Fillable Group Life Insurance Claim Form (Lincoln Financial Benefits)

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Group Life Insurance Claim Form (Lincoln Financial Benefits)

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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 ______________________________________________________________
Certicate Holder _____________________________________________________________
(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 __________
3. Social Security Number or Certicate # _______________________________ _______________________________
(Employee’s SSN) (Dependent SSN)
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 Employed: Full Time __________________________ Part Time _______________________
Annual Salary (if salary based) $ ______________________ Date Of Last Salary Increase __________________________
6. Effective Date of Insurance with Lincoln Financial Group _____________________________________________________
(Certicate Holder)
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 Layoff 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 _________________________________________________
(Certicate Holder)
Completed by ______________________________________________ Date ____________________________________
Title ______________________________________________________ Phone Number ____________________________
E-mail Address _____________________________________________ Fax Number ______________________________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
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
LifeClaims@lfg.com - For claims submission
Claims@lfg.com - For direct claim status inquiries and questions on existing claims
Page 1 of 10
GLC-01253 CLMFRM 8/16
Beneciary’s Statement
Please type or print legibly—name and address as stated will appear on checks
Name
____________________________________________________________________ Sex: 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 effective 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 effective 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 offered 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
www.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.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates. Page 2 of 10
GLC-01253 CLMFRM 8/16
Please sign at the bottom of page 3
Page 3 of 10
GLC-01253 CLMFRM 8/16
• 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 suf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 offered 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. A photocopy 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)
Authorization for Release of Information
1. I (the undersigned) authorize any physician, medical professional, pharmacist or other provider of health care services, hospital,
clinic, other medical or medically related facility; coroner’s of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 of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 not be 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 4 of 10
GLC-01253 CLMFRM 8/16
Page 5 of 10
GLC-01253 CLMFRM 8/16
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 different 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 of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: _____________________
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 of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 6 of 10
GLC-01253 CLMFRM 8/16
Page 7 of 10
GLC-01253 CLMFRM 8/16
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. A person 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 10
GLC-01253 CLMFRM 8/16
Minnesota. A person 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
®
privacy practices notice
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 our customer or our former customer; to process your
requests and transactions; to offer investment or insurance services to you; to pay your claim; or 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 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.
• 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 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 purchases group products from us, we may obtain information about you
from your employer 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 have requested; provide customer service; and 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, 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.
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 trained on the importance of data privacy.
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 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.
Page 9 of 10
GLC-01253 CLMFRM 8/16
Accounting of Disclosures: 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; or
• To law enforcement officials or correctional institutions; or
• For which an authorization is required.
You may request an accounting of disclosures for a time period of less than two years from the date of your request.
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.
Questions about your personal information should be directed to:
Lincoln Financial Group
Attn: Enterprise Compliance and Ethics
Corporate Privacy Office, 7C-01
1300 S. Clinton St.
Fort Wayne, IN 46802
Please include all policy/contract/account numbers with your correspondence.
*This privacy practices notice applies to the following Lincoln Financial Group affiliated companies:
First Penn-Pacific Life Insurance Company
Lincoln Life & Annuity Company of New York
Lincoln Financial Group Trust Company, Inc.
Lincoln Retirement Services Company, LLC
Lincoln Financial Investment Services Corporation
Lincoln Variable Insurance Products Trust
Lincoln Investment Advisors Corporation
The Lincoln National Life Insurance Company
Lincoln Financial Distributors, Inc.
Lincoln Advisors Trust
Page 10 of 10
GLC-01253 CLMFRM 8/16
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Completed 9 February 2021

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