
informationissubjecttocriminalandcivilpenalties.
New Mexico.Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benetorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmay
besubjecttocivilnesandcriminalpenalties.
New York.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonles
an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act,whichisacrimeandsubjecttoacivilpenaltynottoexceedvethousanddollarsandthestatedvalue
oftheclaimforeachsuchviolation.
Ohio.Anypersonwho,withintenttodefraudorknowingthatheisfacilitatingafraudagainstaninsurer,
submitsanapplicationorlesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
Oklahoma.Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesany
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.
Oregon.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherperson:(1)
lesanapplicationforinsuranceorstatementofclaim containinganymateriallyfalseinformation;or,(2)
concealsforthepurpose ofmisleading,informationconcerningany materialfact,mayhavecommitteda
fraudulent insurance act.
Pennsylvania.Any person who knowingly and with intent to defraud any insurance company or other
personlesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformation
or conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties.
Puerto Rico.Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss
oranyotherbenet,orpresentsmorethanoneclaimforthesamedamageorloss,shallincurafelonyand,upon
conviction,shallbesanctionedforeachviolationbyaneofnotlessthanvethousanddollars($5,000)andnot
morethantenthousanddollars($10,000),oraxedtermofimprisonmentforthree(3)years,orbothpenalties.
Shouldaggravatingcircumstancesbepresent,thepenaltythusestablishedmaybeincreasedtoamaximumof
ve(5)years,ifextenuatingcircumstancesarepresent,itmaybereducedtoaminimumoftwo(2)years.
Tennessee, Virginia, and Washington.Itisacrimetoknowinglyprovidefalse,incompleteormisleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment,nesanddenialofinsurancebenets.
Texas.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyof
acrimeandmaybesubjecttonesandconnementinstateprison.
FOR ALL OTHER STATES EXCLUDING CONNECTICUT AND KANSAS. A person may be committing
insurancefraud,ifheorshesubmitsanapplicationorclaimcontainingafalseordeceptivestatementwith
intenttodefraud(orknowingthatheorsheishelpingtodefraud)aninsurancecompany.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its aliates.
The Lincoln Financial Group companies* are committed to protecting your privacy. To provide the products and services you
expect from a financial services leader, we must collect personal information about you. We do not sell your personal information
to third parties. This Notice describes our current privacy practices. While your relationship with us continues, we will update and
send our Privacy Practices Notice as required by law. Even after that relationship ends, we will continue to protect your personal
information. You do not need to take any action because of this Notice, but you do have certain rights as described below.
Information We May Collect And Use
We collect personal information about you to help us identify you as a consumer, our customer or our former customer; to
process your requests and transactions; to offer investment or insurance services to you; to pay your claim; to analyze in order to
enhance our products and services; to tell you about our products or services we believe you may want and use; and as otherwise
permitted by law. The type of personal information we collect depends on your relationship and on the products or services you
request and may include the following:
• Information from you: When you submit your application or other forms, you give us information such as your
name, address, Social Security number; and your financial, health, and employment history. We may also collect
voice recordings or biometric data for use in accordance with applicable law.
• Information about your transactions: We maintain information about your transactions with us, such as the
products you buy from us; the amount you paid for those products; your account balances; and your payment and
claims history.
• Information from outside our family of companies: If you are applying for or purchasing insurance products,
we may collect information from consumer reporting agencies, such as your credit history; credit scores; and
driving and employment records. With your authorization, we may also collect information, such as medical
information, from other individuals or businesses.
• Information from your employer: If your employer applies for or purchases group products from us, we may
obtain information about you from your employer or group representative in order to enroll you in the plan.
How We Use Your Personal Information
We may share your personal information within our companies and with certain service providers. They use this information to
process transactions you, your employer, or your group representative have requested; to provide customer service; to analyze
in order to enhance our products and services; to gain customer insight; and to inform you of products or services we offer that
you may find useful. Our service providers may or may not be affiliated with us. They include financial service providers (for
example, third party administrators; broker-dealers; insurance agents and brokers, registered representatives; reinsurers and
other financial services companies with whom we have joint marketing agreements). Our service providers also include non-
financial companies and individuals (for example, consultants; vendors; and companies that perform marketing services on our
behalf). Information we obtain from a report prepared by a service provider may be kept by the service provider and shared with
other persons; however, we require our service providers to protect your personal information and to use or disclose it only for the
work they are performing for us, or as permitted by law.
When you apply for one of our products, we may share information about your application with credit bureaus. We also may
provide information to group policy owners or their designees (for example, to your employer for employer-sponsored plans and
their authorized service providers), regulatory authorities and law enforcement officials, and to other non-affiliated or affiliated
parties as permitted by law. In the event of a sale of all or part of our businesses, we may share customer information as part of
the sale. We do not sell or share your information with outside marketers who may want to offer you their own products
and services; nor do we share information we receive about you from a consumer reporting agency. You do not need to
take any action for this benefit.
Page 1 of 2
GB06714 11/20
LCN-2876003-121719
Lincoln Financial Group
®
Privacy Practices Notice
Security of Information
We have an important responsibility to keep your information safe. We use safeguards to protect your information from
unauthorized disclosure. Our employees are authorized to access your information only when they need it to provide you with
products, services, or to maintain your accounts. Employees who have access to your personal information are required to keep
it confidential. Employees are required to complete privacy training annually.
Your Rights Regarding Your Personal Information
Access: We want to make sure we have accurate information about you. Upon written request we will tell you, within 30 business
days, what personal information we have about you. You may see a copy of your personal information in person or receive a
copy electronically or by mail, whichever you prefer. We will share with you who provided the information. In some cases we
may provide your medical information to your personal physician. We will not provide you with information we have collected in
connection with, or in anticipation of, a claim or legal proceeding. If you request a copy of the information, we may charge you
a fee for copying and mailing costs. In very limited circumstances, your request may be denied. You may then request that the
denial be reviewed.
Accuracy of Information: If you feel the personal information we have about you is inaccurate or incomplete, you may ask us
to amend the information. Your request must be in writing and must include the reason you are requesting the change. We will
respond within 30 business days. If we make changes to your records as a result of your request, we will notify you in writing and
we will send the updated information, at your request, to any person who may have received the information within the prior two
years. We will also send the updated information to any insurance support organization that gave us the information, and any
service provider that received the information within the prior 7 years. If your requested change is denied, we will provide you
with reasons for the denial. You may write to request the denial be reviewed. A copy of your request will be kept on file with your
personal information so anyone reviewing your information in the future will be aware of your request.
Accounting of Disclosures: If applicable, you may request an accounting of disclosures made of your medical information,
except for disclosures:
• For purposes of payment activities or company operations;
• To the individual who is the subject of the personal information or to that individual’s personal representative;
• To persons involved in your health care;
• For notification for disaster relief purposes;
• For national security or intelligence purposes;
• To law enforcement officials or correctional institutions;
• Included in a limited data set; or
• For which an authorization is required.
You may request an accounting of disclosures for a time period of less than six years from the date of your request.
Basis for Adverse Underwriting Decision: You may ask in writing for the specific reasons for an adverse underwriting decision.
An adverse underwriting decision is where we decline your application for insurance, offer to insure you at a higher than standard
rate, or terminate your coverage.
Your state may provide for additional privacy protections under applicable laws. We will protect your information in accordance
with these additional protections.
If you would like to act upon your rights regarding your personal information, please provide your full name, address and telephone
number and either email your inquiry to our Data Subject Access Request Team at DSAR@lfg.com or mail to: Lincoln Financial
Group, Attn: Corporate Privacy Office, 7C-01, 1300 S. Clinton St., Fort Wayne, IN 46802. The DSAR@lfg.com email address
should only be used for inquiries related to this Privacy Notice. For general account service requests or inquiries, please call
1-877-ASK-LINC.
*This information applies to the following Lincoln Financial Group companies:
First Penn-Pacific Life Insurance Company Lincoln Life & Annuity Company of New York
Lincoln Financial Distributors, Inc. Lincoln Life Assurance Company of Boston
Lincoln Financial Group Trust Company Lincoln Retirement Services Company, LLC
Lincoln Investment Advisors Corporation Lincoln Variable Insurance Products Trust
The Lincoln National Life Insurance Company
Page 2 of 2
GB06714 11/20
LCN-2876003-121719
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