Life Beneficiary Package
FILING A CLAIM FOR LINCOLN LIFE INSURANCE BENEFITS
What this package
provides:
This Life Beneficiary Package will help you apply for your Lincoln Life
Assurance Company of Boston ("Lincoln") Group Life insurance
benefits. This package explains the choices available to you, and
provides easy-to- follow instructions for completing the included claim
form.
Please take the time to review this information. It explains the steps you
need to complete in order to allow us to process your claim in a timely
and efficient manner.
Included:
Beneficiary Claim Form (DP 613 GL)
Where to call with
questions:
If you have additional questions or need assistance, you can call the
Group Life Claims at 1-888-787-2129, between 8:00 A.M. and 5:00 P.M.
(Eastern Standard Time), Monday through Friday.
HOW TO SUBMIT A GROUP LIFE INSURANCE BENEFITS CLAIM
Step Items to Complete
1
Complete the Group Life Insurance Claim Form Beneficiary Statement (DP 613 GL).
Note: If there is more than one beneficiary, each beneficiary should complete a form.
2
If the beneficiary is an estate, attach a copy of the court order appointing the executor or
administrator.
If the beneficiary is a trust, attach a copy of the trust document.
If the beneficiary is a minor (not of legal age), a guardian of the minor’s estate must be
appointed. Attach a certified copy of the court order appointing the guardian of the estate.
3
If the cause of death is listed as “accident” on the death certificate, attach a copy of all
relevant reports (if available), which may include: accident, police, incident, witness
statements, autopsy and/or toxicology report, and medical records.
In some instances, we may require medical information. If this is necessary, a representative
from Group Life claims will contact you.
4
Sign the Group Life Insurance Claim Form Beneficiary Statement (DP 613 GL).
5
If you have not already done so please attach a copy of the Death Certificate. If the Death
Certificate is not legible, we may require the original.
Your completed Beneficiary Statement and Death Certificate can be emailed to
LifeClaimDocs@lfg.com or faxed to1-603-427-1888.
Group products and services are offered by Lincoln Life Assurance Company of Boston
LBSP-Electronic Version
Lincoln Life Assurance Company of Boston
Group Life Claims
P.O. Box 7212
London, KY 40742-7212
Phone 888-787-2129
Fax 603-427-1888
Beneficiary
Statement
Please complete all applicable information. This must be completed by the person or persons
making claim, and
accompanied by a certified copy of Certificate of Death, unless already submitted.
Deceased Name
Social Security #
Claim #
General Claim Information
If the benefic
iary is an estate or a minor, the appropriate legal representative (executor, administrator or guardian of estate) should complete this statement.
This statement must be completed by the person legally entitled to receive the money, who must state in what capacity he or she makes the claim -
whether as Beneficiary named, Assignee, Executor Administrator, Guardian, or Trustee. If the beneficiary is not of legal age, a Guardian must be
appointed. A certified copy of the court order appointing the legal representative should be sent with this claim form.
If a trust is the beneficiary, attach a copy of the trust agreement and a letter that verifies that the trust is still in effect. Unless already submitted, after
completing this form, please attach a certified copy of the death certificate of the insured and return these documents to Lincoln.
Beneficiary Name/Estate or Trust
Date of Birth
Social Security # or Tax ID #
Address
City
Zip
Home Telephone #
Cell #
Relationship to Insured
Email Address:
SETTLEMENT OPTIONS
Lump-Sum Check
Receive a lump-sum check for a total amount of benefits payable.
SecureLine
®
If you are eligible, we will pay total benefits of $10,000 or more through SecureLine
®
, an interest bearing account established in your name. You
can immediately access all or a portion of your funds by writing drafts from the draft book you will receive.
If a payment option is not selected, or the total benefits payable are less than $10,000, we will automatically send you a lump-sum check
The Company reserves the right to require or obtain such additional evidence as may seem necessary. Before transmitting these papers to the Company, review all answers
carefully and see that any necessary papers are attached in accordance with the instructions given above.
If the Social Security # or Taxpayer ID # is not supplied, Federal and State income tax withholding may apply. Under penalty of perjury, I certify that the above information
is true, correct and complete.
THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SPECIAL NOTICE: Any person who knowingly, and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false,
incomplete or misleading information may be guilty of a criminal act punishable under law.
For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
Beneficiary Signature Date
DP 613 GL Rev. 9/19
Fraud Statements
For states not listed below: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
For residents of Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company
files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
For residents of 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.
For residents of Arkansas, Louisiana, Rhode Island, and West Virginia: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
For residents of Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution fines and confinement in prison, or any combination thereof.
For residents of California: For your protection, California law requires the following to appear on this form: Any
person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.
For residents of 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, fines, 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.
For residents of Delaware and Idaho: WARNING: Any person who knowingly and with intent to injure, defraud or
deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading
information is guilty of a felony.
For residents of the District of Columbia: WARNING: 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 fines. In
addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the
applicant.
For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of
the third degree.
For residents of Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete, or misleading information commits a felony.
For residents of Kentucky:
Any person who knowingly and with intend to defraud any insurance company or other person files 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.
For residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
For residents of Maine, 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, fines and denial of insurance benefits.
For residents of Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
For residents of New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution
and punishment for insurance fraud, as provided in NH Rev. Stat. Ann. §638:20.
For residents of New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN
AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES
AND CRIMINAL PENALTIES.
For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other
person files 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation.
For residents of Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
For residents of Oklahoma: WARNING: 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.
For residents of Oregon: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a
loss or benefit or knowingly or willfully presents false information in an application for insurance may be guilty of a crime
and may be subject to fines and confinement in prison.
For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other
person files 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.
For residents of 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 fines and confinement in state prison.
Rev. 6/18
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