Fillable WELLNESS BENEFIT CLAIM FORM (Lincoln Financial Benefits)

Fill Online, Printable, Fillable, Blank WELLNESS BENEFIT CLAIM FORM (Lincoln Financial Benefits) Form

Use Fill to complete blank online LINCOLN FINANCIAL BENEFITS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

WELLNESS BENEFIT CLAIM FORM (Lincoln Financial Benefits)

On average this form takes 8 minutes to complete

The WELLNESS BENEFIT CLAIM FORM (Lincoln Financial Benefits) form is 1 page long and contains:

  • 0 signatures
  • 24 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Lincoln Financial Benefits forms online.

BROWSE LINCOLN FINANCIAL BENEFITS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates. Page 1 of 3
GLC10115 5/16
The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609
toll free (877) 815-9256 Fax (877) 668-5331
www.LincolnFinancial.com
WELLNESS BENEFIT CLAIM FORM
(BENEFITS MAY BE DELAYED IF CLAIM FORM IS NOT FULLY COMPLETED)
Please complete the information on the claim form below and submit a copy of the bill. If you were treated at a non-cost incurred facility,
please furnish verification from that facility of tests performed.
1. Employer Name: __________________________________________________________________________________________
2. Policyholder Name (First, Middle, Last): _________________________________________________________________________
3. Policy Number: ________________________________________________
4. Claimant Name (First, Middle, Last): ____________________________________________________________________________
5. Claimant Social Security Number: _________________________________
6. Claimant Birth Date (MM/DD/YY): _________________________________
7. Address: _________________________________________________________________________________________________
City: ________________________________________________________ State: _______ Zip Code: __________________
8. Phone (including area code): _______________________________________
e-mail Address: ___________________________________________________________________________________________
9. Please check the test(s) performed: Date Test Performed (MM/DD/YY): ______________________
h Abdominal Aortic Aneurysm Ultrasound
h Blood Test for Triglycerides
h Bone Marrow Testing
h Bone Density Screening
h Breast Ultrasound
h CA 15-3 (Blood Test for Breast Cancer)
h CA 125 (Blood Test for Ovarian Cancer)
h Carotid Ultrasound
h CEA (Blood Test for Colon Cancer)
h Chest X-Ray
h Colonoscopy
h CT Angiography
h EKG
h Double Contrast Barium Enema
h Fasting Blood Glucose Test
h Flexible Sigmoidoscopy
h Hemoccult Stool Analysis
h Mammography
h Pap Smear
h PSA (Blood Test for Prostate Cancer)
h Serum Cholesterol Test to determine level of HDL and LDL
h Serum Protein Electrophoresis (Blood Test for Myeloma)
h Stress Test
h Thermography
10. Doctor’s Name: ___________________________________________________________________________________________
Doctor’s Phone: ______________________________________ Doctor’s Fax: _______________________________________
11. Doctor’s Address (Street): ____________________________________________________________________________________
City: ________________________________________________________ State: _______ Zip Code: __________________
CERTIFICATION
Insured’s Name: ________________________________________________ Insured’s Social Security Number: _______________
I have checked the answers on this claim form and they are correct. I certify under penalty of perjury that my correct social security
number is shown on this form. I acknowledge that I have received the Claim Form Addendum, Fraud Warning and State Versions’ form
and that I read the statement required by the State Department of Insurance for my state, if my state was listed on the form.
_____________________________________________________________________ ___________________________________
Insured’s Signature Date
Page 2 of 3
GLC10115 5/16
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 benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
restitution fines or confinement in prison, or any combination thereof.
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.
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 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.
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
fines and confinement 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, 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.
Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files 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 fines. In addition, an insurer
may deny insurance benefits 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 files 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, files 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 files 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 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.
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, fines or a denial of insurance benefits.
Maryland. Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or
benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Minnesota. A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty
of a crime.
Page 3 of 3
GLC10115 5/16
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 RSA 638:20.
New Jersey. Any person who knowingly files 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 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.
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 subject to a civil penalty not to exceed five 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 files 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) files 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
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.
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
benefit, 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 fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed 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 five (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,
fines and denial of insurance benefits.
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.
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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

WELLNESS BENEFIT CLAIM FORM (Lincoln Financial Benefits)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document